RESEARCHrates by gender or HIV status (1,30). The current study didnot include children, which likely explains why previouslyidentified trends of increasing infection levels with agewere not detected. We also did not find a trend of seroprevalenceover time. The only risk factor substantially associatedwith HEV seroprevalence was the METRO studyperiod, 2003–2005, as compared to the ICAR study, whichwas conducted during 1989–1995. Both studies were conductedamong women in Blantyre, Malawi.It is unclear what may have caused the METRO studyparticipants to have higher levels of HEV seroprevalence.We did not collect data on seasonality and source of waterand food; over the years Malawi had fluctuating boutsof drought and food scarcity. We tested diverse studypopulations from rural and urban settings recruited overa period of nearly 20 years, but no clear major trendswere observed.As expected, HAV seroprevalence was nearly universalin this sample of adults, with an overall prevalence of≈100%. In low-resource settings such as Malawi, HAV isa childhood infection, and nearly all persons are infectedwithin the first few years of life. Though children were notincluded in our study, it should be considered that they canbe exposed to HEV because of the high prevalence amongadults we observed. Although HAV and HEV infectiontend to cause mild disease independently, concurrent infectionswith these pathogens in children may lead to accelerateddisease progression (20). The changing epidemiologyof HAV in some settings related to rapid industrializationand urban migration in developing countries may result insome children not being exposed to HAV (10).An overall prevalence of 7.5% (95% CI 5.6%–9.4%)was found for HBsAg and 7.1% (95% CI 5.3%–8.9%) forHCV. The results of the HBsAg and HCV seroprevalencetests are consistent with previously published data fromsub-Saharan Africa. Specifically in Malawi, a study publishedin 2002 reported a prevalence of 14.9% for HBsAgand 10.6% for HCV among the SUCOMA participants(23). In our study, we found a prevalence of 11.8% (95%CI 7.0%–16.6%) and 10.7% (95% CI 6.1%–15.3%) forHBsAg and HCV, respectively, in the SUCOMA studysamples. Women who enrolled in NVAZ had lower oddsof testing positive for HBsAg compared to those in ICAR.The only distinct difference between these studies was theHIV status of the women (some women in the ICAR studywere HIV negative), but because this was included in themultivariate logistic regression, results should not be confoundedby the HIV status. No covariates were found to beassociated with HCV seroprevalence in this study.HEV epidemiology is evolving, and circulating genotypesand modes of transmission appear to be complex inboth developing and industrialized countries (1). We donot know in Malawi if only waterborne HEV genotypesare the source of potential infections or if other less virulentzoonotic HEV genotypes coexist. High seroprevalenceof HEV antibodies does not imply clinical infection or increasedassociation with clinical complications. Nonetheless,some misclassification of acute viral hepatitis is likelyin Malawi where screening for HEV antibodies is not performed.Because the seroprevalence of HEV in this studywas twice that of HBV or HCV, cases of acute hepatitismay frequently be caused by HEV as opposed to HBV orHCV. Notably, 15.7% (95% CI 12.7%–18.7%) of womenin this study cohort had antibodies against HEV, which canpose serious health risks for pregnant women (3).Although no association was found that HIV-positivepersons are at higher risk for anti-HEV than are HIV-negativepersons, the finding that 