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| Yong Chan Lee |
Professor of Medicine Director, Gastrointestinal Research Laboratory Veterans Affairs Medical Center, Univ. California San Francisco San Francisco, USA |
| Jong Pil Im | Seoul National University College of Medicine, Seoul, Korea |
| Robert S. Bresalier | University of Texas M. D. Anderson Cancer Center, Houston, USA |
| Steven H. Itzkowitz | Mount Sinai Medical Center, NY, USA |
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Jeonghyeon Oh1 
, Gwang Hyeon Choi2 , Yeonhwa Chang1 , Jina Kim1 , Kunhee Park1 , Hansol Yeom3 , Soonryu Seo3 , Jin Gwack3 , Sook-Hyang Jeong2
Correspondence to: Sook-Hyang Jeong
ORCID https://orcid.org//0000-0002-4916-7990
E-mail jsh@snubh.org
Jeonghyeon Oh and Gwang Hyeon Choi contributed equally to this work as first authors.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Gut Liver 2024;18(3):531-538. https://doi.org/10.5009/gnl230098
Published online October 6, 2023, Published date May 15, 2024
Copyright © Gut and Liver.
Background/Aims: To investigate a reported outbreak of presumed hepatitis E virus (HEV) infection in a Korean food manufacturing facility and to explore the association between anti-HEV immunoglobulin M (IgM) positivity and coronavirus disease 2019 (COVID-19) infection or vaccination.
Methods: Twenty-four cases of anti-HEV IgM positivity were reported among 646 workers at the facility in 2022. An epidemiological investigation was conducted, comprising HEV-RNA testing of blood and environmental samples, analysis of group meal records, and an association between anti-HEV IgM positivity and confirmed COVID-19 infection or vaccination.
Results: All 24 patients were asymptomatic, with cases spread sporadically across the facility. HEV RNA was not detected in the serum or environmental samples. Four out of 340 meals (1.2%) showed a significantly higher proportion of anti-HEV positivity in each meal intake group than in the non-intake group on certain days. Although the cumulative rate of COVID-19 infection showed no difference, the anti-HEV IgM positive group showed significantly higher proportions of >2 doses of COVID-19 vaccination (83.3% vs 48.7%, p=0.021), vaccination within 90 days (45.8% vs 19.7%, p=0.008), and having the Moderna vaccine administered as the last vaccine (75.0% vs 14.5%, p<0.001) than those of the anti-HEV negative group. In four multivariable models, three or more COVID-19 vaccinations and the Moderna vaccine as the last vaccine were consistently associated with anti-HEV IgM positivity, while the specific day group meal intake was also a significant factor.
Conclusions: This epidemiological investigation showed that anti-HEV IgM positivity may occur as a false-positive result related to COVID-vaccination over three times and use of the Moderna vaccine, although a portion of true HEV infection may not be excluded.
Keywords: Hepatitis E, Diagnosis, Epidemiology, COVID-19, Vaccination
The hepatitis E virus (HEV) is a major cause of acute viral hepatitis worldwide,1 with 20 million incident cases, including 3 million symptomatic cases (14.5%) occurring globally every year. World Health Organization estimated 44,000 deaths attributed to HEV in 2015.2 HEV infection spreads via fecal-to-oral transmission through the ingestion of HEV-contaminated water or incompletely cooked animal meat, including animal livers, particularly pork. Acute hepatitis E may progress to chronic hepatitis, liver cirrhosis, or liver cancer, particularly in immunocompromised patients.3
Acute hepatitis E is generally diagnosed by anti-HEV immunoglobulin M (IgM) positivity in blood or HEV RNA positivity (by reverse-transcription polymerase chain reaction) in the blood or stool.4 However, anti-HEV IgM tests show a low concordance rate among the different test kits and false-positive results in cases of hepatitis A,5 Epstein-Barr viral infection,6 and autoimmune hepatitis.7 The HEV RNA test frequently shows a false negative result following symptom development due to rapid reduction of viremic levels and it is not available in many countries.
Since July 2020, in South Korea, where the anti-HEV IgG prevalence in the population aged 10 to 55 years is 5.9%, all hepatitis E cases have been reported to the Korea Disease Control and Prevention Agency as a class 2 notifiable infectious disease in the mandatory surveillance system. While only one HEV outbreak has been reported in South Korea so far, sporadic cases of HEV infection related to zoonosis have been noted.8,9 Herein, we report on an outbreak of presumed HEV infection in a food manufacturing facility, and explore the association between anti-HEV IgM positivity and coronavirus disease 2019 (COVID-19) infection or COVID-19 vaccination.
