This document summarizes research on hepatitis E virus (HEV) infection in Spain. It finds that HEV is prevalent in swine farms and slaughterhouses, as well as in some wild animals. HEV RNA has been detected in pork meat products, vegetables, and shellfish. About 4% of blood donors and 18% of swine workers in Spain have been found to be positive for anti-HEV IgG. The laboratory has confirmed 342 cases of HEV infection from 2006-2015, with most cases genotype 3. Ongoing actions include establishing HEV surveillance networks and conducting an HEV IgG serosurvey of the general population.

1. Viral Hepatitis Reference
and Research Laboratory
National Center of
Microbiology
Carlos III Health Institute
Ana Avellón
aavellon@isciii.es
HEV infection in Spain

2. SOURCES OF HEV INFECTION
• Prevalence in swine farms and in slaughterhouses
• Prevalence in wild animals (boar, deer) and other domestic animals
• Detection of HEV RNA in food: pork meat products, vegetables, shellfish
• Prevalence of positive HEV RNA blood donors
HEV DIAGNOSTIC TECHNIQUES
• Comparative evaluation of sensitivity of commercial antibody test
HUMAN HEV INFECTION
• Prevalence of anti HEV IgG in general and specific population
• Human hepatitis cases
• Molecular epidemiology
HEV infection in Spain
Ana Avellón
aavellon@isciii.es

3. SOURCES OF HEV INFECTION
• Prevalence in swine farms and in slaughterhouses
HEV infection in Spain
23%
38%
16-59%
2,4-13%
11,5%
At slaughter age
25%55%
48%
37%
28%4,8%
21,4%
14%
61% (adults)
18%
71%
18,8%
Gtp 3 /3fHEV anti IgG + (%) HEV RNA+ (%)
FARMS
SLAUGHTERHOUSES Feces: 22% Liver: 3,9% Meat: 1,9%
Fomites: gloves-hands: 25-28% surface swabs: 40%
Di Bartolo I, et al, 2010
Ana Avellón
aavellon@isciii.es
Cataluña 2000 (Pina S et al 2000); Valencia 2006 (Fernández-Barredo et
al 2006); Cataluña 2006 (de Deus N et al 2007); Valencia 2007
(Fernández Barredo S 2007); Cataluña 2007 (Seminati C et al 2008);
Cataluña, 1985-1997 (Casas M et al 2009); Cataluña, 2009 (Peralta B et
al 2009); Cataluña 2011 (Casas M et al 2011); several 2011 (Jimenez de
Oya N et al 2011); Huesca, Zaragoza, Teruel, Salamanca, Jaén, Lérida;
Barcelona 2000 (Pina S et al 1 998)

4. HEV infection in Spain
BOAR 26% 19,6% (Gtp 3)
SOURCES OF HEV INFECTION
• Prevalence in wild animals (boar, deer) and other domestic animals
Anti HEV IgG HEV RNA
RED DEER 10,4% 13,6% (Gtp 3)
IBERIC PIG 43% 0%
RODENTS 0%
COW 0%
GOAT 0,6%
SHEEP 2%
CAT 11%
Kukielka D et al 2015
Boadella M et al 2010;
Boadella M et al 2012;
De Deus N et al 2008;
Peralta B et al 2009;Ana Avellón
aavellon@isciii.es
n=54
n=1357
n=1143
n=1170
n=166
n=1279
n=968 n=81
n=150
n = 287 n=287

5. HEV infection in Spain
MEAT PROCESSING POINTS
(SAUSSAGE)
6%
SOURCES OF HEV INFECTION
• Detection of HEV RNA in food: pork meat products, vegetables, shellfish
Di Bartolo I, et al, 2010
MEAT SALE POINTS
(SAUSSAGE)
6%
FRESH STRAWBERRY 0%
Rodriguez-Lazaro et al
Spanish virology
Congress 2013
FROZEN STRAWBERRY 2,7%
LETTUCE (FARM MARKET) 3,4%
LETTUCE (SUPERMARKET) 0%
SELLFISH (MYTILUS GALLOPROVINCIALIS) 6%
SELLFISH (MYTILUS EDULIS) 0%
Ana Avellón
aavellon@isciii.es
n=93
n=102
n=37
n=37
n=119
n=51
n=119
n=51

6. HEV infection in Spain
n=9998
BLOOD DONORS 0,03%
SOURCES OF HEV INFECTION
• Prevalence of positive HEV RNA blood donors
Viral load of positive cases (n=3):
• 250 UI/ml
• 564 UI/ml
• 2755 UI/ml; Gtp 3
Sauleda et al 2015
Ana Avellón
aavellon@isciii.es

