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Communicable Diseases Watch Sep 23 - Oct 6 2018 WEEKS 39 - 40 VOL 15 ISSUE NO 20 EDITORIAL BOARD Editor-in-Chief Dr SK Chuang Members Dr Yonnie Lam / Dr Albert Au / Dr TY Wong / Dr Gladys Yeung / Dr Philip Wong / KK So / Sheree Chong / Doris Choi / Chloe Poon Production Assistant Yoyo Chu. This biweekly publication is produced by the Centre for Health Protection (CHP) of the Department of Health, 147C,Argyle Street, Kowloon, Hong Kong ISSN 1818-4111 All rights reserved Please send enquiries to [email protected]. FEATURE IN FOCUS Review of hepatitis E infection in Hong Kong Reported by Dr Jess YIM, Medical and Health Officer, Enteric and Vector-borne Disease Office, Surveillance and Epidemiology Branch, CHP. Facts on hepatitis E Hepatitis E is a liver disease caused by infection of the hepatitis E virus (HEV). HEV is a single-stranded RNA virus and has at least four genotypes, namely, genotypes 1 to 4. While genotypes 1 and 2 viruses have only been found in humans, genotypes 3 and 4 viruses circulate in several animals (including pigs, wild boar and deer) and occasionally infect humans1. Foodborne transmission of HEV can result from ingestion of undercooked meat or meat products produced from infected animals. For instance, HEV has been detected in pig livers. Besides, HEV is also transmitted through the faecal-oral route due to faecal contamination of drinking water. Other rare transmission routes identified include transfusion of infected blood products, organ transplant and vertical transmission from a pregnant woman to her foetus. The incubation period following exposure to HEV ranges from two to ten weeks, with a mean of five to six weeks1. The symptoms of HEV infection typically last between one and six weeks and are often indistinguishable from those of other acute liver diseases. Children often have either no symptoms or only a mild illness without jaundice that goes undiagnosed. Typical signs and symptoms of HEV infection include fever, reduced appetite, nausea, vomiting, abdominal pain, skin itchiness, skin rash, joint pain, jaundice, dark urine, pale stool, and an enlarged and tender liver. In rare cases, acute HEV infection results in fulminant hepatitis which can be fatal. Fulminant hepatitis occurs more frequently in pregnant women with HEV infection. Those in the second or third trimester are at an increased risk of acute liver failure, fetal loss and mortality. Case fatality rates as high as 20% to 25% have been reported among pregnant women in their third trimester1. Cases of chronic HEV infection have been reported in immunosuppressed people, particularly organ transplant recipients on immunosuppressive drugs. According to the World Health Organization, there are an estimated 20 million HEV infections worldwide, leading to an estimated 3.3 million symptomatic cases of HEV infection every year1. HEV infections are most common in East and South Asia. In Hong Kong, viral hepatitis (including acute hepatitis caused by hepatitis E) is a notifiable disease under the Prevention and Control of Disease Ordinance (Cap 599). From 2013 to 2018 (as of September 30), the Centre for Health Protection (CHP) of the Department of Health recorded a total of 461 confirmed cases of acute hepatitis caused by HEV. From 2013 to 2017, the annual number of cases ranged from 64 to 96 (Figure 1). In 2018, 34 cases Figure 1 - Annual number of acute hepatitis E cases in Hong Kong, 2013-2018 (*provisional figure as of September 30, 2018). have been recorded as of September 30. The 461 cases involved 288 males and 173 females, with ages ranging from 15 to 96 years (median: 56 years). The majority of patients were Chinese (420, 91.1%). Most cases (377, 81.8%) were locally acquired infections, while 29 cases (6.3%) were imported infections.The places of infection outside Hong Kong included Mainland China (20 cases), India (two cases), Indonesia COMMUNICABLE DISEASES WATCH 85 Sep 23 - Oct 6 2018 WEEKS 39 - 40 VOL 15 ISSUE NO 20 (one case), Korea (one case), Nepal (one case), Pakistan (one case), the Philippines (one case), Thailand (one case) and the United Kingdom (one case). The places of infection of the remaining 55 cases (11.9%) could not be determined as the patients had stayed both in and outside Hong Kong during the incubation period. From 2013 to 2017, more cases were recorded from January to April (Figure 2). The most common clinical presentation was tea-coloured urine (348, 75.5%), followed by jaundice (313, 67.9%), anorexia (241, 52.3%), nausea (159, 34.5%) and abdominal pain (156, 33.8%). Three hundred and ninety-nine patients (86.6%) required hospitalisation with a median length of stay of seven days. Fifteen (3.3%) patients developed liver failure. A total of nine fatal cases were recorded, giving a case Figure 2 - Seasonality of hepatitis E infection in Hong Kong, fatality rate of 2.0%.The ages of the deceased patients ranged from 49 2013-2017. to 81 years (median: 74 years). Among the fatal cases, eight were known to have underlying illnesses. One case was a pregnant woman in her third trimester of