Hepatitis E in Israel: A nation-wide retrospective study

Table 1 Demographic characteristics of patients with acute hepatitis E vs non A-B-C-E acute hepatitis

	Acute hepatitis
	Non A-B-C-E hepatitis1	Hepatitis E1
	n = 583	n = 68
Gender
M	51.0%	58.8%
F	49.0%	41.1%
Age (yr)
0-16	29 (7.0)	1 (1.6)
17-40	206 (49.8)	40 (63.5)
41-60	132 (31.9)	13 (20.6)
> 60	47 (11.4)	9 (14.3)
Mean	38.96	39.38
Range	0-86	16-87

¹Comparing the groups above in parameters of gender and age reveled non-significant P-value.

Table 2 Clinical characteristics and potential risk factors for hepatitis E virus in patients with autochthonous and travel-related hepatitis E virus infection¹

Character		Autochthonous infection (n = 24)	Travel related (n = 26)	P value2
Demography	Gender: M	9 (37.5)	19 (73.1)	0.011
	Age: mean	41.58	37.38	0.358
	Range	15-69	20-74
Potential risk factors: food related	Eating non-kosher meat	8 (44.4)	22 (81.8)	0.014
	Eating raw meat	3 (14.3)	3 (13.0)	1.000
	Eating sea-food	2 (10.0)	6 (28.6)	0.238
	Consuming food/water from areas with poor sanitation	5 (26.3)	2 (12.5)	0.415
	Contact with animals3	8 (40.0)	8 (34.8)	0.724
Potential risk factors: others	Pregnancy	8 (53.3)	1 (14.3)	0.165
	Immunosuppression4	2 (8.3)	0 (0.0)	0.225
	Chronic liver disease	5 (20.8)	1 (3.8)	0.064
Clinical data	Time from onset of symptoms to diagnosis (d)	59.13 (n = 15)	25.21 (n = 19)	0.009
	Duration of symptoms (average weeks)	5.94 (n = 18)	4.08 (n = 20)	0.149
	Hospitalization (percent of patients)	68.2% (15/22)	20 (80.0)	0.345
	Duration of hospitalization (d)	22.15 (n = 13)	11.11 (n = 19)	0.195
Laboratory tests (average)	Bilirubin mg/dL (STD)	10.95 (10.84)	9.24 (5.93)	0.813
	GPT (ALT) U/L (STD)	1169.3 (1279.4)	2446.4 (1604.3)	0.043
	GOT U/L(STD)	1311.7 (2114.6)	1540.4 (1412.7)	0.436
	ALKP (STD)	566.5 (986.1)	205.6 (54.2)	0.673
	GGT U/L (STD)	470.0 (625.1)	232.2 (243.3)	0.730
	LDH U/L (STD)	2613 (6400.5)	1503 (1511.4)	0.440
	ALB g/dL (STD)	3.3 (0.94)	3.9 (0.42)	0.241
	INR (STD)	1.42 (0.8)	1.21 (0.2)	0.791
Outcome	Self-limited	20 (86.9)	26 (100)	0.085
	Fulminant hepatitis	3 (13)	0 (0)
	Chronic hepatitis	0 (0)	0 (0)

¹Excluding foreign workers with acute HEV;

²Mann-Whitney U Test, the χ² and the Fisher's exact tests were applied as detailed in the text (Methods);

³Contact with animals i.e.,: cats, dogs, chicken, parrots, goose, fish, guinea pigs, horses, and monkeys;

⁴Immune-suppressed patients: (1) Forty five years old woman treated with immune-suppressed therapy (Imuran) for autoimmune hepatitis; and (2) 19 years old woman treated with immune suppressed therapy after liver and kidney transplantation due to cystic fibrosis.

Table 3 Potential risk factors for travel-related hepatitis E virus infection

Risk factor	No. of patients (total: n = 26)	Incidence
Gender - M	19/26	73.07%
Pregnancy	1/7	14.28%
Chronic liver disease1	1/23	4.30%
Immunosuppression	0/23	0.00%
Eating non-kosher meat	18/22	81.81%
Eating raw meat	3/23	13.04%
Eating sea-food	6/21	28.57%
Drinking tap water abroad	8/23	34.78%
Consuming drinks with ice cubes	23/23	100.00%
Brushing teeth with tap water	20/23	86.95%
Eating fresh vegetables abroad	23/23	100.00%
Bath in fresh water	15/23	65.21%
Contact with animals2	8/23	34.78%
Contact with travelers having similar symptoms	2/25	8.00%

¹Chronic hepatitis B virus;

²Contact with animals i.e.,: cat, dog, chicken, parrot, goose, fish, guinea pig, horse and monkey.

Table 4 Summary of the published case reports of acute hepatitis E virus in Israeli patients

Ref.	Year of follow-up	No. of patients	Travel related/autochthonous	Diagnosis
Schwartz et al[20]	1992-1998	5	Travel related (all cases acquired in the Indian subcontinent)	Serology tests (Abbott Laboratories, Abbott Park, IL, United States)
Lachish et al[21]	1997-2012	19	Travel related (84% acquired in the Indian subcontinent)	Molecular or Serology (IgM/IgG) tests (EIA, Abbott Laboratories, Abbott Park, IL, United States)
Mechnik et al[19]	2001	1	Autochthonous	Molecular test (HEV-RNA pos. in serum sample)

HEV: Hepatitis E virus.

Table 5 Hepatitis E virus in industrialized countries¹

Ref.	No. of patients	Travel related	Autochthonous
Norder et al[27]	248	88.3%	11.7%
Romanò et al[14]	134	81.3%	18.7%
Ramalingam et al[28]	16	62.5%	37.5%
Israel (current paper)	68	44.0%2	41.0%
Drobeniuc et al[29]	26	42.0%	58.0%
Chalupa et al[13]	49	3.90%	96.1%
Mansuy et al[30]	62	3.20%	96.8%

¹A Literature review of the prevalence of HEV infection in industrialized countries[13,14,27-30];

²the rest 15% were foreign workers. HEV: Hepatitis E virus.