Epidemiological risks for HEV transmission in Wales SL Cottrell 1, A Mahmood 2, RL Salmon 1, R Smith 1 1 NPHS Wales Communicable Disease Surveillance Centre, Temple of Peace and Health, Cathays, Cardiff. CF10 3NW 2 Herefordshire PCT, Ruckhall Lane, Belmont, Hereford, HR2 9RP Background Infection caused by the hepatitis E virus (HEV), ranges in severity from asymptomatic sub-clinical infection to severe icteric hepatitis. HEV infection in the UK has traditionally been associated with a history of travel to HEV endemic areas. In recent years there has been an increase in reports of locally acquired infection, with no history of travel to HEV endemic areas (Valappil et al. 2006). Results All were white, 12 (55%) were male and 10 female, and all presented with acute illness: 12 (55%) with jaundice and 10 (45%) with a range of symptoms including abdominal pain, loss of appetite and weight, tiredness, weakness and flu-like symptoms but never developed jaundice. All recovered without complication. None of the cases reported contact with a case of jaundice prior to illness. Lifestyle factors: 19 (87%) of cases were retired, 13 (59%) were recreational gardeners (figure 4), 32% of cases stated using horse manure in the garden. 12 (55%) reported contact with farm animals, including one who reported having butchered a wild pig 5 months before onset of symptoms and 77% of cases stated contact with any animals (including pets). 41% reported visiting local parks or theme parks, with smaller numbers visiting farms or the beach. Conclusion This study suggests that direct contact with animals or animal manure could be an important risk factors in indigenously acquired HEV infection; these include horses, cats, dogs, rabbits, rats and pigs. Being a gardener with exposure to animal manure, living in close proximity to a river, lake, pond, water stream, farm, park, or woodland could be risk factors; all of which provide increased opportunity for rodent exposure. Methods A sample of 22/40 laboratory-confirmed cases identified between January 2005 and December 2006 from south Wales were interviewed (AM & RS). Interviews were semi-structured, face-to- face and explored clinical and exposure histories, daily routines, life-style, hobbies, shopping habits and food preferences. Observations were recorded in a risk-factor matrix and analysed in Stata v We included cases (a case was defined as HEV IgM +ve, HEV IgG +ve or HEV detected by PCR), with no history of travel to a HEV endemic area in the 9 weeks preceding illness. Shopping preferences: All cases reported regularly using supermarkets (figure 3) for meat and groceries, 90% also used corner shops/ local grocers. 7 (32%) shopped at local (or mobile) butchers and/or local greengrocers. Less than a quarter of cases grew their own vegetables or shopped at farmers markets. References Valappil, M. Ijaz, S. Nsui, S. L. Owen, N. Westmoreland, D Indigenously acquired hepatitis E infections: the Welsh experience. J Infect, 36, p.S40 StataCorp. (1999) Stata Statistical Software: Release 9.2 College Station, TX: Stata Corporation Between 2004 and 2009, 158 cases of HEV infection were confirmed in Wales; 68% of these cases being in patients aged 50 years and over, 65% of all cases were males (figure 1.). Food preferences: All the cases reported eating a variety of meat products, including: fish, chicken, pork products, beef and lamb. 96% of cases also reported consuming dairy products and fruit (figure 2). 19 (86%) of the cases stated they liked their meat and meat products ‘well done’, with 3 (14%) of cases stating they liked steak to be ‘medium rare’; 12 (55%) of cases reported handling raw fish or meat products. Eight (36%) reported eating shellfish. Limitations of the study Cases were interviewed about a year after their episode of HEV infection, so eliciting exposure history in a 9-week exposure window prior to illness was unrealistic. This may have introduced bias through exaggeration of some risks and understatement of others. Location: 17 (81%) lived within half a mile of a river, lake, stream or canal and 16 (72%) lived near a farm. Figures 1 and 1a. Ages of confirmed HEV cases in Wales 2004 – 2009 (as at 10/03/2009, n=158) and laboratory confirmed cases by year. Data are likely subject to ascertainment bias in Figure 2. Food preferences of cases (n=22). Figure 3. Shopping habits Figure 4. Lifestyle factors