A thesis, Degree of Doctor of Philosophy
Infections caused by hepatitis E virus (HEV) constitute a global public health burden.
Worldwide, over 20 million new cases of asymptomatic infections, 3.4 million illnesses
and 70 000 deaths due to HEV occur each year. Infections with HEV are the leading cause
of oro-fæcally acquired viral hepatitis and outbreaks have occurred in more than 61
countries. In developing countries particularly in Asia and Africa HEV outbreaks cause
10-30% case fatality rates in pregnant women and the infection is more common and fatal
during the third trimester of pregnancy. Several reports in Ghana have pointed to the
country being HEV endemic and sporadic maternal deaths and abortions due to HEV
infections. However, there is not a surveillance system for HEV infections and the Ghana
Ministry of Health (MOH) expressed concerns over knowledge gaps about the infection
and particularly among the most HEV-vulnerable pregnant population.This is important
because in the absence of vaccine to control HEV infection individual actions by the
affected pregnant women to lower the effect of risk factors becomes necessary. There is
also the policy implication of this study. In the absence of vaccines to control HEV
infections the strategy of education becomes an important tool to lower the effects of the
risk factors. The objectives of this thesis therefore were to determine seroprevalence of
subclinical infections of HEV in the third trimester of pregnancy, risk factors and the
delivery outcomes due to infections with HEV in the Sekondi-Takoradi Metropolis,
Ghana. Asymptomatic and apparently healthy pregnant women in third trimester, of 18
years and above were purposively selected in a cross-sectional study. The third trimester
was selected because this is the period reported to be associated with most HEV-related
vulnerabilities of abortions, faetal and maternal mortalities. To reduce confounding effects
on estimates pregnant women with hepatitis B, C and active liver disease profiles
examined earlier as part of antenatal care in routine checks and found not to be free of
these infections were excluded from the study. Because reports have associated human
immunodeficiency virus (HIV) with increased infections of HEV infections those with
HIV have also been excluded. Blood samples were collected and analyzed for HEV
infection. Socio-demographic and household data were collected. Household proximity to
wetlands and domestic pig farms were estimated and farmed swine from two districts
from where the sampled pregnant women originated were also tested for HEV infection.
Data on diagnoses and mode of delivery of the pregnant women were collected from
books on their discharge and also from the Regional Hospital Database. Bivariate and
multivariate logistic regression (LR) analysis was done in SPSS version 20 and by
Microsoft Excel, respectively. R code version 4.1 was used to check model assumptions
and geographical dependence in the dataset. Anti-HEV IgM was 22.5% (81/360) 95%
CI:18.2-26.8: and the anti-HEV IgG 11.0% (11/100) 95% CI: 5.6-18.8. In bivariate LR
analysis statistically significant associations were found between recent HEV infections
and age-groups, level of education, access to household flash water toilet systems. Three
out of 12 (25%) domestic pig farms were infected with HEV. Proximity to 20% (5/20)
farms were significantly associated with recent infections with HEV. Infection with HEV
was significantly associated with complications at delivery (P = 0.029: OR 1.24 95% CI
1.021-1.496). Surprisingly, among 22 diagnoses recorded in ward discharge log books,
normal pregnancy (NP) was the only significant outcome (P = 0.000: OR 0.349 95% CI
0.232-0.525), an indication of recent infections with HEV protective of normal deliverys.
Seroprevalence of active infection with HEV in the third trimester of pregnancy is 22.5%
in Sekondi Takoradi Metropolis of Ghana. The absence of water closet toilets and
proximity to domestic pig farms are risk factors for HEV infection, whilst proximity to
wetlands is not indicative of an infection risk to HEV. Active infection with HEV is not
indicative of having an adverse outcomes on deliveries at delivery. Metropolitan,
municipal and local government authorities should increase support for water closet toilet
facilities in households. Improved swine farm effluent management systems should also
be encouraged. Health authorities should encourage public awareness creation about HEV
infection in pregnancy. Even though the outcomes during delivery of recent HEV
infections appear to be protective of normal pregnancy, clinical realities may be different.
Therefore, research institutions should consider swine HEV as a One Health challenge to
reduce the potential of swine-HEV risks for the development of liver cancers in pregnant
women. The current study provided insights for dealing with geospatial analysis and
provided additional analytic approach in dealing with geospatial data. The seroprevalence
data on recent HEV infections adds to existing data on HEV during pregnancy and the
first study of HEV in swine in Ghana. In the absence of vaccine against HEV infections
education against HEV during pregnancy by the Ministry of Health and related
institutions will improve disease prevention and control.