Hepatitis E infections have been increasing in Hungary since 2002. Between 2002-2007 there were 85 reported cases with an incidence rate of 0.14 per 100,000 people. Between 2008-2013 there were 378 reported cases with an incidence rate of 0.63 per 100,000 people. A total of 686 cases were reported between 2000-2014, with the highest rates among elderly individuals over 60 years old. Surveillance data is collected through mandatory reporting but additional information is needed on risk factors and routes of transmission to better understand the increasing trends.

1. Hepatitis E infections in Hungary,
2002-2014
Ágnes Fehér
National Centre for Epidemiology,
Hungary
1st ECDC Hepatitis E virus expert group meeting
Stockholm, 09-10 December 2015

2. Introduction
• Viral hepatitis has been notifiable in Hungary since 1950. The
basis of the reports was the clinical diagnosis.
• Serological tests for hepatitis diseases have been available
since mid 1980’s.
• Before 2002, acute viral hepatitis E was rarely diagnosed in
Hungary.
• Electronic surveillance system since 2003.

3. Background – hepatitis E surveillance in Hungary
Hepatitis E surveillanve is a part of the general communicable
diseases reporting system in Hungary.
• Reporting is compulsory – based on law.
- hepatitis E is on the list of compulsory notifiable
communicable diseases
• Reporters – laboratories / physicians
• Surveillance is aetiology-based
• Case-based: Physicians have to report data of each case within
24 hours of the diagnosis making
- on a paper-based standard case report form - until 2013
- on-line – since 2014.

4. • Comprehensive and nation-wide: all physicians (GPs,
specialists working in outpatient clinics, physicians working in
hospitals, at emergency service, pathologists, microbiologists)
should report suspected, probable or confirmed cases.
• Passive:
- There is no search for cases, only in the environment of a
known patient
• The EU case definition is used for classifying reported cases.
Main characteristics of hepatitis E surveillance
in Hungary

5. Hepatitis E surveillance in Hungary
Information from cases
- Case report form – online from the physicians
- Case investigation form
- PH workers ask the patients
- 3 different form (not uniform in all counties)
- Questinaire – pilot version (used not widely)
Laboratory results - from regional and central PH laboratories
and occasionally from private and university labs
There is only one central national database.
- nationwide electronic system for registering and analysing
the data of communicable diseases.

6. Analysis of hepatitis E surveillance data
Number of hepatitis E cases in Hungary, 2000-2014 (N=604)
0
20
40
60
80
100
120
140 casescases
years

7. 1 Jan 2000 – 5 Dec 2015
• 686 hepatitis E cases were reported
• Sporadic (6 cases to epidemics)
• Case classification:
– Possible : 3
– Probable: 7
– Confirmed: 641 (97,3%)
– No classification: 8
• 67,1% hospitalized
• 5 death (1-1 in 2003, 2008, 2010, 2011, 2012)
• Reported rates per million inhabitants
increased from 1 in 2002 to 9 in 2014.
Analysis of hepatitis E surveillance data

8. Number of HEV cases and incidence/100000
inhabitants by age-group, 2004-2014 (N=548)
0
2
4
6
8
10
12
14
0
20
40
60
80
100
120
140
160
0-10 10-19 20-29 30-39 40-49 50-59 60-69 70-
cases rate/100000
mean age: 54 years, median: 57 years, range: 4-90 years
cases
rate/100000

9. Hepatitis E cases by sex in Hungary, 2000-2014
62% was man, male/female = 1,39
0
10
20
30
40
50
60
70
80
2000. 2001. 2002. 2003. 2004. 2005. 2006. 2007. 2008. 2009. 2010. 2011. 2012. 2013. 2014.
Male Female
cases

10. The annual trend increased - incidence rate ratio=1.3; 95%
confidence interval: 1.2-3.4 (Poisson regression).
Distribution of hepatitis E cases and
twelf-month runing avarage,
Hungary, 01.01.2004-12.05.2015, N=659
0
2
4
6
8
10
12
14
16
18
20
Jan
Jun
Nov
Apr
Sep
Feb
Jul
Dec
May
Oct
Mar
Aug
Jan
Jun
Nov
Apr
Sep
Feb
Jul
Dec
May
Oct
Mar
Aug
Jan
Jun
Nov
Apr
Sep
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Cases
Month
Year

11. Study on trends of hepatitis E infections in
Hungary, 2002-2013
• Retrospective descirtivetopic analysis - of hepatitis E infections
• Calculate incidence rates using census data and analyzed by
time, place and person.
• Determine epidemiological features and trends of hepatitis E
infections
• Examine the changes in the occurrence and characteristics of
hepatitis E cases compaire data 2002-2007 and 2008-2013
• Case definition - persons with clinical diagnosis of acute
hepatitis and anti-HEV IgM positivity.

12. 2002-2007 2008-2013 2002-2013
Number of cases 85 378 463
Incidence rate /100.000 0,14 0,63 0,37
Hospitalization rate/% 96% 70% 83%
Death number 1 4 5
Letality rate/% 1,2 1,1 1,1
Male/% 60% 62% 62%
Male/Female 1,5 1,6 1,6
Avarage/Year 51 55 54
Mean/Year 56 57 57
Min-max/Year 9-84 5-89 5-89
2002-2013: 480 hepatitis E cases were reported, 7 imported cases excluded.
Result of retrospectiv study, 2002-2013

13. 0
5
10
15
20
25
30
35
40
45
50
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
2002-2007
2008-2013
Six-years cumulative number
of hepatitis E cases by month, 2002-2013 (N=463)

14. A second study was performed using new questionaires since
2012. This new reported form have been completted.
No significant relationships between the number of cases and
• food consumption/habits (sausage)
• comorbidity (liver cirrhosis, alcohol dis.)
• certain medical supply no
• possibility of zoonotic infections more data needed
• occupation more data needed
• education no
• distance to the lab no
Retrospectiv study II., 1 Jan 2012. – 30 Jun 2014.

15. Conclusions
• Last years the number of hepatitis E cases increased
continuously and significantly, although they were
unterreported.
• During 2003-2014 reported rates of hepatitis E cases
increased. The highest rates were among elderly.
• The epidemiological characteristics of hepatitis E cases has not
changed.

16. • We have to enhance the surveillance to collect information
on risk factors .
• Anti-HEV tests should be possible to use for each county
• Should be evaluate the laboratory capacity, know how many
lab can detect HEV and which method they use to diagnoses.
• Is this continously increase due to improving the diagnostic
capacity or is there any other cause?
Recommendations