DOI: 10.7860/JCDR/2013/5966.

3459
Original Article

Water Borne Hepatitis A and Hepatitis E in

Microbiology Section

Malwa Region of Punjab,India

DEEPAK ARORA1, NEERJA JINDAL2, RAVINDER K SHUKLA3, RENU BANSAL4

ABSTRACT infections.
Introduction: Hepatitis-A virus infection (HAV) and Hepatitis Material and Methods: This study was conducted in the
E virus infection (HEV) are faecally contaminated water borne Department of Microbiology in GGMC and Hospital Faridkot,
infection of great public interest in developing countries. HAV A leading Tertiary care hospital and the major referral centre of
has a world-wide distribution and affects infant and young malwa region of Punjab,India.
children in developing countries and its epidemics are not very Collection and Serological Tests: 1.Venous blood samples of
common. HEV is restricted to tropical countries and affects patients of acute hepatitis were taken.
older children and young adults and its epidemics are common.
2.Relavent information regarding their Age, Sex Education,
Studies suggested that HEV is etiologically responsible for
Socio-economic status, personal and community hygiene were
10%–95% of admitted cases of hepatitis. Exposure rates over
recorded. All of the sera were screened for IgM Antibody to HEV
a period of time are different in different parts of the country and
and HAV using IgM capture ELISA Kit (ASIA-LION Biotechnology
in different socio-economic groups.
for HEV and GENERAL BIOLOGICAL CORPORATION for HAV )
Aim of the study 1. To study the prevalence of HAV and HEV in accordance with the manufacturer’s instructions.
in the outbreak of hepatitis in certain areas of Malwa region of
Result and Conclusion : 1.The outbreak was due to hepatitis A
Punjab, India.
&E virus(HEV predominating resulting from fecal contamination
2. To determine the age specific prevalence rates of HAV and of drinking water). 2.Hepatitis E is more widely prevalent 3.There
HEV. is a change in the epidemiology of HAV so,more cases are seen
3. To determine any change in the epidemiology of these in age group of more than 20 years.

Key words: Infections, Punjab, Hepatitis, Water

Introduction 20% mortality has been reported [10]. HEV infection usually does
Hepatitis-A virus infection (HAV) and Hepatitis E virus infection not become chronic, but chronic infections have recently been
(HEV) are enterically transmitted viral diseases of great public health reported in transplant recipients [10].
importance in the developing countries like India. HAV has a world- HEV infection in pregnant women is more common and more
wide distribution and affects infants and young children in developing fatal in the third trimester. The mortality rate due to HEV-induced
countries but its epidemics are rare; whereas HEV is restricted to hepatitis is as high as 15-20% [10].
tropical countries and affects older children and young adults and
its epidemics are common [1-2]. In developing countries like India, Aim and Objectives
HAV and HEV both are endemic. Exposure rates over a period of 1.To study the prevalence of HAV and HEV in the outbreak of
time are different in different parts of the country and in different hepatitis in certain areas of Malwa region of Punjab,India .
socio-economic groups [1]. Hepatitis E virus (HEV), an emerging 2.To determine the age specific prevalence rates of HAV and
pathogen [3,4], causes significant disease in endemic countries HEV.
and is the leading cause of enterically transmitted viral hepatitis 3.To determine any change in the epidemiology of these
illness globally [3]. Large annual epidemics are attributed to HEV infections.
[5], and studies suggested that HEV is etiologically responsible for
10%–95% of admitted cases of hepatitis across South Asia [6,7]. MATERIAL AND METHODS
Globally, prevalence rates of antibody to Hepatitis-E virus (anti- This study was conducted in the Department of Microbiology in
HEV) vary by region, population, and circulating genotypes of HEV, GGMC and Hospital Faridkot, which is the centre for Intergerated
with unexpectedly high seropositivity in some developed settings Disease Surveillance Programme (IDSP) receiving samples from
[8,9]. It is unknown why age-specific seroprevalence rates of HAV surrounding areas too. During 2011 there was an outbreak of water
and HEV are dissimilar in the same country and why antibody borne hepatitis in Bathinda,India and the samples were send to
acquisition rates are different in different countries with similar GGMC Faridkot for testing . Detailed history about the areas with
environmental conditions. the maximum number of cases, their presenting complaints and
HAV has a world-wide distribution and affects infant and young other relevant history was taken from Civil Hospital Bathinda,
children in developing countries and its epidemics are not very India”.
common. In 2012, because of the preventive measures taken after the
Acute infection primarily affects young adults and is generally outbreak, (nil) cases were reported proving the preventable nature
mild, except in women during late pregnancy, among whom of the disease.

