Hepatitis E, Central African Republic

Hepatitis E, Central African Republic

In the context of the previous reports of WUPyV detection in Australia and North America (3), our data suggest a worldwide distribution of WUPyV. Most of the WUPyV-positive children were <4 years of age, and WUPyV DNA was rarely found in children >6 years of age. This age distribution is compatible with WUPyV infection occurring in day nurseries and kindergartens. In keeping with the fi ndings of Gaynor et al. (3), we observed a high number of co-infections. The true number of co-infections in our study is probably higher than the reported 53.2% because we did not test for several respiratory pathogens, such as coronaviruses, rhinoviruses, enteroviruses, and the human metapneumovirus. Hypotheses to account for the detection of WUPyV in respiratory samples include the following: WUPyV is a persisting asymptomatic virus that is detected by chance, WUPyV is a persisting virus that is reactivated by an infl ammatory process, or WUPyV is a predisposing or aggravating factor of respiratory diseases. Further studies are necessary to determine whether WUPyV is a human pathogen.

Hepatitis E, Central African Republic
To the Editor: Outbreaks of hepatitis E virus (HEV) have been documented in many geographic regions and nonindustrialized countries (1-3); they have been primarily associated with fecal contamination of drinking water (4). In the Central African Republic (CAR), economic indicators (CAR ranks 172/177 countries on the 2006 United Nations Development Program Human Development Index), political instability, geographic situation, a deteriorating health network, and a very poor epidemiologic surveillance system all contribute to the country's epidemic susceptibility.
In July 2002, Ministry of Health (MoH) and Médecins sans Frontières (MSF) teams working in the Begoua Commune Health Center, north of CAR's capital Bangui, reported an increased number of patients from the Yembi I neighborhood who were showing signs of jaundice and extreme fatigue.
Patients suspected of having hepatitis E were defi ned as those with clinical jaundice (yellow discoloration of the sclera) and symptoms of malaise, anorexia, abdominal pain, arthralgia, and fever. Confi rmed cases were those in which patients' serum samples were positive for HEV immunoglobulin (Ig) M or IgG.
Initially, 16 pairs of serum and stool samples were collected from jaundiced patients. Fecal samples were stored at -20°C and sent to the National Reference Center of Enterically Transmitted Hepatitis, Hospital Val de Grâce (Paris, France) for HEV marker testing; serum samples were tested at the Bangui Pasteur Institute for yellow fewer (YF) IgM by MAC-ELISA.
The HEV epidemic was confi rmed by the detection of HEV markers: HEV IgG (Enzyme Immuno Assay, HEV, Abbott Laboratories, Abbott Park, IL, USA), HEV IgM (Abbott Laboratories), amplifi cation of RNA (5), and the absence of YF IgM. The HEV genome was detected in 4 of the fecal samples. Genotyping and sequencing showed that one of these was genotype 1, prevalent in Africa; the others were related to genotype 2 (Mexico-like) (GenBank accession nos. DQ151640, DQ151640) (5,6).
Data suggest that the epidemic began in the Yembi I neighborhood, then spread to the rest of the Begoua commune and fi nally to Bangui or surrounding areas (Figure). No signifi cant differences were found among confi rmed case-patients by sex or age-group. Seventy-seven (34.6%) had relatives with suspected HEV, and 163 (73.5%) had drunk untreated water from their own wells.
These epidemiologic fi ndings suggest the water-borne nature of this outbreak. Environmental testing of water from 2 wells (before chlorination was implemented) showed the water to be unsafe to drink (i.e., heatresistant coliforms and aerobic bacteria were present) (7).
The outbreak was not surprising because a 1995 survey in Bangui showed anti-HEV antibodies in 24% of patients tested (8), indicating endemic HEV. Our results for IgG-positive patients were similar (23.2% in men and 20.1% in women). As demonstrated during other outbreaks (3), we found no signifi cant difference between the distribution of HEV-positive patients by age or sex, although most patients were males (58%) and young adults (71% of ages 14-45 years).