Three and one cases of anti-HEV IgM positivity were detected among employees of a food manufacturing facility during annual health examinations for employees on April 13 and April 20, 2022, respectively. All of these first-detected four cases were asymptomatic. The infectious disease control center in the provincial government subsequently initiated an epidemiological investigation of the presumed HEV outbreak on April 26. The subjects of the investigation were 646 employees working at the facility, including at a production plant, research company, and contractor-in-charge of cleaning or washing from February 1 to April 26, 2022, considering the incubation period of HEV infection. Epidemiological investigators requested serum anti-HEV IgM testing for all employees. Fifteen testing rounds were subsequently performed from April 21 to May 20, identifying a total of 24 cases of anti-HEV IgM positivity. On-site investigations were conducted by epidemiological investigators from Gyeonggi Province, the health center, and sanitation departments of the city. Epidemiological data, such as demographic and clinical characteristics of the employees, meal intake history, and environmental factors, were obtained from company records and interviews with workers. This study was approved by the IRB of Seoul National University Bundang Hospital (IRB number: X-2029-781-902), and the need for informed consent was waived due to the retrospective research design.
Currently, the only approved anti-HEV IgM testing kit in South Korea is the enzyme-linked immunosorbent assay produced by AB Diagnostic System GmbH (Berlin, Germany), abia HEV IgM. Among the 24 cases of anti-HEV IgM positivity, 17 obtained on May 6 and May 9 were tested for HEV RNA using the PowerCheck HEV virus qRT-PCR kit (Kogene Biotech, Seoul, Korea), which included primers and probes with HEV genome sequences in the ORF2/3 region. Environmental samples were obtained from the facility and tested for HEV RNA by qRT-PCR using TaqMan analysis with primers and probes targeting the ORF 2/3 region. These samples included groundwater, common items, water purifiers, raw and complete food products, cooking utensils, and preserved food materials, especially meat and shellfish, in the cafeteria for employees (May 4 to 9). The factory operated a closed production system, meaning no direct contact with the raw materials of products for employees.
Only the employees used one cafeteria in the factory. The intake of the group meal was traced using the meal card tagging system data from February 1 to April 26, the presumed incubation period of the HEV. The meal intake group was defined as those who ate meals at least once in the cafeteria that served four meals per day (breakfast, lunch, dinner, or late-night meals; n=508), while those who never used the cafeteria were defined as the non-intake group (n=138). Comparison of anti-HEV IgM positivity between the meal intake and non-intake groups was shown as the relative risk (RR), and statistically significant data were included as variables for further univariate and multivariate analyses to identify factors associated with anti-HEV IgM positivity.
Using COVID-19 information and the vaccination management system operated by the Korea Disease Control and Prevention Agency, we analyzed the COVID-19 infection and vaccination statuses of 576 employees among a total of 646 subjects. The COVID-19 infection rates within 90 days prior to anti-HEV testing between the anti-HEV IgM-positive and -negative groups were subsequently compared. Additionally, COVID-19 vaccination rates and vaccine types were compared between the anti-HEV IgM-positive and -negative groups. Univariate and multivariate analyses were performed to determine whether these variables were independent factors affecting the HEV antibody positivity.
The epidemiological characteristics of the groups are descriptively presented as frequencies for nominal variables and median and interquartile range or mean and standard deviation for continuous variables. The Fisher exact test for nominal variables and the Mann-Whitney U test for continuous variables were used for comparison between the two groups. Comparisons between anti-HEV IgM positivity in a specific day meal intake group and non-intake group were analyzed using RR. Univariate and multivariate analyses were performed using logistic regression to identify independent variables related to anti-HEV IgM positivity, and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Statistical analysis was performed using R (version x64 4.0.5; R Foundation for Statistical Computing, Vienna, Austria) and SPSS version 21 (IBM Corp., Armonk, NY, USA), and p<0.05 was considered statistically significant.
Among 646 employees, the HEV-IgM positivity rate was 3.7% (n=24). In-depth interviews with the 24 employees showed that eight people had a history of eating undercooked meat or salted fish/shellfish (beef tartare in four, salted and fermented squid in four, salted pollack roe in one, and salted small octopus in one person). However, none of the patients showed symptoms of hepatitis. None visited the health management office in the facility or clinic because of hepatitis-related symptoms during the study period, which was confirmed by checking the Drug Utilization Review system. Eight patients had a history of hypertension or diabetes, and one person had been diagnosed with liver cirrhosis. Among the 10 patients who were tested for alanine aminotransferase, three showed mildly elevated alanine aminotransferase levels (45, 59, and 98 IU/L) (Table 1). Also, none of the anti-HEV IgM positivity cases showed hepatitis A virus infection in their test result, likewise four employees who tested positive for hepatitis A virus showed no HEV infection. There were no differences in terms of age, sex, affiliated workplace, and occupation between the anti-HEV positive and negative groups, as shown in Table 1. The median age was 42.5 years, 76.5% were men, and anti-HEV IgM positivity was not concentrated in a specific workplace.
