title: Hepatitis E in Israel: A nation-wide retrospective study.
abstract: OBJECTIVE
  To investigate the epidemiology, risk factors and clinical course of acute hepatitis E virus (HEV) infection in Israel, an industrialized country.
  
  
  METHODS
  A retrospective analysis of acute HEV cases diagnosed in Israel from 1993 to 2013. Acute HEV was defined by ALT/AST elevation and a positive HEV PCR test or positive anti-HEV-IgM serology. HEV RNA was tested by quantitative reverse transcription PCR. Antibodies to HEV were tested retrospectively using an ELISA assay. HEV-RNA was sequenced using RT-PCR of ORF1 and ORF2 regions to diagnose genotype of the virus. Epidemiologic and clinical data were collected by reviewing the clinical files and through a telephone interview according to a structured questionnaire.
  
  
  RESULTS
  Acute HEV was diagnosed in 68 patients. Among the 59 patients who gave an informed consent and were interviewed, 41% of infections were autochthonous (acquired in Israel), 44% travel-related and 15% imported by foreign workers. Autochthonous patients were mainly females (62.5%), more than half of them pregnant, 26% recalled consuming food or water in areas with poor sanitation, 44% ate non-kosher meat. Fulminant hepatitis developed in 3 patients (5%), all of them were females, two of them with post-partum infection, all acquired the disease in Israel (autochthonous). Israeli travelers with imported infection were predominantly males (73%), acquired the disease in the Indian subcontinent (81%), with 100% reporting having consumed fresh vegetables and drinks with ice cubes abroad. Six patients' sera were tested for genotype and revealed HEV genotype 1 (all cases acquired in the Indian subcontinent).
  
  
  CONCLUSIONS
  This is the first report which highlights the existence of hepatitis E as an autochthonous infection in Israel. Imported HEV originates mostly from the Indian subcontinent.
authors.affiliation: Ortal Erez-Granat, Pediatrics Department, Sheba Medical Center, Tel Hashomer, Ramat Gan 5262110, Israel.
authors.forename: Ortal
authors.initials: O
authors.lastname: Erez-Granat
authors.affiliation: Ortal Erez-Granat, Pediatrics Department, Sheba Medical Center, Tel Hashomer, Ramat Gan 5262110, Israel.
authors.forename: Tamar
authors.initials: T
authors.lastname: Lachish
authors.affiliation: Ortal Erez-Granat, Pediatrics Department, Sheba Medical Center, Tel Hashomer, Ramat Gan 5262110, Israel.
authors.forename: Nili
authors.initials: N
authors.lastname: Daudi
authors.affiliation: Ortal Erez-Granat, Pediatrics Department, Sheba Medical Center, Tel Hashomer, Ramat Gan 5262110, Israel.
authors.forename: Daniel
authors.initials: D
authors.lastname: Shouval
authors.affiliation: Ortal Erez-Granat, Pediatrics Department, Sheba Medical Center, Tel Hashomer, Ramat Gan 5262110, Israel.
authors.forename: Eli
authors.initials: E
authors.lastname: Schwartz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D005838:Genotype; D006508:Hepatitis Antibodies / Q000276:immunology; D016751:Hepatitis E / Q000453:epidemiology* / Q000276:immunology; D016752:Hepatitis E virus / Q000235:genetics; D006801:Humans; D007075:Immunoglobulin M / Q000276:immunology; D007194:India; D007557:Israel / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D016133:Polymerase Chain Reaction; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology* / Q000276:immunology; D012367:RNA, Viral / Q000235:genetics; D012189:Retrospective Studies; D012307:Risk Factors; D014171:Transients and Migrants; D014195:Travel / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D006508:Hepatitis Antibodies; D007075:Immunoglobulin M; D012367:RNA, Viral
keywords: Autochthonous; Foreign workers; Hepatitis E; India; Indian subcontinent; Israel; Nepal; Post-partum; Pregnancy; Travel