12.9% (95% CI 9.6%–16.2%)of samples from HIV-positive persons were HEV positiveis of concern. Malawi and other countries in sub-SaharanAfrica have high levels of HIV infection, and co-infectionwith HEV may lead to chronic HEV infection and accelerateddisease progression.The findings from this study should be regarded aspreliminary and require confirmation. Therefore, additionalepidemiologic and virological studies should be conductedin this region. As with all cross-sectional data, inferencesregarding associations should be interpreted with caution.A related limitation is that the samples used for serologictesting in this study included both enrollment and followupsamples (in cohort studies) to maximize availability ofsamples, whereas the covariate data used for all participantswas baseline enrollment data. Despite these limitations,we suspect that many of the covariates used, suchas having running water in the house, did not substantiallychange over time. Very few risk factors associated withHEV, HBV, or HCV seroprevalence were found. This resultmay be because of differences in population characteristicsor definitions used in multiple studies. For example,participants in the SUCOMA study were all men workingin a rural sugar estate occupational setting and may be consideredto be at high risk (23). We also did not have dataon some behaviors associated with HCV seroprevalence,such as intravenous drug use, although the practice is veryrare in Malawi. The lack of association between viral hepatitidesand various risk factors conventionally collected inthese studies suggests that better data collection tools toevaluate potential risk factors and different study designstargeting at risk populations may need to be considered infuture studies.Confirmation of the hepatitis testing results, particularlyHEV seroprevalence, reported in this study will becritical in subsequent studies because each sample wastested once. Retesting of a subset of positive and negativesamples should ideally be done with the same Wantai assayused in this study as well as with other assays. The hepatitis1180 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 7, July 2015
Seroprevalence of Hepatitides, MalawiA, B, and C assays used were commercially available inthe United States and well validated, but it is recommendedthat samples be tested in duplicate for these assays. Theconsistency of our results with findings from previous seroprevalencestudies in Malawi and other countries suggestsmisclassification may be minimal (taking into account thecontroversy regarding HCV testing). Molecular analysis todetermine what genotypes of HEV are prevalent in Malawimay also be useful and would provide further insight intothe epidemiology of this virus.AcknowledgmentsWe thank the Wantai Biological Pharmacy Enterprise Co., Ltd.,for donating the HEV IgG ELISA kits for this research. We alsothank the technologists in H.F.’s laboratory at the Johns HopkinsBloomberg School of Public Health, Baltimore, Maryland, USA,for assistance in performing the hepatitis assays.Dr. Taha is professor of Infectious Disease Epidemiology in theDepartment of Epidemiology at the Johns Hopkins BloombergSchool of Public Health in Baltimore. His primary researchinterest is HIV acquisition and transmission and the impact ofinfectious diseases on the health of children and adults in sub-Saharan Africa.References1. Labrique AB, Kuniholm MH, Nelson K. The global impact ofhepatitis E: new horizons for an emerging virus. In: Scheld WM,Grayson ML, Hughes JM, editors. Emerging Infections 9. 