Table 1. Demographic Characteristics According to Anti-HEV IgM-Positivity
| Variable | Total | Anti-HEV IgM positive (n=24) | Anti-HEV IgM negative (n=622) | p-value |
|---|---|---|---|---|
| Age, median (IQR), yr (n=638)* | 42.5 (34–52) | 43.0 (30–50) | 42.0 (34–52) | 0.579 |
| Age group, No. (%) (n=638)* | 0.072 | |||
| 20–29 yr | 82 (12.9) | 7 (29.2) | 75 (12.2) | |
| 30–39 yr | 180 (28.2) | 3 (12.5) | 177 (28.8) | |
| 40–49 yr | 173 (27.1) | 8 (33.3) | 165 (26.9) | |
| 50–59 yr | 162 (25.4) | 4 (16.6) | 158 (25.7) | |
| ≥60 yr | 41 (6.4) | 2 (8.4) | 39 (6.4) | |
| Sex, No. (%) (n=638)* | 0.505 | |||
| Male | 488 (76.5) | 17 (70.8) | 471 (76.7) | |
| Female | 150 (23.5) | 7 (29.2) | 143 (28.3) | |
| Affiliation, No. (%) | 0.168 | |||
| Factory | 414 (64.1) | 12 (50.0) | 402 (64.6) | |
| Company A | 113 (17.5) | 6 (25.0) | 107 (17.2) | |
| Company B | 11 (1.7) | 1 (4.2) | 10 (1.6) | |
| Company C | 39 (6.0) | 3 (12.5) | 36 (5.8) | |
| Contractor | 69 (10.7) | 2 (8.3) | 67 (10.8) | |
| Job position, No. (%) | 0.901 | |||
| Production worker | 223 (34.5) | 8 (33.3) | 215 (34.6) | |
| Non-production worker | 423 (65.5) | 16 (66.7) | 407 (65.4) | |
| Institutional group meal intake at least once | 508 (78.6) | 10 (41.7) | 498 (80.1) | 0.000 |
| Total bilirubin level, mean±SD, mg/dL (n=101) | 1.0±1.7 | 0.8±0.2 | 1.0±1.8 | 0.458 |
| AST, mean±SD, IU/L (n=223) | 25.7±12.7 | 25.7±11.5 | 25.6±12.8 | 0.994 |
| ALT, mean±SD, IU/L (n=222) | 27.9±21.6 | 33.1±27.2 | 27.6±21.6 | 0.468 |
HEV, hepatitis E virus; IgM, immunoglobulin M; IQR, interquartile range; AST, aspartate aminotransferase; ALT, alanine aminotransferase.
*Number of workers at the investigation time excluding resigned persons.
Serum HEV RNA was negative in 17 employees with anti-HEV IgM positivity. The blood sampling interval between anti-HEV and HEV RNA testing ranged from to 3–15 days. Moreover, HEV-RNA was not detected in any of the environmental samples, including six samples collected from water purifiers, washing water, and common objects in the factory; seven samples from groundwater wells used for washing equipment; and four from raw materials and products.
During the study period, four out of 340 meals (1.2%) showed a significantly higher proportion of anti-HEV positivity in the meal intake group than in the non-intake group (Table 2). The detailed menu of the four meals is as follows: stir-fried pork kimchi (lunch on February 2: RR, 3.95; 95% CI, 1.38 to 11.34), braised pork ribs, chicken fillet (dinner on February 14: RR, 3.21; 95% CI, 1.31 to 7.85), pork cutlet (dinner on February 17: RR, 3.55; 95% CI, 1.24 to 10.21), and fried chicken (dinner on February 18: RR, 3.78; 95% CI, 1.32 to 10.86), although all dishes were completely cooked by boiling or deep frying. HEV-anti-IgM test results were negative for all nine food handlers.
Table 2. Summary of Significantly Higher RRs of Anti-HEV Positivity in the Eaters of Institutional Group Meals Compared to the Non-eaters
| Date | Type | Exposed (eaters) | Unexposed (non-eaters) | RR (95% CI) | p-value | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Subtotal | Anti-HEV IgM+ | Prevalence rate | Subtotal | Anti-HEV IgM+ | Prevalence rate | |||||
| February 2 | Lunch | 51 | 5 | 9.8 | 363 | 9 | 2.5 | 3.95 (1.38–11.34) | 0.02 | |
| February 14 | Dinner | 64 | 6 | 9.4 | 582 | 17 | 2.9 | 3.21 (1.31–7.85) | 0.02 | |
| February 17 | Dinner | 56 | 5 | 8.9 | 358 | 9 | 2.5 | 3.55 (1.24–10.21) | 0.04 | |
| February 18 | Dinner | 53 | 5 | 9.4 | 361 | 9 | 2.5 | 3.78 (1.32–10.86) | 0.03 | |
RR, relative risk; HEV, hepatitis E virus; IgM, immunoglobulin M; CI, confidence interval.