gestation at the time of diagnosis. She recovered uneventfully without developing any complications. Epidemiological investigations revealed that 252 (54.7%) and 132 (28.6%) patients reported consumption of pork and pig liver during the incubation period, respectively. Among those who consumed pig liver, 19 and seven consumed it with hotpot and congee, respectively. Besides, 133 (28.9%) patients reported consumption of shellfish during the incubation period. The commonest shellfish consumed was oyster (68, 51.1%), followed by clams (62, 46.6%) and mussels (22, 16.5%).Among those who had consumed oyster, nine reported consuming it raw. One case recorded in August 2018 acquired the infection from organ transplant. The incident involved a single deceased donor whose organs (heart, lungs, liver and two kidneys) had been donated to five recipients in February 2018. One of the recipients, the liver transplant recipient, was found to have deranged liver function during a follow-up in June and his serum was subsequently tested positive for anti-HEV immunoglobulin M (IgM). Epidemiological investigations revealed that the patient likely acquired HEV infection through liver transplant. Subsequent laboratory investigations confirmed that the donor and the other four recipients also had HEV infection. Among the five recipients, four remained in stable condition all along and had recovered from the infection while the lung recipient had passed away due to other causes. Vaccine for hepatitis E is not available in Hong Kong. The mainstay of prevention of hepatitis E is maintaining good personal hygiene, especially hand hygiene, and adherence to food and water safety. The risk of hepatitis E infection can be reduced by adopting the Five Keys to Food Safety in handling food, i.e. Choose (Choose safe raw materials); Clean (Keep hands and utensils clean); Separate (Separate raw and cooked food); Cook (Cook thoroughly); and Safe Temperature (Keep food at safe temperature) to prevent foodborne diseases, for example: ✦ Maintain hygienic practices such as hand washing with soap and water, particularly before handling food or eating, and after using the toilet or handling vomitus or faecal matter; ✦ Obtain drinking water from the mains and boil it before consumption; ✦ Avoid consumption of water and ice of unknown purity; ✦ Purchase fresh food from reliable sources. Do not patronise illegal hawkers; ✦ Clean and wash food thoroughly; ✦ Cook food, especially seafood (e.g. shellfish), pork and pig offal, thoroughly before consumption. Avoid raw food or undercooked food; and ✦ Use separate chopsticks for handling raw food and cooked food when having hotpot. References 1World Health Organization (2018) Hepatitis E. Available at: http://www.who.int/news-room/fact-sheets/detail/hepatitis-e, accessed on October 7, 2018. COMMUNICABLE DISEASES WATCH 86 Sep 23 - Oct 6 2018 WEEKS 39 - 40 VOL 15 ISSUE NO 20 Review of Leptospirosis in Hong Kong, 2008-2018 Reported by Dr Eric LAM, Medical and Health Officer, Communicable Disease Surveillance and Intelligence Office, Surveillance and Epidemiology Branch, CHP. Leptospirosis is a zoonotic disease, caused by bacteria of genus Leptospira, which occurs most prevalently in tropical and subtropical regions. The disease can be transmitted to humans through contact of cuts and abrasions of the skin or mucous membranes of the eyes, nose and mouth with water or soil contaminated with the urine or other body fluids (except saliva) of infected animals. Consumption of contaminated food or water is also a possible route of transmission. Human-to-human transmission is very rare. Although many wild and domestic mammals can harbour Leptospira, rodents are considered to be the major source of human infection. The disease is often associated with outdoor water sports such as swimming, wading, kayaking, and rafting in contaminated lakes and rivers. In addition, some occupations pose an increased risk of exposure to Leptospira, such as farmers, veterinarians, sewer workers, fish workers and slaughterhouse workers, etc. Outbreaks of leptospirosis have been reported in some countries following natural disasters such as flooding, when people had a higher chance of exposure to contaminated water. The incubation period of leptospirosis is usually five to 14 days, with a range of two to 30 days. Infection with Leptospira can cause mild and non-specific symptoms such as fever, headache, chills, myalgia, abdominal pain, diarrhoea and vomiting. Leptospirosis can be treated with antibiotics. If untreated, the disease could develop into more severe conditions including acute liver and kidney failure with a case fatality rate of 5% to 15%. No human vaccine is currently available in Hong Kong. Leptospirosis has been a notifiable infectious disease in Hong Kong since July 14, 2008 while it was a voluntarily reportable disease before. Since the disease was made notifiable, up until September 30, 2018, the Centre for Health Protection of the Department of Health has recorded a total of 50 cases of leptospirosis (Figure 1).
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