Int.J.Curr.Microbiol.App.

Sci (2017) 6(9): 1304-1309

International Journal of Current Microbiology and Applied Sciences

ISSN: 2319-7706 Volume 6 Number 9 (2017) pp. 1304-1309
Journal homepage: http://www.ijcmas.com

Original Research Article https://doi.org/10.20546/ijcmas.2017.609.157

Seroprevalance and Co-infection of Hepatotropic Viruses

in Acute Viral Hepatitis Cases

Nasiruddin M. Shaikh, Tanmay K. Mehta* and Parul D. Shah

Department of Microbiology, Smt. N.H.L. Municipal Medical College,

Ahmedabad, Gujarat, India-380006
*Corresponding author

ABSTRACT

Acute viral hepatitis (AVH) is a major public health problem and is an important cause of
morbidity and mortality. The aim of the present study is to find seroprevalance and co-
Keywords infection rate of hepatotropic viruses in suspected cases of acute viral hepatitis at a tertiary
care hospital of western India. Samples of Acute viral Hepatitis cases were tested for
Co-infection, HAV, hepatitis B surface antigen, anti-HAV IgM and anti-HEV IgM by the enzyme-linked
HEV, HBV, Acute
viral hepatitis.
immunosorbent assay from 1st April 2014 to 31st March 2015 at a tertiary care hospital in
western India. HEV infection was found in 687 (74.43%) cases, followed by HAV
Article Info 226(24.48%) cases and HBV 46 (4.98%) cases. Infection with more than one virus was
detected in 69 (7.47%) cases, the most common being HAV and HEV co-infection in 44
Accepted: (4.76%) cases. Co-infection of hepatitis viruses is not infrequent and detected in many
17 July 2017
Available Online:
cases of AVH. Therefore, testing for all hepatotropic viruses’ infection should be done in
10 September 2017 acute viral hepatitis cases regardless of route of transmission. The declined incidence of
HEV infection with an evolving epidemiologic shift of HAV infection indicates the
improvement in sanitary conditions.

Introduction
Acute viral hepatitis (AVH) is a major public any residual consequences. However, in some
health problem in India and other developing persons, acute liver failure (ALF) may occur.
nations having inadequate sanitary conditions. Patients with ALF have a high case-fatality
Acute viral hepatitis (AVH) is a systemic rate, in the absence of liver transplantation,
infection affecting the liver predominantly. It which is either inaccessible or non-affordable
is caused by six distinct types of viruses A, B, for a large majority of Indian population.
C, D, E and G.[1] Infection with HBV, HCV, or HDV too may
present as acute hepatitis.
HAV and HEV are an important cause of
acute viral hepatitis and acute liver failure in However, these viruses have the potential to
India. The most common clinical cause persistent infection in a subset of those
consequence of infection with hepatitis A or E infected. Such infection may be associated
virus is acute hepatitis. A large majority of with ongoing liver damage, which may
people with acute viral hepatitis recover progress to liver cirrhosis or liver cancer,
spontaneously within a few weeks, without which can be life-threatening. India has
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“intermediate to high endemicity” for −20 °C until tested. Only aadequate amount
Hepatitis B surface antigen and an estimated of non-hemolysed, non-lipemic serum without
40 million chronic HBV infected people, precipitate or particulate matter was tested.
constituting approximately 11% of the
estimated global burden. [2] The serum samples were tested to detect HAV
immunoglobulin M (IgM) against capsid
Very few studies describing the pattern of protein for HAV infection, hepatitis B surface
hepatitis viruses in AVH are available from antigen (HBsAg) for HBV infection and HEV
India.[3-7] Therefore, this study was IgM for HEV infection. All analyses were
undertaken to determine the sero-prevalence performed using commercial kits based on the
and co-infection rate of hepatotropic viruses enzyme-linked immunosorbent assay
among suspected cases of AVH to plan (ELISA) as per the manufacturer's
appropriate management of cases as well as instructions which include blank, negative
preventive strategies. control, positive control and calibrator in
dispensation scheme. Relevant clinical
The main objectives of this study include to information was collected from the laboratory
find out seroprevalance and co-infection rate database and forms. Appropriate descriptive
of hepatotropic viruses in suspected cases of statistics (e.g. percentages etc.) was used to
acute viral hepatitis (AVH) at a tertiary care describe studied variables.
hospital of western India.
Results and Discussion
Materials and Methods
Total 923 serum samples from suspected
A cross-sectional observational study was cases of Acute Viral Hepatitis (AVH) were
done from 1st April 2014 to 31st March 2015 tested. Hepatitis E virus infection was found
at a tertiary care hospital in western India. in 687 (74.43%) cases, followed by HAV
Total 923 suspected cases of acute viral infection in 226(24.48%) cases and HBV
hepatitis (AVH) patients were enrolled in the infection in 46 (4.98%) cases (Table 1).
study.
Infection with more than one virus in same
An Acute Viral Hepatitis (AVH) case was patient at a time could be detected in 69
defined as a person having an acute illness of (7.47%) cases, the most common being HAV
less than 15 days duration with a discrete and HEV co-infection in 44 (4.76%) cases.
onset of any sign or symptom (e.g., fever, Co-infection of HBV with HAV or HEV or
headache, malaise, anorexia, nausea, both was present in 25 (2.70%) cases (Table
vomiting, diarrhea and abdominal pain) and 2).
either a) jaundice or b) elevated serum alanine
aminotransferase (ALT) levels more than 100 Although cases were seen throughout the
IU/L documented at least twice at a 1-week year, 86 (9.31%) and 280 (30.33%) of cases
interval without any history of pre-existing of HAV and HEV were seen from August to
liver disease. [8] October that is monsoon seasons in this part
of the country. HBV infection did not show
Three ml of human blood sample irrespective any seasonal pattern (Table 3).
of age and gender was collected from each
patient. Serum was separated with In age group 0-15 years HAV IgM positive
centrifugation of each sample and stored at cases were 184 (19.93%), HAV and HEV

