NJ Health Officials Investigating a Hepatitis E Outbreak Potentially Linked to Food

New Jersey Environmental Health officials are investigating an outbreak of Hepatitis E.  According to the report, one potential source may be undercooked pork.

Hepatitis E, an emerging threat in the industrialized world, has been more an issue in the developing world where it causes large outbreaks and presents a significant public-health problem. It is a non-enveloped virus (although it can be enveloped when found in the bloodstream).  "In endemic regions where most infections are waterborne the primary prevention strategy involves improving sanitation and drinking water facilities. It has been shown that failure to take action to sterilize drinking water during epidemics is associated with larger scale outbreaks. In areas where zoonotic transmission is predominant infection can be prevented by ensuring proper preparation of food products. Meat products, particularly pork and game, should be cooked thoroughly."

https://www.itv.com/news/channel/2023-05-28/environmental-health-investigating-after-hepatitis-e-cases-found
Environmental Health investigating small number of Hepatitis E cases in Jersey
Sunday 28 May 2023 at 3:17pm

Environmental Health says it is investigating a small number of Hepatitis E cases in Jersey.

The infections are thought to be from eating underdone pork, with Public Health urging people to cook white meat products all the way through.

The virus affects the liver and mostly causes mild symptoms that clear up within a month.

However, it can be more serious for those who are pregnant or have weakened immune systems.

Person-to-person transmission is rare but anyone feeling unwell with the following symptoms is asked to contact their GP:

• Mild flu-like symptoms
• Fatigue (extreme tiredness)
• Change in urine colour – dark or brown
• Abdominal pain
• Jaundice – yellowing of the skin or eyes
• Fever (high temperature)
• Loss of appetite
• Itching
• Nausea and vomiting (sickness)
• Aching joints and muscles
• Tingling, numbness and weakness in your arms and legs

Ther Adv Infect Dis. 2019 Jan-Dec; 6: 2049936119837162.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448100/
Published online 2019 Apr 3. doi: 10.1177/2049936119837162
PMCID: PMC6448100
PMID: 30984394

Hepatitis E: an underestimated emerging threat
Glynn W. Webb and Harry R. Dalton

Abstract

Hepatitis E virus (HEV) is the most common cause of viral hepatitis in the world. It is estimated that millions of people are infected every year, resulting in tens of thousands of deaths. However, these estimates do not include industrialized regions and are based on studies which employ assays now known to have inferior sensitivity. As such, this is likely to represent a massive underestimate of the true global burden of disease. In the developing world, HEV causes large outbreaks and presents a significant public-health problem. Until recently HEV was thought to be uncommon in industrialized countries, and of little relevance to clinicians in these settings. We now know that this is incorrect, and that HEV is actually very common in developed regions. HEV has proved difficult to study in vitro, with reliable models only recently becoming available. Our understanding of the lifecycle of HEV is therefore incomplete. Routes of transmission vary by genotype and location: endemic regions experience large waterborne epidemics, while sporadic cases in industrialized regions are zoonotic infections likely spread via the food chain. Both acute and chronic infection has been observed, and a wide range of extrahepatic manifestations have been reported. This includes neurological, haematological and renal conditions. As the complete clinical phenotype of HEV infection is yet to be characterized, a large proportion of cases go unrecognized or misdiagnosed. In many cases HEV infection does not feature in the differential diagnosis due to a lack of knowledge and awareness of the disease amongst clinicians. In combination, these factors have contributed to an underestimation of the threat posed by HEV. Improvements are required in terms of recognition and diagnosis of HEV infection if we are to understand the natural history of the disease, improve management and reduce the burden of disease around the world.

Selected sections

• HEV is an icosahedral, positive-strand RNA virus with a 7.2kb genome which contains three open reading frames (ORFs).29 These ORFs are translated into proteins responsible for RNA replication (ORF1), the viral capsid (ORF2) and viral particle secretion (ORF3).29 While ORF2 is the most well-studied of the HEV proteins, given its role as an antigen, the less well characterized ORF3 protein may play a key role in how HEV interacts with the host’s immune response.29 HEV has always been considered to be a nonenveloped virus. This was based on the appearance of virions isolated from faeces, which are naked. The same is true of virions found in bile. However, virions found in blood are wrapped in host-cell membranes.30 The process by which HEV particles become enveloped is not fully understood, but ORF3 appears to play a key role.31 It has been suggested that the detergent action of bile may degrade the envelope of HEV virions, resulting in the nonenveloped particles observed in bile and faeces.32 The quasi-enveloped HEV virions do not have any antigenic proteins on their surfaces, and as such are resistant to the neutralizing effects of anti-ORF2 antibodies.31 Interestingly, HEV isolated from serum is less infectious than that derived from faeces,33,34 and quasi-enveloped and nonenveloped virions have separate mechanisms for entering host cells.35 By adopting these two distinct forms, HEV is able both to evade an existing host’s immune response and maximize infectivity of new hosts.
• HEV1 and HEV2 are both restricted to humans and are primarily spread faecal–orally via contaminated water. In hyperendemic regions with poor sanitation there are regular, large-scale epidemics resulting in significant morbidity and mortality. This includes most of southern Asia,116–118 parts of Africa,119 rural areas of China, particularly the remote Xinjiang region,42,120 and several Latin American countries.121 However, outbreaks do not occur year on year in the same geographical region. Instead they appear periodically, despite the perennial presence of faecal contamination in the water supply. It has been suggested that this pattern is the result of a cohort effect.122 Anti-HEV IgG seropositivity increases by as much as five times following an epidemic. Over the following years there is a decline in IgG seroprevalence, until it reaches a critical level where it no longer offers herd immunity and another epidemic occurs.122
• The routes of transmission which are particular to industrialized regions add a further layer of complexity. Both HEV3 and HEV4 are zoonotic infections. The primary host species is thought to be pigs,143 but the virus has been found in a range of mammalian species including wild boar,144 deer145 and rabbits.146 Prevalence of antibodies to HEV exceeds 90% in UK pigs, and around 20% have evidence of active infection at the time of slaughter.147 The virus is apathogenic in pigs,148 making identification of infected animals difficult. It is thought that consumption of infected meat is the most important vector for HEV3 and HEV4, and the virus has been isolated from pork products at the point of sale.149 Other food stuffs such as shellfish150 and arable crops151–153 have also been implicated.
• Prevention - In endemic regions where most infections are waterborne the primary prevention strategy involves improving sanitation and drinking water facilities.187,188 It has been shown that failure to take action to sterilize drinking water during epidemics is associated with larger scale outbreaks.189 In areas where zoonotic transmission is predominant infection can be prevented by ensuring proper preparation of food products. Meat products, particularly pork and game, should be cooked thoroughly.190,191 At-risk individuals, such as pregnant women, those with pre-existing liver disease and immunosuppressed individuals should take particular care and avoid uncooked meat. Individuals who work with pigs, wild boar, game and their products should take steps to minimize direct contact and use protective equipment.192