Seroprevalence of Hepatitis E Virus Among Injection Drug Users and Non-Injection Drug Users in Hamadan, West of Iran

Fariba Keramat; Mojgan Mamani; Mahdi Samadi; Somaieh Mohammadnezhad; Peyman Eini; Abbas Moradi

doi:10.17795/ajcmi-22343

Seroprevalence of Hepatitis E Virus Among Injection Drug Users and Non-Injection Drug Users in Hamadan, West of Iran

Fariba Keramat ¹ , Mojgan Mamani ^{1 , *} , Mahdi Samadi ² , Somaieh Mohammadnezhad ³ , Peyman Eini ¹ and Abbas Moradi ⁴

Authors Information

¹ Brucellosis Research Center, Farshchian Hospital, Hamadan University of Medical Sciences, Hamadan, IR Iran

² Department of Psychology, Farshchian Hospital, Hamadan University of Medical Sciences, Hamadan, IR Iran

³ School of Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran

⁴ Department of Community Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, IR Iran

Article Notes and Dates

Avicenna Journal of Clinical Microbiology and Infection: October 2014, 1 (3); e22343.Published Online: October 12, 2014

Article Type: Research Article; Received : July 27, 2014; Revised : August 26, 2014; Accepted : September 21, 2014
DOI: http://dx.doi.org/10.17795/ajcmi-22343

To Cite : Keramat F, Mamani M, Samadi M, Mohammadnezhad S, Eini P, et al. Seroprevalence of Hepatitis E Virus Among Injection Drug Users and Non-Injection Drug Users in Hamadan, West of Iran, Avicenna J Clin Microb Infec. 2014 ;1(3):e22343. doi: 10.17795/ajcmi-22343.

Abstract

Copyright: Copyright © 0, Avicenna Journal of Clinical Microbiology and Infection. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

Hepatitis E virus (HEV) infection is a self-limited hepatitis and the most common cause of acute adult hepatitis in Asia, Africa, the Mediterranean region, Mexico and South America. In these areas, poor individual and public sanitations may lead to fecal-oral transmission of HEV and consequently large outbreaks may occur through contamination of water and foods (1-3). Young adults and middle-aged populations are more likely to be infected than other age groups (4). Several reports from Iran indicated that seroprevalence of HEV was more than 5% in population-based studies (5). Therefore, Iran is classified as an endemic area for HEV infection. The prevalence of HEV infection has been reported about 7% in center and north-west of Iran (Tehran and Tabriz) and 11% in southwest of Iran (Khuzestan) among blood donors (6-8). Hamadan is located in the west of Iran near the epidemic HEV region of Kermanshah province. A previous report in Hamadan province (Nahavand city) showed a rate of 9.3% for the seroprevalence of HEV (9). Other studies reported that percutaneous and blood transfusion transmission should be considered as possible routes of HEV infection (10-13). However, another study did not support this hypothesis (14). In addition, transmission of HEV infection from prenatal transmission was reported in some studies (15-17). Some studies in Iran indicated a higher transmission rate of HEV infection among injection drug users (IDUs) and hemodialysis patients than the general population (18-23).

2. Objectives

3. Patients and Methods

A cross-sectional study was conducted on injection drug users in Farshchian Hospital, Hamadan, Iran between March 2011 and March 2012. In this study, 131 IDUs referred to the Farshchian hospital and 131 non-IDU healthy visitors were selected and enrolled. Prior to enrollment, the purpose of the study was explained to all participants and a writing informed consent was obtained. A total of 262 subjects were enrolled in the study. A 3-mL blood sample was drawn from each subject. Serum was separated by centrifugation and stored at -20°C. Specific IgG antibody for HEV (anti-HEV) was measured using a third generation enzyme immunoassay (EIA, DiaPro, Milan, Italy) in Farshchian Laboratory. In addition, demographic data such as age, gender, education, location and duration of injection drug used (in IDUs group) were collected from each subject using a questionnaire. Data was compared between the two groups by T-test and Chi-square test using SPSS software (SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). P value less than 0.05 was considered as statistically significant.

4. Results

In this study, 131 IDUs referred to the Farshchian Hospital with a mean age of 35.57 ± 8.13 (ranged 22-70) years, 130 males and one female, and 131 non-IDUs with a mean age of 31.57 ± 8.19 (ranged 20-45) years, 130 males and one female were enrolled (Table 1). In this study, the seroprevalence of hepatitis E virus among IDUs was 6.1%, and 1.5% among non-IDUs (Odds Ratio = 5.48; CI = 1/069-22/84), indicating that injection drug users were almost five and a half times more than non-IDUs at risk of HEV infection (Table 2). There was no statistically significant difference between the two groups in different age groups as shown in Table 2 (P = 0.79).