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IgM positive cases were 27 (2.95%). In age monsoon months from August to October.
group >15 years HEV IgM positive cases Since this is a hospital based data the true
were 595 (64.46%), HBs Antigen positive seasonal distribution in the community could
cases were 42 (4.55%), HEV IgM and HBs not be assessed. Earlier studies have found
antigen positive cases were 16(1.73%). In the either no seasonal peaks or a peak in summer
same age group HEV IgM, HAV IgM and and monsoon months of the year. [12-13]
HBs antigen positive cases were 2(0.21%)
(Table 4). We found decreased seroprevalance of HAV
(4.55%) induced AVH in adults compared to
In our study HEV infection (74.43%) was the previous studies done in India (8%).[14] In
most common cause of acute viral hepatitis children HAV infection is low (19.93%) in
followed by HAV infection (24.48%) and present data compared to other studies (37.5-
HBV infection (4.98%). Several other studies 64%).[15] HEV seroprevalance in children
on Acute viral hepatitis have reported varying (9.96%) was lower than that reported by other
prevalence of hepatotropic viruses infections: studies (16.3-66.3%). Several studies from
HAV (1.7-67%), HBV (7.3-42%) and HEV different parts of India have reported a shift in
(16.3-66.3%). [5-10] Patients with acute viral the age of acquiring HAV infection has been
hepatitis due to HAV also had high co- seen from childhood to older age groups in
infection rate of HEV probably because of India and globally; this shift is known as
similar routes of transmission for hepatitis A epidemiological shift.[15-16] Our observations
and E viruses. [11] HAV and HEV infections indicates improvement in living standards and
are endemic in India and infections occur hygiene of the Indian population.
throughout the year, though peaks are seen in

Table.1 Sero-prevalence of HAV, HBV and HEV

Total suspected cases of HBs Antigen HAV IgM Antibody HEV IgM Antibody
AVH tested Negative Positive Negative Positive Negative Positive
923 877 (95.01%) 46 (4.98%) 697 (75.51%) 226 (24.48%) 236 (25.56%) 687 (74.43%)

Table.2 Co-infection cases among HAV, HBV and HEV sero-positive cases
HAV IgM and HEV HBs Ag and HAV HBs Ag and HEV HBs Ag, HAV IgM and Total Co-
IgM positive cases IgM positive cases IgM positive cases HEV IgM positive cases infection cases
44 (4.76%) 3 (0.32%) 19 (2.05%) 3 (0.32%) 69(7.47%)