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 Deepak Arora et al., Water Borne Hepatitis A and Hepatitis E in Malwa Region of Punjab, India www.jcdr.net

Collection and Serological Tests

1 Venous blood samples of patients of acute hepatitis were
taken.
2. All of the sera were screened for IgM Antibody to HEV and
HAV by using IgM capture ELISA Kit (Asia-Lion Biotechnology for
HEV and GENERAL BIOLOGICAL CORPORATION for HAV ) in
accordance with the manufacturer’s instructions.

Results
1. The serum samples of 81 patients of jaundice and hepatitis
were diagnosed with HAV and HEV infection by demonstrating
the IgM antibody by capture by Elisa.
2. Most of the patients presented within one week of onset of
symptoms to the hospital with the major presenting complaints of
Pain abdomen, fever ,vomiting, jaundice and fatigue.
3. Total 81 cases of acute hepatitis were reported out of which
66(81.48%) cases were positive for Hepatitis A and E [Table/ [Table/Fig-3]: Area wise distribution of cases
Fig-1]. Nine cases (13.63 %) were positive for Hepatitis-A [Table/
Fig-1] , 52 cases(78.78%) were positive for Hepatitis-E [Table/ Male Female %Age
Fig-1] and 5 cases (7.5%) were positive for Hepatitis -A+ E co-
infection [Table/Fig-1]. HAV 6 3 9
4. Of the 14(9+5) patients of HAV infection 7(50%) were in the HEV 42 10 52
age group≥ 20 years and 7(50%) were in the age group of ≤20 HAV+HEV 4 1 5
years . Of the 57{52+5} patients of HEV 10(17.54%) were in the
TOTAL NO. OF CASES POSITIVE 52(78.78) 14(21.21) 66
age group of≥ 20 and rest 47(82.45%) were in the age group of
≤20 yrs. as shown in [Table/Fig-2]. [Table/Fig-4]: Sex distribution
5. Out of 9 HAV positive cases Males were 6( 9.09%)and 3(4.54%)
were females , of the 52 cases of HEV 42(63.63%) were males
and 10(15.15%) were female . Of the 5 cases with co-infection of
HAV and HEV 4( 6.06%) were males and 1(1.5%) was female as
shown in [Table/Fig-3].

Discussion
India is considered to be a hyper endemic region for HAV [11].
In the present population-based study, prevalence of HAV is
13.63% as compared to 81.48% of total prevalence as shown
in [Table/Fig-1]. In the present study, the trend of the decrease in
the prevalence was in accordance with shifting patterns of sero-
prevalence over the past 20 years seen in South-east Asia and
China that reflected improved living standards and environmental
hygiene [12–14].
However many recent reports indicate a global change in sero-
epidemiological patterns of hepatitis A infection [15]. In Delhi (India),
sero prevalence in people younger than 35-year–old was similar to
that of the more developed European countries and in many
[Table/Fig-1]: Showing positive cases of hepatitis a, e & co-infection (a+e)
Western European countries [16], followed by the improvement of
the standard of living in the industrialized world,
HAV seroprevalence remained high in all age groups and changed
under the age of five years old. This finding confirmed that the
greatest exposure still occurs early in life and that individuals
acquire HAV immunity at a very young age, but these findings are
not correlating with us as in our case out of the 14 cases of HAV 7
are in age group of >20year and 7 cases are in age group of <20
years as shown in [Table/Fig-2].
Regarding socio-demographic variables, our findings are consistent
with several previous studies showing a clear inverse correlation
between exposure to HAV and socio-economic level [17–19]. It
is a well known fact that HAV infection is strongly correlated with
poverty and inadequate sanitation. Increasing household income,
education, water quality and quantity, sanitation, and hygiene
lead to decreased HAV prevalence. Indeed, the prevalence of
HAV infection could even be used as an index of the level of
development in a given country. Prevalence of the disease varies
[Table/Fig-2]: (HAV) & 3(HEV) Age wise distribution of cases widely, as a consequence of basic sanitation conditions. The