9thedition. Herndon (VA): ASM Press; 2010. p. 53–92.2. Teshale EH, Hu DJ, Holmberg SD. The two faces of hepatitis Evirus. Clin Infect Dis. 2010;51:328–34. http://dx.doi.org/10.1086/6539433. Nelson KE, Kmush B, Labrique AB. The epidemiology of hepatitisE virus infections in developed countries and among immunocompromisedpatients. Expert Rev Anti Infect Ther. 2011;09:1133–48.http://dx.doi.org/10.1586/eri.11.1384. Jacobs C, Chiluba C, Phiri C, Lisulo MM, Chomba M, Hill PC,et al. Seroepidemiology of hepatitis E virus infection in an urbanpopulation in Zambia: strong association with HIV and environmentalenteropathy. J Infect Dis. 2014;209:652–7. http://dx.doi.org/10.1093/infdis/jit4095. Gerbi GB, Williams R, Bakamutumaho B, Liu S, Downing R,Drobeniuc J, et al. Hepatitis E as a cause of acute jaundicesyndrome in northern Uganda, 2010–2012. Am J Trop Med Hyg.2015;92:411–4. http://dx.doi.org/10.4269/ajtmh.14-01966. Ahmed JA, Moturi E, Spiegel P, Schilperoord M, Burton W,Kassim NH, et al. Heptitis E outbreak, Dadaab refugee camp,Kenya, 2012. Emerg Infect Dis. 2013;19:1010–2. http://dx.doi.org/10.3201/eid1906.1302757. Menendez C, Sanchez-Tapias JM, Kahigwa E, Mshinda H,Costa J, Vidal J, et al. Prevalence and mother-to-child transmissionof hepatitis viruses B, C, and E in Southern Tanzania. J MedVirol. 1999;58:215–20. http://dx.doi.org/10.1002/(SICI)1096-9071(199907)58:33.0.CO;2-K8. Stark K, Poggensee G, Hohne M, Bienzle U, Kiwelu I. Schreier E.Seroepidemiology of TT virus, GBC-C/HGV, and hepatitisviruses B, C, and E among women in rural area of Tanzania.J Med Virol. 2000;62:524–30. http://dx.doi.org/10.1002/1096-9071(200012)62:43.0.CO;2-N9. Kim J-H, Nelson KE, Panzner U, Kasture Y, Labrique AB,Wierzba TF. A systematic review of the epidemiology of hepatitisE virus in Africa. BMC Infect Dis. 2014;14:308. http://dx.doi.org/10.1186/1471-2334-14-30810. Jacobsen KH, Wiersma ST. Hepatitis A virus seroprevalence byage and world region, 1990 and 2005. Vaccine. 2010;28:6653–7.http://dx.doi.org/10.1016/j.vaccine.2010.08.03711. World Health Organization. Hepatitis B 2014 [cited 11/03/2014].http://www.who.int/mediacentre/factsheets/fs204/en/12. World Health Orgamization. Hepatitis C 2014 [cited 11/03/2014].http://www.who.int/mediacentre/factsheets/fs164/en/#13. Barth RE, Huijgen Q, Taljaard J, Hoepelman AI. Hepatitis B/C andHIV in sub-Saharan Africa: an association between highlyprevalent infectious diseases. A systematic review andmeta-analysis. Int J Infect Dis. 2010;14:e1024–31.http://dx.doi.org/10.1016/j.ijid.2010.06.01314. Ocama P, Seremba E. Management of HIV and hepatitis C virusinfections in resource-limited settings. Curr Opin HIV AIDS.2010;6:539–45.15. Chasela CS, Wall P, Drobeniuc J, King CC, Teshale E,Hosseinipour MC, et al. Prevalence of hepatitis C virus infectionamong human immunodeficiency virus-1–infected pregnant womenin Malawi: the BAN study. J Clin Virol. 2012;54:318–20.http://dx.doi.org/10.1016/j.jcv.2012.05.00316. Mullis CE, Laeyendecker O, Reynolds S, Ocama P,Jeffrey Quinn J, Boaz I, et al. High frequency of false-positivehepatitis C virus enzyme-linked immunosorbent assay in Rakai,Uganda. Clin Infect Dis. 2013;57:1747–50. http://dx.doi.org/10.1093/cid/cit60217. Franco E, Bagnato B, Marino MG, Meleleo C, Serino L,Zaratti L. Hepatitis B: epidemiology and prevention in developingcountries. World J Hepatol. 2012;4:74–80. http://dx.doi.org/10.4254/wjh.v4.i3.7418. Nyirenda M, Beadsworth MB, Stephany P, Hart CA, Munthali C,Beeching NJ, et al. Prevalence of infection with hepatitis Band C virus and coinfection with HIV in medical inpatients inMalawi. J Infect. 