Estimating the Burden of Maternal and Neonatal Deaths Associated With Jaundice in Bangladesh: Possible Role of Hepatitis E Infection

Emily S. Gurley, Amal K. Halder, Peter K. Streatfield, Hossain M. S. Sazzad, Tarique M. Nurul Huda, M. Jahangir Hossain, and Stephen P. Luby are with the International Centre for Diarrheal Diseases Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh. Steven P. Luby is also with Centers for Disease Control and Prevention (CDC), Atlanta, GA.
American Journal of Public Health (Impact Factor: 4.55). 10/2012; 102(12). DOI: 10.2105/AJPH.2012.300749
Source: PubMed


We estimated the population-based incidence of maternal and neonatal mortality associated with hepatitis E virus (HEV) in Bangladesh.

We analyzed verbal autopsy data from 4 population-based studies in Bangladesh to calculate the maternal and neonatal mortality ratios associated with jaundice during pregnancy. We then reviewed the published literature to estimate the proportion of maternal deaths associated with liver disease during pregnancy that were the result of HEV in hospitals.

We found that 19% to 25% of all maternal deaths and 7% to 13% of all neonatal deaths in Bangladesh were associated with jaundice in pregnant women. In the published literature, 58% of deaths in pregnant women with acute liver disease in hospitals were associated with HEV.

Jaundice is frequently associated with maternal and neonatal deaths in Bangladesh, and the published literature suggests that HEV may cause many of these deaths. HEV is preventable, and studies to estimate the burden of HEV in endemic countries are urgently needed.

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Available from: Peter K Streatfield, Sep 23, 2015
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    • "In a study from Bangladesh, it was observed that 19% to 25% of all maternal deaths and 7-13% of all neonatal deaths were associated with jaundice in pregnant women. Further, 58% of deaths in pregnant women with acute liver disease in hospitals were associated with HEV.[3] "
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    ABSTRACT: Background: Pregnant women are at increased risk of complications in hepatitis E virus (HEV) infection, with the risk increasing as the pregnancy progresses, often leading to fulminant hepatic failure and adverse fetal outcome. Aims: The primary objective of the following study is to evaluate the maternal and fetal complications of this infection and secondary aim is to compare the clinical features of hepatitis E in pregnant women to those in non-pregnant women. Subjects and Methods: This was a hospital based case-controls study, carried out from July 2008 to June 2010. Over a period of 2 years, cases were serologically confirmed pregnant women with hepatitis E, selected by screening in antenatal clinic. Controls were serologically confirmed non-pregnant women with hepatitis E, selected by screening in Medicine Outpatient Department. We studied 96 women with HEV infection, of which 52 were pregnant and 44 were non-pregnant. Clinical and laboratory profile of patients in both groups were studied. Patients were treated as per protocol and the outcome was studied in both groups. Pregnant women were followed-up for fetal and maternal outcome. We used t-test and z-test to compare normally distributed data and non-normally distributed data, respectively. Chi-square test was used to compare discrete values between groups. Results: Mean (standard deviation [SD]) age in pregnant patients was 24.1 (3.3) years while 32.6 (10.5) years in non-pregnant patients. 71.1% (37/52) of the patients were primigravida and 28.8% (15/52) patients were multigravida, by natural occurrence. Mean (SD) gestational age when infection occurred was 27.5 (7.2) weeks. Among pregnant women, 63.4% (33/52) were in 3 rd trimester. Jaundice 1-5 days before presentation was seen in 51.9% (27/52) pregnant and 44.2% (23/44) non-pregnant women. Myalgia/arthralgia, fever, nausea/vomiting, right upper quadrant pain, jaundice, dark urine, light-colored stools, pruritus, diarrhea, altered sensorium and hematemesis/melena were presenting features. In pregnant group, 46.1% (24/52) patients developed encephalopathy while in non-pregnant group 34% (15/44) developed this complication. Among pregnant cases, 67.3% (35/52) survived and 32% (17/52) cases died. In non-pregnant group, nearly 90% (40/44) patients survived and only 9% (4/44) patients died. This difference was statistically significant (P < 0.01). Adverse fetal outcome was seen in 71.1% (37/52) pregnant women with acute hepatitis E, including pre-term delivery in 23% (12/52), stillbirth in 23% (12/52), abortion in 3.8% (2/52) and intra-uterine fetal death in 21.1% (11/52) patients. Conclusions: There is significantly higher occurrence of hepatitis E infection in pregnant women than in non-pregnant women, which increases with gestation, with associated fulminant hepatic failure, maternal mortality and worse fetal outcome.
    Full-text · Article · Aug 2014
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    • "Waterborne outbreaks of HEV are often reported in endemic countries [9,10], where most infections occur in young adults aged 15-45 years [11,12]. HEV has a relatively low fatality rate, ranging 0.5-4%, but infections can induce acute liver failure in pregnant women, leading to 20-30% mortality [13-15]. Fulminant hepatitis and hepatic encephalopathy are the main causes of death [15]. "
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    ABSTRACT: Hepatitis E has traditionally been considered an endemic disease of developing countries. It generally spreads through contaminated water. However, seroprevalence studies have shown that hepatitis E virus (HEV) infections are not uncommon in industrialized countries. In addition, the number of autochthonous hepatitis E cases in these countries is increasing. Most HEV infections in developed countries can be traced to the ingestion of contaminated raw or undercooked pork meat or sausages. Several animal species, including pigs, are known reservoirs of HEV that transmit the virus to humans. HEVs are now recognized as an emerging zoonotic agent. In this review, we describe the general characteristics of HEVs isolated from humans and animals, the risk factors for human HEV infection, and the current status of human vaccine development.
    Full-text · Article · Jan 2014
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    ABSTRACT: Space-time clustering of people who fall acutely ill with jaundice, then slip into coma and death, is an alarming phenomenon, more markedly so when the victims are mostly or exclusively pregnant. Documentation of the peculiar, fatal predisposition of pregnant women during outbreaks of jaundice identifies hepatitis E and enables construction of its epidemic history. Between the last decade of the 18th century and the early decades of the 20th century, hepatitis E-like outbreaks were reported mainly from Western Europe and several of its colonies. During the latter half of the 20th century, reports of these epidemics, including those that became serologically confirmed as hepatitis E, emanated from, first, the eastern and southern Mediterranean littoral and, thereafter, Southern and Central Asia, Eastern Europe, and the rest of Africa. The dispersal has been accompanied by a trend towards more frequent and larger-scale occurrences. Epidemic and endemic hepatitis E still beset people inhabiting Asia and Africa, especially pregnant women and their fetuses and infants. Their relief necessitates not only accelerated access to potable water and sanitation but also vaccination against hepatitis E.
    Full-text · Article · Jan 2012 · Epidemiology and Infection
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