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www.jcdr.net Deepak Arora et al., Water Borne Hepatitis A and Hepatitis E in Malwa Region of Punjab, India

maximum number of cases which are found in our study were 2. IN 2012, as nil cases were reported after the outbreak of 2011
from underdeveloped area of Bathinda,India as shown in [Table/ thus, showing the preventable nature of the disease .So, in this
Fig-3]. situation, it is necessary to keep water supply free from fecal
Hepatitis-A virus (HAV) is a health problem in countries where contamination to prevent outbreak of water borne diseases.
sero-epidemiology shows changes from hyperendemicity to
intermediate endemicity [20]. Then,there are different patterns References
with pockets of low prevalence; some studies indicate a decline [1] Arankalle VA, Chadha MS, Chitambar SD, Walimbe AM, Chobe LP,
Gandhe SS. Changing epidemiology of Hepatitis A and Hepatitis E in
of anti-HAV prevalence and the possibility of an outbreak of HAV
urban and rural India (1982-98). J Viral Hepat. 2001;8(4):293-303.
infection among this population. [2] SU Emerson, Purcell RH: Running like water--the omnipresence of
HEV mainly affects young adults of 15-40 years of age and hepatitis E. N Engl J Med. 2004;351(23):2367-8.
relatively spares children [21]. In India, HEV is responsible for 50- [3] Balayan MS, Andjaparidze AG, Savinskaya SS, Braginsky DM, Savinov AP,
Poleschuk VF. Evidence for a virus in non-A, non-B hepatitis transmitted via the
70% of all cases of sporadic acute viral hepatitis [22,23], and also, fecal-oral route. Intervirology. 1983;20(1):23-31.
is responsible for large outbreaks with source of infection mainly [4] Reyes GR, Purdy MA, Kim JP, Luk KC, Young LM, Fry KE, et al. Isolation of
being contaminated water supplies [21]. The occurrence of large a cDNA from the virus responsible for enterically transmitted non-A, non-B
epidemics of HEV in disease-endemic areas, as it was the case in hepatitis.Science. 1990;247(4948):1335-39.
[5] Labrique AB, Thomas DL,Stoszek SK, Hepatitis E: an emerging infectious
the present study, suggests the possibility of doubtful protection
disease. Epidemiol Rev. 1999;21(2):162-79.
from the antibody, gradual decline in the protective level of the [6] Sheikh A, Sugitani M, Kinukawa N. Hepatitis E virus infection in fulminant
antibody or infection from divergent strains of the virus [21]. hepatitis patients and an apparently healthy population in Bangladesh. Am J
Trop Med Hyg. 2002;66(6):721-24.
In most disease-endemic areas like India, HEV seroprevalence is
[7] Acharya SK, Panda SK, Saxena A. Acute hepatic failure in India: a perspective
high in the population under the age of 10, it is less ,but increases from the East. J Gastroenterol Hepatol. 2000;15(5):473-79.
up to 30 % among adults > 25 years of age [1]. The results of the [8] Abe K, Li TC, Ding X. International collaborative survey on epidemiology of
present epidemiological study showed the presence of an overall hepatitis E virus in 11 countries. Southeast Asian J Trop Med Public Health.
high endemicity of HEV infection (78.78 %) as shown in [Table/ 2006;37(1):90-95.
[9] Kuniholm MH, Purcell RH, McQuillan GM. Epidemiology of hepatitis E virus in the
Fig-1]. and a significantly lower seroprevalence in the age groups
United States: results from the Third National Health and Nutrition Examination
