Molecular Detection of Hepatitis E Virus in Sewage Samples

Human hepatitis E virus (HEV) is considered an emerging pathogen in industrialized countries. In Italy, the true burden of HEV infection is unknown. Molecular HEV screening of raw sewage samples from 11 wastewater treatment plants yielded 19 positives (16%; 18 genotype I, 1 genotype III) evenly distributed throughout Italy. Evidence that HEV could be establishing itself in our region is accumulating and may justify more active surveillance to monitor its spread.Hepatitis E is a self-limited, enterically transmitted acute viral hepatitis that occurs most frequently in epidemic outbreaks and often spreads by way of fecally contaminated drinking water (5, 20). Hepatitis E virus (HEV) infections are caused by a positive-sense, nonenveloped RNA virus of the Hepevirus genus. The four major genotypes (GI to GIV), all belonging to a single serotype, are known to infect humans. While GI and GII are restricted to humans, GIII and GIV are zoonotic and may infect animals (swine, chickens, deer, mongooses, and rabbits), as well as humans, in both industrialized and nonindustrialized countries (18, 19). GI consists of epidemic strains circulating in Africa and Asia. GII is found in Mexico and Africa. GIII is widely distributed, mainly—but not exclusively—in the United States, Europe, and Japan. GIV is present in Asia (16). An HEV strain belonging to a fifth genotype has been identified in birds (12).HEV is transmitted by the fecal-oral route. Large waterborne outbreaks with high attack rates among young adults have been described in regions characterized by poor sanitary conditions (22). Hepatitis E is responsible for over 50% of cases of acute viral hepatitis in countries where the disease is endemic (Central and Southeast Asia, North and West Africa, and Mexico), where seroprevalence rates range from 15% to 60% (8). North America and Europe have traditionally been considered areas where HEV is not endemic, with acute infection diagnosed rarely and largely confined to travelers returning from areas where the disease is endemic. The high rates of HEV IgG positivity reported in different studies, however, suggest that unrecognized or subclinical infection is common (8). In Europe, increasing numbers of HEV infections not associated with travel have been recently reported (15).HEV infection may vary in severity from asymptomatic to fulminant. Case fatality rates range between 0.5% and 4% overall but may reach 25% among pregnant women (1). In industrialized countries, the case fatality rate seems to be higher than in areas where the disease is endemic, since infection occurs more frequently in elderly people with chronic liver disease, a subgroup of patients with a case fatality rate approaching 70% (26).HEV, which is shed in the feces of infected individuals, has been detected in sewage samples, suggesting that HEV contamination of aquatic environments may also be present (2, 6, 7, 23). In Italy, the true burden of HEV infection is still unknown and there are no available studies on the presence of this virus in sewage. The prevalence of anti-HEV antibodies among healthy individuals has been found to be approximately 1% in the northern regions and up to 5% in the southern regions, including Sicily and Sardinia. Higher prevalence rates have been found among drug users (especially HIV-infected individuals), hemodialysis patients, and patients with chronic hepatitis C, suggesting that HEV may be transmitted not only by the fecal-oral route (the main mode of transmission) but also parenterally (27).The objective of the present study was to investigate the occurrence of HEV through the molecular screening of raw sewage samples collected from urban wastewater treatment plants (WTPs) in different regions of Italy.