title: Outbreak of hepatitis E in urban Bangladesh resulting in maternal and perinatal mortality.
abstract: BACKGROUND
  Hepatitis E virus (HEV) causes outbreaks of jaundice associated with maternal mortality. Four deaths among pregnant women with jaundice occurred in an urban community near Dhaka, Bangladesh, in late 2008 and were reported to authorities in January 2009. We investigated the etiology and risk factors for jaundice and death.
  
  
  METHODS
  Field workers identified suspected cases, defined as acute onset of yellow eyes or skin, through house-to-house visits. A subset of persons with suspected HEV was tested for immunoglobulin M (IgM) antibodies to HEV to confirm infection. We used logistic regression analysis to identify risk factors for HEV disease and for death. We estimated the increased risk of perinatal mortality associated with jaundice during pregnancy.
  
  
  RESULTS
  We identified 4751 suspected HEV cases during August 2008-January 2009, including 17 deaths. IgM antibodies to HEV were identified in 56 of 73 (77%) case-patients tested who were neighbors of the case-patients who died. HEV disease was significantly associated with drinking municipally supplied water. Death among persons with HEV disease was significantly associated with being female and taking paracetamol (acetaminophen). Among women who were pregnant, miscarriage and perinatal mortality was 2.7 times higher (95% confidence interval, 1.2-6.1) in pregnancies complicated by jaundice.
  
  
  CONCLUSIONS
  This outbreak of HEV was likely caused by sewage contamination of the municipal water system. Longer-term efforts to improve access to safe water and license HEV vaccines are needed. However, securing resources and support for intervention will rely on convincing data about the endemic burden of HEV disease, particularly its role in maternal and perinatal mortality.
authors.affiliation: icddr,b (International Center for Diarrhoeal Disease Research, Bangladesh).
authors.forename: Emily S
authors.initials: ES
authors.lastname: Gurley
authors.affiliation: icddr,b (International Center for Diarrhoeal Disease Research, Bangladesh).
authors.forename: M Jahangir
authors.initials: MJ
authors.lastname: Hossain
authors.affiliation: icddr,b (International Center for Diarrhoeal Disease Research, Bangladesh).
authors.forename: Repon C
authors.initials: RC
authors.lastname: Paul
authors.affiliation: icddr,b (International Center for Diarrhoeal Disease Research, Bangladesh).
authors.forename: Hossain M S
authors.initials: HM
authors.lastname: Sazzad
authors.affiliation: icddr,b (International Center for Diarrhoeal Disease Research, Bangladesh).
authors.forename: M Saiful
authors.initials: MS
authors.lastname: Islam
authors.affiliation: icddr,b (International Center for Diarrhoeal Disease Research, Bangladesh).
authors.forename: Shahana
authors.initials: S
authors.lastname: Parveen
authors.affiliation: icddr,b (International Center for Diarrhoeal Disease Research, Bangladesh).
authors.forename: Labib I
authors.initials: LI
authors.lastname: Faruque
authors.affiliation: Ministry of Health and Family Welfare, Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh.
authors.forename: Mushtuq
authors.initials: M
authors.lastname: Husain
authors.affiliation: Ministry of Health and Family Welfare, Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh.
authors.forename: Khorshed
authors.initials: K
authors.lastname: Ara
authors.affiliation: Ministry of Health and Family Welfare, Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh.
authors.forename: Yasmin
authors.initials: Y
authors.lastname: Jahan
authors.affiliation: Ministry of Health and Family Welfare, Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh.
authors.forename: Mahmudur
authors.initials: M
authors.lastname: Rahman
authors.affiliation: icddr,b (International Center for Diarrhoeal Disease Research, Bangladesh) Global Disease Detection Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Luby
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000914:Antibodies, Viral / Q000097:blood; D001459:Bangladesh / Q000453:epidemiology; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D005260:Female; D016751:Hepatitis E / Q000453:epidemiology* / Q000401:mortality; D016752:Hepatitis E virus / Q000276:immunology; D006801:Humans; D007075:Immunoglobulin M / Q000097:blood; D007223:Infant; D007231:Infant, Newborn; D007565:Jaundice / Q000209:etiology; D008297:Male; D063130:Maternal Death; D008875:Middle Aged; D066087:Perinatal Death; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology* / Q000401:mortality; D011256:Pregnancy Outcome; D012307:Risk Factors; D012722:Sewage / Q000821:virology; D014881:Water Supply; D055815:Young Adult
chemical_list: D000914:Antibodies, Viral; D007075:Immunoglobulin M; D012722:Sewage
keywords: Bangladesh; hepatitis E; outbreak; pregnancy; safe water