<10 years and <50 years. Compared to other series, the higher Survey, 1988–1994. J Infect Dis. 2009;200(1):48-56.
rate of HEV seroprevalence in the population under the age of [10] Kamar N, Selves J, Mansuy JM, Ouezzani L, Péron JM, Guitard J, Cointault O,
10 was seen from Andaman-Nicobar (32.9%) [12] and in one Esposito L, Abravanel F, Danjoux M : Hepatitis E virus and chronic hepatitis in
organ-transplant recipients. N Engl J Med. 2008 ;358:811–17.
from Northern India (>60%) [24]. This was in sharp contrast to
[11] Tandon BN, Gandhi BM, Joshi YK. Etiological spectrum of viral hepatitis and
our studies as in our study as maximum no.of cases out of 57, prevalence of markers of Hepatitis-A and B virus infection in North India. Bull
47(82.45%) of the cases are found in age group of more than 20 World Health Organ. 1984;62(1):67-73.
years as shown in [Table/Fig-2]. These differences might be due [12] Murhekar MV, Sehgal SC, Murhekar KM, Padbhidri SP, Chitambar SD, Arankalle
to either varying environmental conditions in different geographical VA: Changing scenario of Hepatitis-A virus and Hepatitis-E virus exposure
among the primitive tribes of Andaman and Nicobar Islands, India over the 10-
areas or the differences in the diagnostic tests used. year period 1989-99. J Viral Hepat. 2002;9(4):315-21.
Another, important finding which we got was the 5(7.5%) cases [13] Acharya SK, BatraY, Bhatkal B.Sero-epidemiology of Hepatitis-A virus
infection among school children in Delhi and North Indian patients with chronic
out of the total 66 cases of hepatitis were the patients with co-
liver disease: implications for HAV vaccination. J Gastroenterol Hepatol.
infection of HAV+HEV [Table/Fig-1].Out of these 5 patients of 2003;18(7):822-27.
co-infection of HAV and HEV 4 (80%)are in age group of less [14] Barzaga BN. Hepatitis A shifting epidemiology in South-East Asia and China.
than 20 and only 1(20%) is in age group of more than 20 .This, Vaccine. 2000;18 Suppl 1:S61-4.
is the paradoxical finding as in case of HEV positive cases. Out [15] Ratanasuwan W, Sonji A, Tiengrim S, Techasathit W, Suwanagool S. Serological
survey of viral Hepatitis-A, B, and C at Thai Central Region and Bangkok.
of 57, 47(82.45%) were in age group of more than 20 years and Southeast Asian. J Trop Med Public Health. 2004, 35(2):416-20.
also against the finding of Parana R et al., [25] as study by them [16] Francesco C, Giampiero C. Travelers Age-Specific Anti-Hepatitis A Virus Sero
states that Patients with acute viral hepatitis due to hepatitis A epidemiology in Italian Travelers Indications for Anti-Hepatitis A Vaccination.
also have high frequency of anti-HEV, probably because of similar Travel Med. 1996, 3:214-18.
[17] Zago MP, Stantolin GC, Perazzio S. Prevalence of antihepatitis A antibodies in
routes of transmission for hepatitis A and E viruses This finding
children of different socioeconomic conditions in Vila Velha. Rev Soc bras Med
also supports the that HEV is encountered early in childhood as trop. 2005, 38:285-89.
HAV infection. [18] Pereira FE, Gonçalves SC. Hepatite A. Rev Soc bras Med trop. 2003, 36:387-
400.
Although the major route of transmission of HAV and HEV is
[19] Raharimanga V, Carod JF, Ramarokoto CE, Chrétien JB, Rakotomanana F,