Of the study population, 94 IDUs (71.76%) lived in urban area, as well as 94 (71.76%) of non-IDU subjects. Moreover, 62 (47.33%) IDUs had education lower than high-school diploma, but 54 (41.22%) non-IDU subjects had education lower than high-school diploma; however, there was no statistically significant difference (Table 1). There was no significant association between the seroprevalence of hepatitis E virus and location of the two groups (P = 0.19), and duration of injection among IDUs (P = 0.38).

Table 1. Comparison of Demographic Characteristics of Injection Drug Users (IDUs) and Non-Injection Drug User Groups^a,b

Variable	Group		P Value
Variable	IDUs (n = 131)	Non-IDU (n = 131)	P Value
Age, y	35.57 ± 8.13	31.57 ± 8.19	< 0.001
Gender
Male	130	130
Female	1	1
Residency			0.19
Urban area	94 (71.76)	94 (71.76)
Rural area	37 (28.24)	37 (28.24)
Education			0.46
Illiterate	7 (5.34)	0 (0)
Less than high-school diploma	62 (47.33)	54 (41.22)
High-school diploma or more	62 (47.33)	77 (58.78)

^aAbbreviations: IDU, Injection Drug User.

^bData are presented as Mean ± SD or No. (%).

Table 2. Comparison of Seroprevalence of Anti-HEV Among Injection Drug Users (IDUs) and Non-IDU Groups in different Age Groups^a,b

	IDUs Group		Non-IDU Group		P Value
	Anti-HEV Serology		Anti-HEV Serology
	Positive	Negative	Positive	Negative
Age group, y					0.79
20-29	4 (12)	27 (88)	1 (1.6)	63 (98.4)
30-39	3 (5)	57 (95)	0	36 (100)
40-49	1 (3.4)	28 (96.6)	1 (3.3)	30 (96.7)
50-59	0	10 (100)	0	0
≥ 60	0	1 (100)	0	0
Total^c	8 (6.1)	123 (93.3)	2 (1.52)	129 (98.48)	0.053

^aAbbreviations: IDU, Injection Drug User; HEV, Hepatitis E virus.

^bData are presented as No. (%).

^cOdds Ratio = 5.48; CI = 1.069- 22.84.

5. Discussion

The seroprevalence of HEV infection has been reported between 10-35% in developing countries and it is the most common cause of acute adult hepatitis in Asia (3-5). In the present study, the seroprevalence of hepatitis E virus among IDUs was 6.1% and 1.5% among non-IDU subjects. The prevalence among IDUs is similar to the prevalence of HEV infection in endemic area such as Iran (5). In this study, there was no statistically significant difference between the two groups in different age groups (P = 0.79), which is similar to Clemente-Casares’s study (24). Although, the association between age and anti-HEV seropositivity can reflect the link between duration of exposure and infection. However, in this study, the seroprevalence of HEV was zero in the 50-70 year age groups. In other studies, seroprevalence of HEV in general populations were 3.8% in Isfahan (25), 7.2% in Mazandaran (26) and 9.3% Nahavand (9). In addition, some reports from different provinces of Iran revealed anti-HEV seroprevalence rates of 7.8% in Tabriz (6), 7.8% in Tehran (8), 11.5% in Khozestan (7), and 12.9% in Hamadan (27) among blood donors (Table 3).

Table 3. Comparison of Seroprevalence of HEV Among Iranian Population According to Different Studies in Iran

Studies In Iran	Location	Date	Study Population	Seropositivity Anti-HEV, %
Present study	Hamadan	2011-2012	IDUs and non-IDU persons	6.1 and 1.5
Alavi et al. (20)	Ahvaz	2005-2006	IDUs and Inhalant drug users	22.8 in IDUs and 7.9 in Inhalant DUs
Rezazadeh et al. (27)	Hamadan	2005	Blood donors	12.9
Aminiafshar et al. (8)	Tehran	2004	Blood donors	7.8
Taremi et al. (6)	Tabriz	2007	Blood donors	7.8
Assarezadegan et al. (7)	Khozestan	2008	Blood donors	11.5
Saffar et al. (26)	Mazandaran	2004	General population	1.1 under 10 years old and 7.2 in 20-25 years age group
Ataei et al. (25)	Isfahan	2007	General population	3.8
Taremi et al. (9)	Nahavan	2003	General population	9.3
Taremi et al. (22)	Tabriz	2004	Hemodialysis patients	7.4