Among the 24 HEV antibody-positive and 522 HEV IgM-negative employees, COVID-19 infection and vaccination before anti-HEV testing were investigated using the national COVID-19 management system. We identified no significant difference in the cumulative COVID-19 infection rate (45.8% vs 40.9%) or 90-day COVID-19 infection rate before anti-HEV testing (29.2% vs 35.5%) between the anti-HEV IgM-positive and -negative groups (Table 3). More than 97% of the employees were vaccinated at least once against COVID-19. However, the anti-HEV IgM positive group showed a significantly higher rate of COVID-19 vaccination more than two times (83.3% vs 48.7%, p=0.021), as well as a higher rate of recent vaccination within 90 days before anti-HEV testing (45.8% vs 19.7%, p=0.008). Interestingly, a significant difference was found in the most recent COVID-19 vaccine used; namely, the Moderna vaccine was more commonly used in the anti-HEV IgM positive group (75.0%) than in the negative group (14.5%) (p<0.001) (Table 3).
Table 3. Comparison of the Rates of COVID-19 Infection and Vaccination before HEV Antibody Testing Date between the Anti-HEV Positive and Negative Groups
| COVID-19 infection or vaccination before HEV testing date | Anti HEV-IgM positive (n=24) | Anti HEV-IgM negative (n=552) | p-value |
|---|---|---|---|
| COVID-19 infection | |||
| Ever infected | 11 (45.8) | 226 (40.9) | 0.675 |
| Recent infection (<90 day) | 7 (29.2) | 196 (35.5) | 0.664 |
| COVID-19 vaccination | |||
| Ever vaccinated | 24 (100) | 535 (96.9) | 1.000 |
| No. of vaccination | 0.021 | ||
| 1 | 0 | 10 (1.8) | |
| 2 | 4 (16.7) | 256 (46.4) | |
| 3 | 20 (83.3) | 266 (48.2) | |
| 4 | 0 | 3 (0.5) | |
| Recent vaccination (<90 day) | 11 (45.8) | 109 (19.7) | 0.008 |
| Last vaccine manufacturer | <0.001 | ||
| Moderna | 18 (75.0) | 80 (14.5) | |
| Pfizer | 6 (25.0) | 411 (74.5) | |
| Janssen | 0 | 7 (1.3) | |
| AstraZeneca (AZ) | 0 | 3 (0.5) | |
| Novavax | 0 | 1 (0) | |
| Missing | 0 | 33 (6.0) | |
| Detailed vaccination profile | <0.001 | ||
| 1st | |||
| Pfizer | 0 | 5 (0.9) | |
| Janssen | 0 | 4 (0.7) | |
| Missing | 0 | 1 (0.2) | |
| 1st-2nd | |||
| Moderna-Moderna | 3 (12.5) | 161 (29.2) | |
| Pfizer-Pfizer | 1 (4.2) | 11 (2.0) | |
| Janssen-Pfizer | 0 | 10 (1.8) | |
| Janssen-Moderna | 0 | 39 (7.1) | |
| Others | 0 | 16 (2.9) | |
| 1st-2nd-3rd | |||
| Moderna-Moderna-Moderna | 13 (54.2) | 16 (2.9) | |
| Pfizer-Pfizer-Pfizer | 5 (20.8) | 192 (34.8) | |
| AZ-AZ-Moderna | 1 (4.2) | 16 (2.9) | |
| AZ-AZ-Pfizer | 1 (4.2) | 9 (1.6) | |
| AZ-Pfizer-Pfizer | 0 | 8 (1.4) | |
| Pfizer-Pfizer-Moderna | 0 | 2 (0.4) | |
| Missing | 0 | 22 (4.0) | |
| 1st-2nd-3rd-4th | |||
| AZ-AZ-Moderna-Novavax | 0 | 1 (0.2) | |
| AZ-AZ-Moderna-Pfizer | 0 | 1 (0.2) | |
| AZ-AZ-AZ-Pfizer | 0 | 1 (0.2) |
COVID-19, coronavirus disease 2019; HEV, hepatitis E virus; IgM, immunoglobulin M.