Table.3 Seasonal distribution among HAV, HBV and HEV sero-positive cases
Total suspected HAV IgM and HBsAg and HBsAg and HAV IgM, HEV
Month
cases of AVH HBsAg HAV IgM HEV HEV IgM HAV IgM HEV IgM IgM and
and Year
tested Positive Positive IgM Positive Positive Positive Positive HBsAg Positive
Apr-14 38 (4.11%) 3 (0.32%) 8 (0.86%) 27(2.92%) 0 (0%) 0 (0%) 1 (0.1%) 0 (0%)
May-14 36 (3.90%) 0 (0%) 9 (0.97%) 27(2.92%) 1(0.1%) 0 (0%) 0 (0%) 0 (0%)
Jun-14 76 (8.23%) 12 (1.3%) 11 (1.19%) 54(5.85%) 0 (0%) 0 (0%) 5 (0.54%) 0 (0%)
Jul-14 132 (14.30%) 0 (0%) 27 (2.92%) 103 (11.15%) 5 (0.54%) 0 (0%) 0 (0%) 0 (0%)
Aug-14 79 (8.55%) 3 (0.32%) 20 (2.1%) 61 (6.60%) 5 (0.54%) 1 (0.1%) 2 (0.21%) 0 (0%)
Sep-14 158 (17.11%) 6 (0.65%) 38 (4.11%) 124 (13.43%) 9 (0.97%) 1 (0.1%) 2 (0.21%) 2 (0.21%)
Oct-14 118 (12.78%) 5 (0.54%) 28 (3.03%) 95 (10.29%) 6 (0.65%) 0 (0%) 5 (0.54%) 0 (0%)
Nov-14 73 (7.90%) 6 (0.65%) 22 (2.38%) 48 (5.2%) 2 (0.21%) 0 (0%) 3 (0.32%) 0 (0%)
Dec-14 49 (5.30%) 2 (0.21%) 15 (1.62%) 35 (3.79%) 4 (0.43%) 0 (0%) 0 (0%) 0 (0%)
Jan-15 74 (8.01%) 5 (0.54%) 23 (2.49%) 47 (5.09%) 5 (0.54%) 0 (0%) 0 (0%) 0 (0%)
Feb-15 54 (5.85%) 2 (0.21%) 15 (1.62%) 38 (4.11%) 3 (0.32%) 0 (0%) 0 (0%) 0 (0%)
Mar-15 36 (3.90%) 2 (0.21%) 10 (1.08%) 28 (0.30%) 4 (0.43%) 1 (0.1%) 1 (0.1%) 1 (0.1%)

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Table.4 Age distribution among HAV, HBV and HEV seropositive cases
Name of Test(s) Less than or equal to 15 years More than 15 years
HAV IgM positive 184 (19.93%) 42 (4.55%)
HEV IgM positive 92 (9.96%) 595 (64.46%)
HBs Ag positive 4 (0.43%) 42 (4.55%)
HAV and HEV IgM positive 27 (2.95%) 16 (1.73%)
HAV IgM and HBsAg positive 3 (0.32%) 0 (0%)
HEV IgM and HBs Ag positive 3 (0.32%) 16 (1.73%)
HEV, HAV IgM and HBsAg positive 1 (0.1%) 2 (0.21%)

Diagnosis of HEV is primarily based on HAV, HEV and HBV co-infections was also
detection of specific antibody. Anti-HEV IgM found in 3 cases in our study.
antibodies indicate recent infection, but they
disappear rapidly. Anti-HEV IgG antibodies This study had a limitation of not studying
can be detected in up to 96% of acute epidemiological shift of HAV and HEV
infections during the first 4 weeks, and they infections based on age specific
disappear in at least 50% of patients by 3 immunoglobulin G (IgG) prevalence levels.
months after the onset of acute disease.[17]
Another limitation here is that testing for
The duration of HEV antibody persistence HCV infection was not done for all acute viral
after exposure has not been established. hepatitis cases which are reported to have
Recurrent acute HEV infections have been prevalence of 1.1-3.1% in children and 2.02-
documented, suggesting that the HEV 10.6% in adults in other studies.
antibody does not persist on a long-term basis
[18].
This could also explain the low The reduced seroprevalance of HEV infection
prevalence of HEV IgM positive cases among with an epidemiologic shift of HAV infection
our patients. indicate the improvement in living and
hygienic standards of the Indian population.
Other studies have found Hepatitis B as the
second most important cause of AVH, while Co-infection of HAV, HEV and HBV was not
we observed it as the third causative agent of infrequent and detected in many cases of
AVH. It could not be determined whether AVH. So Testing for all hepatotropic viruses
these were co-infections or super-infections. e.g., HAV, HEV, HBV and HCV should be
done in all acute viral hepatitis cases
But, it is known that both co-infection and regardless of route of transmission.
super-infection usually cause complications
leading to high morbidity and Testing for all hepatotropic viruses’ infection
[19]
mortality. Study done earlier at Lucknow, should be done in acute viral hepatitis cases
states that co-infection does not produce a regardless of route of transmission as co-
more severe disease. [20] infection of hepatitis viruses is not infrequent
and detected in many cases of AVH.
HBV and HEV co-infection was found in
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How to cite this article:

Nasiruddin M. Shaikh, Tanmay K. Mehta and Parul D. Shah. 2017. Seroprevalance and Co-
infection of Hepatotropic Viruses in Acute Viral Hepatitis Cases. Int.J.Curr.Microbiol.App.Sci.
6(9): 1304-1309. doi: https://doi.org/10.20546/ijcmas.2017.609.157

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