In Alavi’s study (20), seroprevalence of HEV in IDUs was reported as 22.8% and 7.9% in inhalant drug users, which was higher than the results of our study, in which the seroprevalence of hepatitis E virus among IDUs and non-IDU subjects were 6.1% and 1.5%, respectively. Moreover, other studies reported higher seroprevalence rates of HEV in IDUs group than the present study (13, 20). These differences could be due to sharing syringes, environmental and socioeconomic variations as well as differences in level of hygiene, safe water sources and sewage disposal systems in these studied populations. Seroprevalence rates of HEV among blood donors were 1.2%, 16.8% and 27% in the USA, Germany and the Netherlands, respectively (28-30); however, Iran is in an endemic area with a rate of more than 5% regarding the seroprevalence of HEV (5, 7-9). The most common transmission route of HEV infection is fecal-oral through contaminated foods and water; thus, high sanitation, public health and personal hygiene can prevent transmission of HEV infection in endemic areas (1-3). In the present study, the seroprevalence of hepatitis E virus among IDUs group was 6.1%, and 1.5% among non-IDU group (Odds Ratio = 5.48; CI = 1/069-22/84), indicating that injection drug users were almost five and a half times more than non-IDUs at risk of HEV infection. Moreover, in the first epidemic outbreak of HEV infection in 1991 in Kermanshah, Iran, 18% mortality rate, 4% spontaneous abortions, 11% stillbirths, and 21% preterm labors in pregnant women were reported (5, 17). It seems that blood transmission might be another route of transmission for HEV infection. In conclusion, the seroprevalence of hepatitis E virus among IDUs was higher than non-IDU healthy persons, which might be due to possible percutaneous or blood transmission of HEV among IDUs. Therefore, blood transmission for HEV infection should be considered especially in high-risk groups such as IDUs and hemodialysis patients in endemic areas.