feco-oral route and poor sanitation and contaminated food/ Talarmin A, Richard V .Age-specific seroprevalence of hepatitis A in Antananarivo
water supplies are frequently cited as a source of infection; (Madagascar). BMC Infect Dis. 2008 Jun 6;8:78.
changes in exposure rates of HAV and HEV in all age groups [20] Letaief A, Kaabia N, Gaha R, Bousaadia A, Lazrag F, Trabelsi H et al. Age-
specific seroprevalence of hepatitis a among school children in central Tunisia.
suggest either a difference in mode of transmission. A difference
Am J Trop Med Hyg. 2005, July 73(1):40-43.
in the characteristics of virus (virulence-infectivity/ viability/ [21] Aggarwal R, Krawczynski K. Hepatitis E.An overview and recent advances in
transmissibility) or a difference in sensitivities and concordance clinical and laboratory research. J Gastroenterol Hepatol. 2000;15(1):9-20.
rates of various anti-HEV assays [2,21]. Sex wise distribution show [22] Khuroo MS, Rustgi VK, Dawson GJ, Spectrum of hepatitis E virus infection in
that males incidence of HAV,HEV and HEV+HEV co-infection were India. J Med Virol. 1994;43(3):281-6.
[23] Amarapurkar DS, Agar, Baijal P, Gupte P, Kamani N. Epidemiology of Hepatitis
more as shown in [Table/Fig-4].This can might be because major
E Virus Infection in Western India, Journal of Hepatic Monthly Original Article.
route of transmission of HAV and HEV is feco-oral route and poor Volume: 8, 2008: 8(4): 258–62.
sanitation and contaminated food/water supplies and as male go [24] Aggarwal R, Shahi H, Naik S, Yachha SK, Naik SR. Evidence in favour of high
out more for work ,so chances of eating outside also increases as infection rate with hepatitis E virus among young children in India. J Hepatol.
1997;26(6):1425-6.
shown by other studies [22,23,26].
[25] Parana R, Cotrim HP, Cortey-Boennec ML, Trepo C, Lyra L. Prevalence of
Hepatitis E virus IgG antibodies in patients from a referral unit of liver diseases
CONCLUSION in Salvador, Brazil. Am J Trop Med Hyg. 1997;57:60-1.
1.Even though sample size is less but, it will definitely act as the [26] Rao P, Shenoy SM, Baliga S and Joon A .Prevalence of HAV and HEV in the
patients presenting with acute viral hepatitis. BMC Infectious Diseases. 2012,
eye opener because at present, there is no system available which
12(Suppl 1):1471-2334-12-S1-P30.
can track the quality of water supplied to the population. The
situation is just like a tip of iceberg.
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 Deepak Arora et al., Water Borne Hepatitis A and Hepatitis E in Malwa Region of Punjab, India www.jcdr.net

PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of Microbiology, G.G.S Medical College, Faridkot Punjab, India.
2. Professor & Head, Department of Microbiology, G.G.S Medical College, Faridkot Punjab, India.
3. Controller of Examination, BFUHS, Faridkot Punjab, India.
4. Associate Professor, Department of Microbiology, G.G.S Medical College, Faridkot Punjab, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Deepak Arora,
Associate Professor, Department of Microbiology, G.G.S Medical College, Faridkot Punjab, India.
Mobile: 09781566786, Email: drdeepakarora78@gmail.com Date of Submission: Feb 27, 2013
Financial OR OTHER COMPETING INTERESTS: None. Date of Peer Review: May 07, 2013
Date of Acceptance: Sep 11, 2013
Date of Publishing: Oct 05, 2013

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