As shown in Table 4, univariate analysis revealed that the specific day group meal intake (lunch on February 2, dinner on February 14, and dinner on February 17), vaccination rate within 90 days of anti-HEV testing (OR, 3.44; 95% CI, 1.50 to 7.89; p=0.004), receiving over 3 doses of COVID-19 vaccination (OR, 5.26; 95% CI, 1.78 to 15.59; p=0.003), and Moderna vaccine use as the last vaccine (OR, 17.06; 95% CI, 6.57 to 44.30; p<0.001) were significantly related to HEV IgM positivity (Table 4). In four multivariable models, three or more COVID-19 vaccinations and the use of the Moderna vaccine as the last vaccine were consistently associated with anti-HEV IgM positivity, while specific day group meal intake was a significant factor in the model. Among the 24 individuals tested as anti-HEV positive, 17 were not exposed to any of the four related group meals (no exposure group), and seven had at least one of these meals (exposure group). Compared to the exposure group, the non-exposure group showed a significantly higher rate of COVID-19 vaccination over three times and a higher rate of the last vaccination within 90 days of anti-HEV testing (Table 5).
Table 4. Results of Logistic Regression Analysis for Factors Associated with Anti HEV-IgM Positivity
| Univariate model | Multivariate model 1 | Multivariate model 2 | Multivariate model 3 | Multivariate model 4 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | |||||
| Age | 0.99 (0.95–1.03) | 0.611 | ||||||||||||
| Female sex | 1.36 (0.55–3.34) | 0.507 | ||||||||||||
| Production worker | 0.95 (0.40–2.25) | 0.901 | ||||||||||||
| Group meal (lunch on February 2) | 2.92 (1.05–8.15) | 0.041 | 2.93 (0.88–9.74) | 0.079 | ||||||||||
| Group meal (dinner on February 14) | 3.21 (1.23–8.41) | 0.017 | 3.04 (0.99–9.32) | 0.052 | ||||||||||
| Group meal (dinner on February 17) | 3.55 (1.35–9.32) | 0.010 | 3.26 (1.03–10.31) | 0.044 | ||||||||||
| Group meal (dinner on February 18) | 2.74 (0.99–7.64) | 0.053 | 2.34 (0.71–7.63) | 0.161 | ||||||||||
| COVID-19 infection within 90 day of HEV antibody testing | 0.90 (0.36–2.20) | 0.808 | ||||||||||||
| COVID-19 vaccination within 90 day of HEV antibody testing | 3.44 (1.50–7.89) | 0.004 | 2.07 (0.74–5.81) | 0.169 | 1.78 (0.64–4.91) | 0.267 | 1.71 (0.61–4.75) | 0.305 | 1.78 (0.65–4.91) | 0.264 | ||||
| More than 3 time of COVID-19 vaccination | 5.26 (1.78–15.59) | 0.003 | 4.22 (1.20–14.86) | 0.025 | 4.59 (1.31–16.11) | 0.018 | 4.46 (1.28–15.59) | 0.019 | 4.51 (1.29–15.71) | 0.018 | ||||
| Moderna vaccination | 17.06 (6.57–44.30) | <0.001 | 18.90 (7.05–50.67) | <0.001 | 19.56 (7.26–52.70) | <0.001 | 19.69 (7.30–53.09) | <0.001 | 19.13 (7.15–51.10) | <0.001 | ||||
HEV, hepatitis E virus; IgM, immunoglobulin M; OR, odds ratio; CI, confidence interval.
Table 5. Comparison of the Rates of COVID-19 Infection and Vaccination before HEV Antibody Testing According to Exposure to the High-Risk Group Meal* in the Anti-HEV Positive Group
| Anti-HEV positive persons (n=24) | p-value | ||
|---|---|---|---|
| No exposure (n=17) | Exposure (n=7) | ||
| COVID-19 infection | |||
| Ever infected | 7 (41.2) | 4 (57.1) | 0.476 |
| Recent infection (<90 day) | 5 (29.4) | 2 (28.6) | 0.967 |
| COVID-19 vaccination | |||
| Ever vaccinated | 17 (100) | 7 (100) | 1.000 |
| No. of vaccination | 0.027 | ||
| 2 | 1 (5.9) | 3 (42.9) | |
| 3 | 16 (94.1) | 4 (57.1) | |
| Recent vaccination (<90 day) | 10 (58.8) | 1 (14.3) | 0.047 |
| Last vaccine manufacturer | 0.195 | ||
| Moderna | 14 (82.4) | 4 (57.1) | |
| Pfizer | 3 (17.6) | 3 (42.9) | |
| Detailed vaccination profile | 0.011 | ||
| 1st-2nd | |||
| Moderna-Moderna | 1 (5.9) | 2 (28.6) | |
| Pfizer-Pfizer | 0 | 1 (14.3) | |
| 1st-2nd-3rd | |||
| Moderna-Moderna-Moderna | 13 (76.5) | 0 | |
| Pfizer-Pfizer-Pfizer | 3 (17.6) | 2 (28.6) | |
| AZ-AZ-Moderna | 0 | 1 (14.3) | |
| AZ-AZ-Pfizer | 0 | 1 (14.3) | |
COVID-19, coronavirus disease 2019; HEV, hepatitis E virus; AZ, AstraZeneca.