7. HEV infection in Spain
HEV DIAGNOSTIC TECHNIQUES
• Antibody detection: evaluation of sensitivity
Avellon et al 2015
 Specific sample panel: IgM evaluation: 13 samples RNA+
IgG evaluation: 10 follow up samples of patients previously RNA+
 Serially diluted 1:10 (high positive), 1:100 (medium positive), 1:1000 (low positive) and 1:10000 (very low positive)
 Sensitivity= number of diluted samples positive or grey-zone (GZ) from the total
Ana Avellón
aavellon@isciii.es
*
* higher
P<0,005
*
equal
P>0,005

8. HEV infection in Spain
HUMAN HEV INFECTION
• Prevalence of anti HEV IgG in general and specific
population
5%
13-15Y
1*%
0,6%
Pregnant
7,3*%
0,8%
4% Blood donors
18% swine workers
There are no data of general whole country
sero-survey
Fogeda et al 2012
*General population Madrid (urban) (n=2305, 2-60Y)
Ana Avellón
aavellon@isciii.es
Regional sero-survey: youngs, blood donors,
pregnant women, swine workers
Regional sero-survey: general population*
Madrid and Catalonia
*General population Catalonia (urban and rural)
(n=1280, 15-74Y)
Buti et al 2006

9. HEV infection in Spain
n % anti HEV IgG +
Liver transplantation (n=332)
7,4% (without cirrhosis)
32,1% (with cirrhosis)
Kidney transplantation (n=296) 3,7%
Ana Avellón
aavellon@isciii.es
n Anti HEV IgG + RNA +
HIV + (n=238) 9% 1.2%
HIV + (n=894) 9,8% 0.5%
HIV + (n=448) 10,4% Not done
HIV+hepatitis of unknown origin
(n=31) 29% 3.2%
HUMAN HEV INFECTION
• Prevalence of anti HEV IgG in immunocompromised
TRANSPLANTATION
Jardi R et al 2012; Merchante N et al 2015; Riveiro-Barciela M 2014; Rivero-
Juarez A et al 2015; Mateos-Lindemann ML 2014;
HIV+

10. HEV infection in Spain
HUMAN HEV INFECTION
• Human hepatitis cases
DIAGNOSIS OF HEV INFECTION IN SPAIN
Ana Avellón
aavellon@isciii.es
• Screening of HEV infection is not usually performed at Spanish
hospital laboratories as routine test.
• The Viral Hepatitis Laboratory of the National Center of Microbiology
performs screening or confirmation of HEV infection for about 80% of
the country:
 From 2006 to 2015 a total of 342 cases were confirmed in
our laboratory as HEV infection cases (IgM and/or RNA+).
 4 patients were diagnosed as chronic infection and followed
up:
 Case 1: 6-year follow up
 Case 2: 2-year follow up
 Case 3: 2-year follow up
 Case 4: 2-year follow up

11. HEV infection in Spain
HUMAN HEV INFECTION
• Human hepatitis cases
NATIONAL CENTER OF MICROBIOLOGY
HEV ACTIVITY 2006-2015
Percentage of RNA positive samples
Ana Avellón
aavellon@isciii.es

12. HEV infection in Spain
HUMAN HEV INFECTION
• Human hepatitis cases
NATIONAL CENTER OF MICROBIOLOGY
HEV ACTIVITY 2006-2015
Geographical distribution
Age/ gender distribution
Average age: 50,3 Y
Male>>FemaleAna Avellón
aavellon@isciii.es
>10 cases
9-5 cases
>5 cases
0 cases

13. HEV infection in Spain
HUMAN HEV INFECTION
• Molecular epidemiology 2009-2015 n=91
3efg: 89,1%
Ana Avellón
aavellon@isciii.es Avellon et al in preparation
Monophyletic clusters
include different years for
both phylogenetic groups
Endemicity of both 3f
and 3abchij
3abchij: 10,9%
3f all
3c (n=3)
Other (n=7)
Monophyletic clusters not
geographically linked
Not associated to regional
food consumption

14. Viral Hepatitis Reference
and Research Laboratory
National Center of
Microbiology
Carlos III Health Institute
Ana Avellón
aavellon@isciii.es
Ongoing actions
(National Center of Microbiology)
• Recommendation to hospital laboratories:
Implementing screening HEV techniques
• Creation of a laboratory network for acute and chronic
HEV surveillance
• Molecular epidemiology surveillance
• HEV IgG serosurvey in general population
Future actions
• RNA in food: prevalence and molecular
epidemiology together with human cases.
(National Center of Epidemiology)
(ITACYL)

15. Viral Hepatitis Reference
and Research Laboratory
National Center of
Microbiology
Carlos III Health Institute
Ana Avellón
aavellon@isciii.es
Thank you for your attention