Acknowledgements

Footnotes

References

1. Teshale EH, Hu DJ, Holmberg SD. The two faces of hepatitis E virus. Clin Infect Dis. 2010; 51(3): 328-34[DOI][PubMed]
2. Purcell RH, Emerson SU. Principles and practice of infectious diseases. 2010; : 2117-20
3. Aggarwal R, Naik S. Epidemiology of hepatitis E: current status. J Gastroenterol Hepatol. 2009; 24(9): 1484-93[DOI][PubMed]
4. Aggarwal R, Krawczynski K. Hepatitis E: an overview and recent advances in clinical and laboratory research. J Gastroenterol Hepatol. 2000; 15(1): 9-20[PubMed]
5. Sepanlou S, Rezvan H, Amini-Kafiabad S, Dayhim M, Merat S. A Population-based Seroepidemiological Study on Hepatitis E Virus in Iran. Middle East J Dig Dis. 2010; 2(2): 97-103[PubMed]
6. Taremi M, Gachkar L, MahmoudArabi S, Kheradpezhouh M, Khoshbaten M. Prevalence of antibodies to hepatitis E virus among male blood donors in Tabriz, Islamic Republic of Iran. East Mediterr Health J. 2007; 13(1): 98-102[PubMed]
7. Assarehzadegan MA, Shakerinejad G, Amini A, Rezaee SA. Seroprevalence of hepatitis E virus in blood donors in Khuzestan Province, southwest Iran. Int J Infect Dis. 2008; 12(4): 387-90[DOI][PubMed]
8. Aminiafshar S, Alimagham M, Gachkar L, Yousefi F, Attarchi Z. Anti hepatitis E virus seropositivity in a group of blood donors. Iran J Public Health. 2004; 33(4): 53-6
9. Taremi M, Mohammad Alizadeh AH, Ardalan A, Ansari S, Zali MR. Seroprevalence of hepatitis E in Nahavand, Islamic Republic of Iran: a population-based study. East Mediterr Health J. 2008; 14(1): 157-62[PubMed]
10. Arankalle VA, Chobe LP. Retrospective analysis of blood transfusion recipients: evidence for post-transfusion hepatitis E. Vox Sang. 2000; 79(2): 72-4[PubMed]
11. Arankalle VA, Chobe LP. Hepatitis E virus: can it be transmitted parenterally? J Viral Hepat. 1999; 6(2): 161-4[PubMed]
12. Matsubayashi K, Nagaoka Y, Sakata H, Sato S, Fukai K, Kato T, et al. Transfusion-transmitted hepatitis E caused by apparently indigenous hepatitis E virus strain in Hokkaido, Japan. Transfusion. 2004; 44(6): 934-40[DOI][PubMed]
13. Christensen PB, Engle RE, Jacobsen SE, Krarup HB, Georgsen J, Purcell RH. High prevalence of hepatitis E antibodies among Danish prisoners and drug users. J Med Virol. 2002; 66(1): 49-55[PubMed]
14. Watson J, Sjogren MH. Schiff's diseases of the liver. 2011; : 880-90[DOI]
15. Ayoola EA, Want MA, Gadour MO, Al-Hazmi MH, Hamza MK. Hepatitis E virus infection in haemodialysis patients: a case-control study in Saudi Arabia. J Med Virol. 2002; 66(3): 329-34[PubMed]
16. Khuroo MS, Kamili S, Jameel S. Vertical transmission of hepatitis E virus. Lancet. 1995; 345(8956): 1025-6[PubMed]
17. Hatami H. Epidemic report of hepatitis E in Kermanshah. Nabz J. 1991; 9: 23-31
18. Trinta KS, Liberto MI, de Paula VS, Yoshida CF, Gaspar AM. Hepatitis E virus infection in selected Brazilian populations. Mem Inst Oswaldo Cruz. 2001; 96(1): 25-9[PubMed]
19. Psichogiou M, Vaindirli E, Tzala E, Voudiclari S, Boletis J, Vosnidis G, et al. Hepatitis E virus (HEV) infection in haemodialysis patients. The Multicentre Haemodialysis Cohort Study on Viral Hepatitis. Nephrol Dial Transplant. 1996; 11(6): 1093-5[PubMed]
20. Alavi S, Ahmadi F, Ghasemirad M. Seroepidemiological Study of Hepatitis E Virus in Drug Addicts in Ahwaz, Southern Iran: 2005-2006. Hepat Mon. 2008; 8(4): 263–6
21. Lee CK, Chau TN, Lim W, Tsoi WC, Lai ST, Lin CK. Prevention of transfusion-transmitted hepatitis E by donor-initiated self exclusion. Transfus Med. 2005; 15(2): 133-5[DOI][PubMed]
22. Taremi M, Khoshbaten M, Gachkar L, EhsaniArdakani M, Zali M. Hepatitis E virus infection in hemodialysis patients: a seroepidemiological survey in Iran. BMC Infect Dis. 2005; 5: 36[DOI][PubMed]
23. Morteza P, AbdolReza S, Hamid N. Hepatitis E virus infection in hemodialysis patients: a seroepidemiological survey in Jahrom, Southern Iran. Hepat Mon. 2009; 9(3): 232-5
24. Clemente-Casares P, Pina S, Buti M, Jardi R, MartIn M, Bofill-Mas S, et al. Hepatitis E virus epidemiology in industrialized countries. Emerg Infect Dis. 2003; 9(4): 448-54[DOI][PubMed]
25. Ataei B, Nokhodian Z, Javadi AA, Kassaian N, Shoaei P, Farajzadegan Z, et al. Hepatitis E virus in Isfahan Province: a population-based study. Int J Infect Dis. 2009; 13(1): 67-71[DOI][PubMed]
26. Saffar MJ, Farhadi R, Ajami A, Khalilian AR, Babamahmodi F, Saffar H. Seroepidemiology of hepatitis E virus infection in 2-25-year-olds in Sari district, Islamic Republic of Iran. East Mediterr Health J. 2009; 15(1): 136-42[PubMed]
27. Hajiloii Rezazadeh M, Gachkar L, Yadegari D, Mani Kashani K, Naghdi M. Survey of seroprevalence of hepatitis E virus among blood donors to Hamadan Blood Transfusion Organization in 2005. Iran J Clin Infect Dis. 2006; 34(11): 13-8
28. Mast EE, Kuramoto IK, Favorov MO, Schoening VR, Burkholder BT, Shapiro CN, et al. Prevalence of and risk factors for antibody to hepatitis E virus seroreactivity among blood donors in Northern California. J Infect Dis. 1997; 176(1): 34-40[PubMed]
29. Faber MS, Wenzel JJ, Jilg W, Thamm M, Hohle M, Stark K. Hepatitis E virus seroprevalence among adults, Germany. Emerg Infect Dis. 2012; 18(10): 1654-7[DOI][PubMed]
30. Slot E, Hogema BM, Riezebos-Brilman A, Kok TM, Molier M, Zaaijer HL. Silent hepatitis E virus infection in Dutch blood donors, 2011 to 2012. Euro Surveill. 2013; 18(31)[PubMed]

Avicenna Journal of Clinical Microbiology and Infection

Published by: Kowsar

Seroprevalence of Hepatitis E Virus Among Injection Drug Users and Non-Injection Drug Users in Hamadan, West of Iran

Abstract

1. Background

2. Objectives

3. Patients and Methods

4. Results

5. Discussion

Acknowledgements

Footnotes

References

Share This Article on: