Sero-prevalence and mother-to-infant transmission of hepatitis E virus among pregnant women in the United Arab Emirates

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Abstract

Objectives: (1) To study the prevalence of HEV infection in a cohort of pregnant women in the United Arab Emirates (UAE). (2) The rate of mother-to-infant transmission. Method: Sera of 469 pregnant women residing in the UAE was tested for anti-HEV with ELISA and for HEV-RNA by polymerase chain reaction (PCR). Neonatal cord-blood and infant blood was similarly tested for anti-HEV and HEV-RNA. Out of these 469 women, 33% were UAE nationals (Group A) and Egyptians (Group B), respectively, and 34% were from the Indian sub-continent (Group C). Results: Out of 469 mothers 93 (20%) were anti-HEV positive and 28 (30%) of these 93 were HEV-RNA positive and symptomatic with on-going infection. The prevalence of anti-HEV was significantly increased amongst Groups B and C (Group A:B, P<0.001; Group A:C, P<0.001). Twelve of these 28 symptomatic women developed acute hepatic disease and two died undelivered, thus, were excluded from further study. Six of the remaining 10 women had non-fulminant acute viral hepatitis and four developed fulminant hepatic failure, of which one died in the early post-partum period. The remaining 16 women had mild symptomatic disease with complete recovery as did the remaining nine women with acute illness. Of the 10 babies born to mothers with acute disease, two were pre-term, three had anicteric hepatitis and two babies were born with hypothermia and hypoglycaemia and died within 48 h. Noteworthy is the fact that, the 26 infants born to the 26 HEV-RNA positive mothers developed acute/on-going clinical infection and were HEV-RNA positive. Apart from the two early neonatal deaths, the remaining 24 infants had full recovery. No infant of the other mothers were symptomatic or had HEV-RNA. Thus, the mother-to-infant transmission was 100%. The remaining 65 sero-positive women remained asymptomatic with no evidence of clinical infection, continued to be HEV-RNA negative and delivered at term. Their infants had no evidence of infection and were sero-negative by 9 months of age, suggesting transplacental transmission of IgG antibodies. Conclusions: There is a high prevalence of anti-HEV among pregnant women residing in the UAE. Twelve of infected women developed fulminant/acute hepatitis resulting in three fatalities. Evidence suggests significant vertical transmission of HEV among HEV-RNA positive mothers with appreciable perinatal morbidity and mortality. Excluding mothers with acute hepatic disease, Breast-feeding appears to be safe in HEV sero-positive mothers.

Introduction

Hepatitis E virus (HEV) is responsible for water-borne epidemics of acute hepatitis in Asia, Africa and Mexico as well as sporadic disease [1], [2]. Some distinct epidemiologic features of HEV are faecal-oral route transmission presumably through contaminated water supplies, a high attack rate among adults 15–40 years age and high mortality (15–20%) among pregnant women [3], [4].

Although transmission of HEV occurs primarily by the feco-oral route, the parenteral route has also been implicated. There is evidence to suggest vertical transmission of HEV via the intra-uterine and perinatal routes [2].

There is limited information regarding (a) sero-prevalence of hepatitis E among parturient women residing in the United Arab Emirates (UAE), and the value of risk factors in its prevalence, (b) mother-to-infant transmission of hepatitis E virus from infected pregnant women and the natural history of such an acquired infection. Thus, we studied these parameters.

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Material and methods

Consecutive serum samples from 469 pregnant women in the third trimester of pregnancy attending the routine ante-natal clinics of the UAE University teaching hospitals (Al-Ain), were screened for sero-prevalence to HEV, or for the presence of HEV-RNA, after obtaining ethical committee approval and written consent for this study. No patient declined to give consent to this study. All positive assays were done in duplicate. In the UAE, the hospital population is representative of the UAE

Results

Serum samples from 469 pregnant women were analysed. Out of 469 mothers 93 (20%) were anti-HEV positive and 28 (30%) of these 93 were HEV-RNA positive and symptomatic whilst 65 (70%) remained asymtomatic with no evidence of clinical infection at any time. Twelve of these 28 symptomatic women developed acute hepatic disease and two died undelivered, thus, were excluded from further study. Of the 469 serum samples, 87 women (19%) were concomitantly positive for anti-HAV IgG; but negative for

Discussion

Our data suggests a high prevalence of anti-HEV (20%; P<0.001) among pregnant women residing in the UAE; a significant majority being from Egypt and the Indian sub-continent (Table 1). Out of the 28 mothers 21 with on-going hepatic disease are from the eastern states of India and Bangladesh, were there was a rescent escalation of acute hepatitis, although not declared as an epidemic zone. Out of the 12 women 10 who developed acute hepatitis were from the Indian sub-continent, which was

Conclusion

There is a high rate of anti-HEV antibody in pregnant women of Asian and Egyptian origin, residing in the UAE, with a significantly low prevalence among UAE women. Our data revealed that (1) mother-to-infant transmission of the hepatitis E virus, occurred frequently in symptomatic HEV-RNA positive mothers, which contributed to appreciable neonatal morbidity and mortality, (2) HEV infected pregnant women can develop fulminant hepatitis with resultant maternal mortality. This study supports the

Acknowledgements

The authors are deeply grateful to Dr. Ianny Cornfield Consultant Maternal and Foetal Medicine and Consultant Obstetrician and Gynaecologist King Faisal Specialist Hospital and Research Centre Riyadh, for critically appraising this paper and also to Mr. F.A. Khartabeal (Roche Diagnostics) for the gift of PCR kits, and Abbott Laboratories for providing their kits, equipment and technical assistance. We thank Ms. Maureen Dawood for excellent assistance and sister Cynthia and the staff of the

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