2008;57:72–7. http://dx.doi.org/10.1016/j.jinf.2008.05.00419. Sutcliffe S, Taha TE, Kumwenda NI. Taylor, Liomba GN. HIV-1prevalence and herpes simplex virus 2, hepatitis C virus, andhepatitis B virus infections among male workers at a sugar estate inMalawi. J Acquir Immune Defic Syndr. 2002;31:90–7.http://dx.doi.org/10.1097/00126334-200209010-0001220. Labrique AB, Zaman K, Hossain Z, Saha P, Yunus M, Hossain A,et al. Epidemiology and risk factors of incident hepatitis E virusinfections in rural Bangladesh. Am J Epidemiol. 2010;172:952–61.http://dx.doi.org/10.1093/aje/kwq22521. Miotti PG, Dallabetta GA, Chiphangwi JD, Liomba G, Saah AJ.A retrospective study of childhood mortality and spontaneousabortion in HIV-1 infected women in urban Malawi. Int JEpidemiol. 1992;21:792–9. http://dx.doi.org/10.1093/ije/21.4.79222. Taha TE, Dallabetta GA, Hoover DR, Chiphangwi JD,Mtimavalye LA, Liomba GN, et al. Trends of HIV-1 and sexuallytransmitted diseases among pregnant and postpartum womenin urban Malawi. AIDS. 1998;12:197–203. http://dx.doi.org/10.1097/00002030-199802000-0001023. Kumwenda NI, Taha TE, Hoover D, Markakis D, Liomba NG,Chiphangwi JD, et al. Three surveys of HIV-1prevalence and riskfactors among men working at a sugar estate in Malawi.Sex Transm Dis. 2002;29:366–71. http://dx.doi.org/10.1097/00007435-200206000-0001024. Taha TE, Kumwenda NI, Gibbons A, Broadhead RL, Fiscus S,Lema V, et al. Short postexposure prophylaxis in newborn babies toreduce mother-to-child transmission of HIV-1: NVAZ randomisedclinical trial. Lancet. 2003;362:1171–7. http://dx.doi.org/10.1016/S0140-6736(03)14538-2Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 21, No. 7, July 2015 1181
- Page 3 and 4:
July 2015SynopsisOn the CoverMarian
- Page 5 and 6:
1240 Gastroenteritis OutbreaksCause
- Page 7 and 8:
SYNOPSISDisseminated Infections wit
- Page 9 and 10:
Disseminated Infections with Talaro
- Page 11 and 12:
Disseminated Infections with Talaro
- Page 13 and 14:
Macacine Herpesvirus 1 inLong-Taile
- Page 15 and 16:
Macacine Herpesvirus 1 in Macaques,
- Page 17 and 18:
Macacine Herpesvirus 1 in Macaques,
- Page 19:
Macacine Herpesvirus 1 in Macaques,
- Page 23:
Malaria among Young Infants, Africa
- Page 26 and 27:
RESEARCHFigure 3. Dynamics of 19-kD
- Page 28 and 29:
Transdermal Diagnosis of MalariaUsi
- Page 30 and 31:
RESEARCHFigure 2. A) Acoustic trace
- Page 32 and 33:
RESEARCHof malaria-infected mosquit
- Page 34 and 35:
Lack of Transmission amongClose Con
- Page 36 and 37: RESEARCH(IFA) and microneutralizati
- Page 38 and 39: RESEARCHoropharyngeal, and serum sa
- Page 40 and 41: RESEARCH6. Assiri A, McGeer A, Perl
- Page 42 and 43: RESEARCHadvanced genomic sequencing
- Page 44 and 45: RESEARCHTable 2. Next-generation se
- Page 46 and 47: RESEARCHTable 3. Mutation analysis
- Page 48 and 49: RESEARCHReferences1. Baize S, Panne
- Page 50 and 51: Parechovirus Genotype 3 Outbreakamo
- Page 52 and 53: RESEARCHFigure 1. Venn diagramshowi
- Page 54 and 55: RESEARCHTable 2. HPeV testing of sp
- Page 56 and 57: RESEARCHFigure 5. Distribution of h
- Page 58 and 59: RESEARCHReferences1. Selvarangan R,
- Page 60 and 61: RESEARCHthe left lobe was sampled b
- Page 62 and 63: RESEARCHTable 2. Middle East respir
- Page 64 and 65: RESEARCHseroprevalence in domestic
- Page 66 and 67: RESEARCHmeasure their current surve
- Page 68 and 69: RESEARCHTable 2. States with labora
- Page 70 and 71: RESEARCHFigure 2. Comparison of sur
- Page 72 and 73: RESEARCH9. Centers for Disease Cont
- Page 74 and 75: RESEARCHthe analyses. Cases in pers
- Page 76 and 77: RESEARCHTable 3. Sampling results (
- Page 78 and 79: RESEARCHpresence of Legionella spp.
