title: A Single Lineage of Hepatitis E Virus Causes Both  Outbreaks and Sporadic Hepatitis in Sudan.
abstract: Few studies have reported sporadic hepatitis E virus (HEV) infections during non-outbreak periods in Africa. In this study, the prevalence of HEV infection in Sudan was investigated in 432 patients with acute hepatitis from 12 localities in North Kordofan, and from 152 patients involved in smaller outbreaks of hepatitis in the neighbouring Darfur. HEV infection was diagnosed in 147 (25%) patients: 98 from Kordofan and 49 from Darfur. The mortality was 10%; six of the patients who died from the infection were pregnant women. HEV RNA was detected by quantitative real-time polymerase chain reaction (RT-qPCR) in 38 (26%) patients: 22 from Kordofan and 16 from Darfur. Partial open reading frame (ORF) 1 and ORF2 were sequenced from HEV from nine and three patients, respectively. Phylogenetic analysis showed that the Sudanese strains belonged to genotype 1 (HEV1), and confirmed the segregation of African HEV1 strains into one branch divergent from Asian HEV1. It also revealed that the Sudanese strains from this study and from an outbreak in 2004 formed a separate clade with a common ancestor, distinct from strains from the neighbouring Chad and Egypt. This HEV strain has thus spread in a large area of Sudan, where it has caused both sporadic hepatitis E and outbreaks from at least 2004 and onwards. These data demonstrate that hepatitis E is a constant, on-going public health problem in Sudan and that there is a need for hepatitis E surveillance, outbreak preparedness, and general improvements of the sanitation in these remote areas of the country.
authors: National Public Health Laboratory, Ministry of Health-Sudan, 11111 Khartoum, Sudan. dumanet@yahoo.com.
authors: Adel Hussein
authors: AH
authors: Elduma
authors: Public Health Laboratory, Ministry of Health North Kordofan State-Sudan, 51111 Obeid, Sudan. mailabbb@gmail.com.
authors: Mai Mohammed Adam
authors: MM
authors: Zein
authors: Department of Infectious Diseases, Institute of Biomedicine at Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden. marie.karlsson.2@gu.se.
authors: Marie
authors: M
authors: Karlsson
authors: Department of Microbiology and Parasitology, Faculty of Medicine, University of Khartoum-Sudan, Khartoum, Sudan. isamelkhidir@gmail.com.
authors: Isam M E
authors: IM
authors: Elkhidir
authors: Department of Infectious Diseases, Institute of Biomedicine at Sahlgrenska Academy, University of Gothenburg, 405 30 Gothenburg, Sweden. helene.norder@gu.se.
authors: Heléne
authors: H
authors: Norder
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D005260:Female; D005838:Genotype; D016751:Hepatitis E / Q000453:epidemiology* / Q000401:mortality / Q000821:virology*; D016752:Hepatitis E virus / Q000145:classification* / Q000235:genetics / Q000302:isolation & purification*; D006801:Humans; D008297:Male; D017720:Molecular Epidemiology; D016366:Open Reading Frames; D010802:Phylogeny; D015995:Prevalence; D012367:RNA, Viral / Q000235:genetics / Q000302:isolation & purification; D060888:Real-Time Polymerase Chain Reaction; D017422:Sequence Analysis, DNA; D013397:Sudan / Q000453:epidemiology; D016019:Survival Analysis
chemical_list: D012367:RNA, Viral
keywords: hepatitis E virus;  HEV;  Sudan;  endemic;  outbreak;  sporadic hepatitis E