*Definition of high-risk group meal: patient who had exposure to lunch on the February 2, dinner on the February 14, dinner on the February 17, or dinner on the February 18.
This epidemiological investigation of 24 cases of anti-HEV IgM positivity initially presumed to be an HEV outbreak showed that anti-HEV IgM positivity may be a false-positive result related to COVID-vaccination over three times and use of the Moderna vaccine, while a portion of true HEV infection may not be excluded because a certain-day group meal intake was significantly associated with anti-HEV IgM positivity in multivariate analysis. This peculiar experience should raise awareness regarding the COVID-19 pandemic and widespread COVID-19 vaccination.
In Korea, cases of acute hepatitis caused by HEV have rarely been reported since 2002; however, cases may still occur sporadically and can be accompanied by typical hepatitis symptoms. As a class 2 notifiable infectious disease the reported number of hepatitis E cases over the 2 years from July 2020 to June 2022 was 938. However, the HEV antibody prevalence (IgG anti-HEV) of individuals using blood samples from the National Health and Nutrition Survey in 2005 and during 2007 to 2009 showed an increase with age: less than 10% in individuals in their 30s, 10% to 20% in 40s, 20% to 30% in 50s, 40% in 60s or older, and 5.9% in the domestic population aged 10 to 55 years.10,11 The large gap between the number of cases and HEV seroprevalence suggests that the majority of HEV infections are asymptomatic, which is consistent with the results of this study.
In the present study, intake of the four groups of meats was higher in the anti-HEV IgM-positive group than in the negative group, and intake of dinner on February 18 was an independent factor associated with anti-HEV IgM positivity in multivariate analysis. This result was compatible with Hills criteria, including the intensity of association, temporal precedence, and biological plausibility. This indicates that group meal intake may be associated with HEV infection or anti-HEV IgM positivity, although we did not detect HEV RNA in the related foods. In addition, among the anti-HEV positive individuals, a subgroup that consumed the risk group meal showed a lower rate of COVID-19 vaccination than the non-intake group.
The examination of these 24 cases of anti-HEV IgM positivity was interesting as this was the second event of an HEV outbreak in South Korea. However, all cases were asymptomatic and all HEV RNA tests were negative. In addition, the anti-HEV IgM positivity rates among the tested employees in the same factory were 0% in 2018 to 2019, 0.8% in 2020, 1.7% in 2021, and 3.7% in 2022. Therefore, we believe that these peculiar findings may reflect a false-positive reaction of anti-HEV IgM related to widespread COVID-19 infection or COVID-19 vaccination. However, we found no significant difference in the cumulative COVID-19 infection rate or the rate within the 90 days prior to anti-HEV testing between the anti-HEV IgM-positive and -negative groups.
In our analysis, multiple vaccinations against COVID-19 (over three times) and the use of the Moderna vaccine were consistently associated with anti-HEV IgM positivity in our four multivariate analysis models. This suggests a false-positive reaction to anti-HEV IgM after the COVID-19 vaccination. COVID-19 infection causes liver injuries such as cholangiopathy and chronic cholestasis,12,13 and COVID-19 vaccination may induce autoimmune hepatitis. However, COVID-vaccination-induced false-positive HEV serology reaction was not yet reported. Because anti-HEV false positivity was observed in hepatitis A, Epstein-Barr infection, and autoimmune hepatitis, the assumed mechanism of false positivity in our study was a systemic inflammatory response generated by COVID-19 vaccination with predominantly RNA vaccines. Both the Pfizer and Moderna vaccines are lipid-formulated RNA vaccines. The vaccine adjuvant activity of the lipid formulation itself or modified or unmodified single-stranded RNA induces a strong innate immune response.14 Recent studies have shown that Moderna has a higher antibody titer, lasts longer, and prevents breakthrough infection better than the Pfizer vaccine,15 which may be related to differences in RNA amount, lipid nanoparticle composition, and vaccination interval.16 In fact, a recent study reported that false reactivity in common infectious disease serologies such as Epstein-Barr virus, measles, and rubella after mRNA vaccination and it was more likely to occur in those receiving the Moderna vaccine in a longitudinal cohort.17 These findings are consistent with our results showing a strong association between anti-HEV positivity and the use of Moderna vaccine. To the best of our knowledge, this is the first study to report an association between COVID-19 vaccination and anti-HEV positivity.