The observed CFR was similar to that in other reported HEV outbreaks, in which CFR varied from 1% to 4% (9,10), but it was as high as >30% in pregnant women (9). Deliveries during pregnancy months 6-8 in this outbreak highlight the need for close surveillance of pregnant women affected by this disease.
We recommended application of preventive measures, including water disinfection, safe disposal of excreta, community health education, and the strengthening of case management and disease surveillance. For the CAR, free access to a safe water supply and drugs was the only way to achieve these goals.
The number of HEV cases in the Yembi I neighborhood declined after the crisis team implemented hygienic and chlorination measures in the district, although the number of cases remained constant in other neighborhoods of the commune (Figure). Definite conclusions cannot be drawn from this fi nding. First, the MSF hospital was within the Begoua commune. Thus, patients from the rest of Bangui (outside the commune) only started arriving at the center for treatment after hearing about the hospital through broadcast messages. Second, a military coup d'état during epidemiologic week 43 prevented us from conducting further surveillance.
Our results agree with international data on HEV outbreaks in other nonindustrialized countries. However, studies to improve our understanding of this epidemic and to identify the main risk factors involved would be benefi cial. To the Editor: Rickettsia sibirica subsp. mongolitimonae is an intracellular bacterium that belongs to the species R. sibirica (1). To date, only 11 cases of infection with this bacterium have been reported (2)(3)(4)(5)(6). We report a case in a pregnant woman with ocular vasculitis.
A 20-year-old woman in the 10th week of her pregnancy was admitted in June 2005 to St. Eloi Hospital in Montpellier, France, with an 8-day history of fever, eschar, hemifacial edema, and headache. On examination the day of admission, she had a fever of 38.5°C, headache, and frontal eschar surrounded by an infl ammatory halo. Painful retroauricular and cervical lymphadenopathies were noted. Results of a clinical examination were otherwise within normal limits. No tick bite was reported by the patient, although she had been walking a few days before in Camargue (southern France). Serologic results for R. conorii, R. typhi, Brucella spp., Borrelia spp., and Coxiella burnetii were negative.
One day after admission, she reported loss of vision (scotoma) in her right eye. She underwent a complete ophthalmic evaluation. Measurement of visual acuity and results of a slitlamp examination were within normal limits, but a funduscopic examination showed a white retinal macular lesion that corresponded in a fl uorescein angiograph to an area of retinal ischemia induced by vascular infl ammation and subsequent occlusion (Figure). The following day, a rash with a few maculopapular elements developed, which involved only the palms of the hands and soles of the feet. Mediterranean spotted fever was suspected. Cyclines and fl uoroquinolones were contraindicated because of her pregnancy, and the patient had a history of maculopapular rash after taking josamycin. She was treated with azithromycin, 500 mg/day for 10 days, under close surveillance. After 2 days of treatment, she was afebrile and the rash completely resolved. No obstetric complications occurred and she gave birth to a healthy boy at term. Two years later, the right scotoma remained unchanged.
Serologic tests for rickettsiosis were performed with an acute-phase serum sample and a convalescentphase serum sample (1 month after onset of symptoms). Samples were sent to the World Health Organization Collaborative Center in Marseille for rickettsial reference and research. Immunoglobulin (Ig) G and IgM titers were estimated by using a microimmunofl uorescence assay; results were negative. Culture of a skin biopsy specimen from the eschar showed negative results.
DNA was extracted from eschar biopsy specimen and used as template in a PCR with primers complementary to portions of the coding sequences of the rickettsial outer membrane protein A and citrate synthase genes as described (5). Nucleotide sequences of the PCR products were determined. All sequences shared 100% similar- Figure. Fluorescein angiograph of the right eye of the patient showing retinal occlusive vasculitis with arteriolar leakage at late phase.