- Page 80 and 81: Seroprevalence for Hepatitis Eand O
- Page 82 and 83: RESEARCHTable 1. Description of stu
- Page 84 and 85: RESEARCHTable 3. Crude and adjusted
- Page 88 and 89: RESEARCH25. Taha TE, Kumwenda N, Ka
- Page 90 and 91: POLICY REVIEWDutch Consensus Guidel
- Page 92 and 93: POLICY REVIEWTable 3. Comparison of
- Page 94 and 95: POLICY REVIEW6. Botelho-Nevers E, F
- Page 96 and 97: DISPATCHESFigure 1. Phylogenetic tr
- Page 98 and 99: DISPATCHESSevere Pediatric Adenovir
- Page 100 and 101: DISPATCHESTable 1. Demographics and
- Page 102 and 103: DISPATCHES13. Kim YJ, Hong JY, Lee
- Page 104 and 105: DISPATCHESTable. Alignment of resid
- Page 106 and 107: DISPATCHESFigure 2. Interaction of
- Page 108 and 109: DISPATCHESSchmallenberg Virus Recur
- Page 110 and 111: DISPATCHESFigure 2. Detection of Sc
- Page 112 and 113: DISPATCHESFigure 1. Histopathologic
- Page 114: DISPATCHESFigure 2. Detection of fo
- Page 117 and 118: Influenza Virus Strains in the Amer
- Page 119 and 120: Novel Arenavirus Isolates from Nama
- Page 121 and 122: Novel Arenaviruses, Southern Africa
- Page 123 and 124: Readability of Ebola Informationon
- Page 125 and 126: Readability of Ebola Information on
- Page 127 and 128: Patients under investigation for ME
- Page 129 and 130: Patients under investigation for ME
- Page 131 and 132: Wildlife Reservoir for Hepatitis E
- Page 133 and 134: Asymptomatic Malaria and Other Infe
- Page 135 and 136: Asymptomatic Malaria in Children fr
- Page 137 and 138:
Bufavirus in Wild Shrews and Nonhum
- Page 139 and 140:
Bufavirus in Wild Shrews and Nonhum
- Page 141 and 142:
Range Expansion for Rat Lungworm in
- Page 143 and 144:
Slow Clearance of Plasmodium falcip
- Page 145 and 146:
Slow Clearance of Plasmodium falcip
- Page 147 and 148:
Gastroenteritis Caused by Norovirus
- Page 149 and 150:
Ebola Virus Stability on Surfaces a
- Page 151 and 152:
Ebola Virus Stability on Surfaces a
- Page 153 and 154:
Outbreak of Ciprofloxacin-Resistant
- Page 155 and 156:
Outbreak of S. sonnei, South KoreaT
- Page 157 and 158:
Rapidly Expanding Range of Highly P
- Page 159 and 160:
Cluster of Ebola Virus Disease, Bon
- Page 161 and 162:
Cluster of Ebola Virus Disease, Lib
- Page 163 and 164:
ANOTHER DIMENSIONThe Past Is Never
- Page 165 and 166:
Measles Epidemic, Boston, Massachus
- Page 167 and 168:
LETTERSInfluenza A(H5N6)Virus Reass
- Page 169 and 170:
LETTERSsystem (8 kb-span paired-end
- Page 171 and 172:
LETTERS3. Van Hong N, Amambua-Ngwa
- Page 173 and 174:
LETTERSTable. Prevalence of Bartone
- Page 175 and 176:
LETTERSavian influenza A(H5N1) viru
- Page 177 and 178:
LETTERSprovinces and a total of 200
- Page 179 and 180:
LETTERS7. Manian FA. Bloodstream in
- Page 181 and 182:
LETTERSforward projections. N Engl
- Page 183 and 184:
LETTERS3. Guindon S, Gascuel OA. Si
- Page 185 and 186:
BOOKS AND MEDIAin the port cities o
- Page 187 and 188:
ABOUT THE COVERNorth was not intere
- Page 189 and 190:
Earning CME CreditTo obtain credit,
- Page 191:
Emerging Infectious Diseases is a p
Change language