This study has several limitations including its retrospective cohort nature and the non-optimal timing of HEV RNA testing for blood and environmental samples. Furthermore, detailed laboratory results including complete blood count with differential were not available due to the epidemiological investigation setting. Finally, there is no standard diagnostic method for hepatitis E that is commonly used worldwide until now,18 and only one available test was performed in this study. Finally, there is a lack of basic studies and literature reports on the mechanisms for the false-positive results of anti-HEV IgM after COVID-19 vaccination.
In conclusion, the results of this study indicate that anti-HEV IgM positivity may be a false-positive result related to COVID-vaccination over three times and the use of the Moderna vaccine, while a portion of true HEV infection may not be excluded. Further studies on the mechanisms underlying these results are warranted.
The authors extend their appreciation to the technical staffs, Song A Park, Sun-Whan Park, Deog-Yong Lee, at the Division of Viral Diseases, Korea Disease Control and Prevention Agency for their analysis in conducting the research. We also extend our appreciation to the study participants for their time and effort in providing the data for this research.
No potential conflict of interest relevant to this article was reported.
Study concept and design: S.H.J. Data acquisition: J.O., Y.C., J.K. Data analysis and interpretation: S.H.J., J.O., G.H.C. Drafting of the manuscript: S.H.J., J.O., G.H.C. Critical revision of the manuscript for important intellectual content: S.H.J., J.O., G.H.C. Statistical analysis: S.H.J., J.O., G.H.C. Administrative, technical, or material support; study supervision: K.P., H.Y., S.S., J.G. Approval of final manuscript: all authors.
Gut and Liver 2024; 18(3): 531-538
Published online May 15, 2024 https://doi.org/10.5009/gnl230098
Copyright © Gut and Liver.
Jeonghyeon Oh1 , Gwang Hyeon Choi2 , Yeonhwa Chang1 , Jina Kim1 , Kunhee Park1 , Hansol Yeom3 , Soonryu Seo3 , Jin Gwack3 , Sook-Hyang Jeong2
1Gyeonggi Infectious Disease Control Center, Health Bureau, Gyeonggi Provincial Government, Suwon, Korea; 2Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea; 3Division of Infectious Disease Control, Korea Disease Control and Prevention Agency, Osong Health Technology Administration Complex, Cheongju, Korea
Correspondence to:Sook-Hyang Jeong
ORCID https://orcid.org//0000-0002-4916-7990
E-mail jsh@snubh.org
Jeonghyeon Oh and Gwang Hyeon Choi contributed equally to this work as first authors.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Background/Aims: To investigate a reported outbreak of presumed hepatitis E virus (HEV) infection in a Korean food manufacturing facility and to explore the association between anti-HEV immunoglobulin M (IgM) positivity and coronavirus disease 2019 (COVID-19) infection or vaccination.
Methods: Twenty-four cases of anti-HEV IgM positivity were reported among 646 workers at the facility in 2022. An epidemiological investigation was conducted, comprising HEV-RNA testing of blood and environmental samples, analysis of group meal records, and an association between anti-HEV IgM positivity and confirmed COVID-19 infection or vaccination.
Results: All 24 patients were asymptomatic, with cases spread sporadically across the facility. HEV RNA was not detected in the serum or environmental samples. Four out of 340 meals (1.2%) showed a significantly higher proportion of anti-HEV positivity in each meal intake group than in the non-intake group on certain days. Although the cumulative rate of COVID-19 infection showed no difference, the anti-HEV IgM positive group showed significantly higher proportions of >2 doses of COVID-19 vaccination (83.3% vs 48.7%, p=0.021), vaccination within 90 days (45.8% vs 19.7%, p=0.008), and having the Moderna vaccine administered as the last vaccine (75.0% vs 14.5%, p<0.001) than those of the anti-HEV negative group. In four multivariable models, three or more COVID-19 vaccinations and the Moderna vaccine as the last vaccine were consistently associated with anti-HEV IgM positivity, while the specific day group meal intake was also a significant factor.
Conclusions: This epidemiological investigation showed that anti-HEV IgM positivity may occur as a false-positive result related to COVID-vaccination over three times and use of the Moderna vaccine, although a portion of true HEV infection may not be excluded.
Keywords: Hepatitis E, Diagnosis, Epidemiology, COVID-19, Vaccination
The hepatitis E virus (HEV) is a major cause of acute viral hepatitis worldwide,1 with 20 million incident cases, including 3 million symptomatic cases (14.5%) occurring globally every year. World Health Organization estimated 44,000 deaths attributed to HEV in 2015.2 HEV infection spreads via fecal-to-oral transmission through the ingestion of HEV-contaminated water or incompletely cooked animal meat, including animal livers, particularly pork. Acute hepatitis E may progress to chronic hepatitis, liver cirrhosis, or liver cancer, particularly in immunocompromised patients.3
Acute hepatitis E is generally diagnosed by anti-HEV immunoglobulin M (IgM) positivity in blood or HEV RNA positivity (by reverse-transcription polymerase chain reaction) in the blood or stool.4 However, anti-HEV IgM tests show a low concordance rate among the different test kits and false-positive results in cases of hepatitis A,5 Epstein-Barr viral infection,6 and autoimmune hepatitis.7 The HEV RNA test frequently shows a false negative result following symptom development due to rapid reduction of viremic levels and it is not available in many countries.
Since July 2020, in South Korea, where the anti-HEV IgG prevalence in the population aged 10 to 55 years is 5.9%, all hepatitis E cases have been reported to the Korea Disease Control and Prevention Agency as a class 2 notifiable infectious disease in the mandatory surveillance system. While only one HEV outbreak has been reported in South Korea so far, sporadic cases of HEV infection related to zoonosis have been noted.8,9 Herein, we report on an outbreak of presumed HEV infection in a food manufacturing facility, and explore the association between anti-HEV IgM positivity and coronavirus disease 2019 (COVID-19) infection or COVID-19 vaccination.
Three and one cases of anti-HEV IgM positivity were detected among employees of a food manufacturing facility during annual health examinations for employees on April 13 and April 20, 2022, respectively. All of these first-detected four cases were asymptomatic. The infectious disease control center in the provincial government subsequently initiated an epidemiological investigation of the presumed HEV outbreak on April 26. The subjects of the investigation were 646 employees working at the facility, including at a production plant, research company, and contractor-in-charge of cleaning or washing from February 1 to April 26, 2022, considering the incubation period of HEV infection. Epidemiological investigators requested serum anti-HEV IgM testing for all employees. Fifteen testing rounds were subsequently performed from April 21 to May 20, identifying a total of 24 cases of anti-HEV IgM positivity. On-site investigations were conducted by epidemiological investigators from Gyeonggi Province, the health center, and sanitation departments of the city. Epidemiological data, such as demographic and clinical characteristics of the employees, meal intake history, and environmental factors, were obtained from company records and interviews with workers. This study was approved by the IRB of Seoul National University Bundang Hospital (IRB number: X-2029-781-902), and the need for informed consent was waived due to the retrospective research design.
Currently, the only approved anti-HEV IgM testing kit in South Korea is the enzyme-linked immunosorbent assay produced by AB Diagnostic System GmbH (Berlin, Germany), abia HEV IgM. Among the 24 cases of anti-HEV IgM positivity, 17 obtained on May 6 and May 9 were tested for HEV RNA using the PowerCheck HEV virus qRT-PCR kit (Kogene Biotech, Seoul, Korea), which included primers and probes with HEV genome sequences in the ORF2/3 region. Environmental samples were obtained from the facility and tested for HEV RNA by qRT-PCR using TaqMan analysis with primers and probes targeting the ORF 2/3 region. These samples included groundwater, common items, water purifiers, raw and complete food products, cooking utensils, and preserved food materials, especially meat and shellfish, in the cafeteria for employees (May 4 to 9). The factory operated a closed production system, meaning no direct contact with the raw materials of products for employees.
Only the employees used one cafeteria in the factory. The intake of the group meal was traced using the meal card tagging system data from February 1 to April 26, the presumed incubation period of the HEV. The meal intake group was defined as those who ate meals at least once in the cafeteria that served four meals per day (breakfast, lunch, dinner, or late-night meals; n=508), while those who never used the cafeteria were defined as the non-intake group (n=138). Comparison of anti-HEV IgM positivity between the meal intake and non-intake groups was shown as the relative risk (RR), and statistically significant data were included as variables for further univariate and multivariate analyses to identify factors associated with anti-HEV IgM positivity.
Using COVID-19 information and the vaccination management system operated by the Korea Disease Control and Prevention Agency, we analyzed the COVID-19 infection and vaccination statuses of 576 employees among a total of 646 subjects. The COVID-19 infection rates within 90 days prior to anti-HEV testing between the anti-HEV IgM-positive and -negative groups were subsequently compared. Additionally, COVID-19 vaccination rates and vaccine types were compared between the anti-HEV IgM-positive and -negative groups. Univariate and multivariate analyses were performed to determine whether these variables were independent factors affecting the HEV antibody positivity.
The epidemiological characteristics of the groups are descriptively presented as frequencies for nominal variables and median and interquartile range or mean and standard deviation for continuous variables. The Fisher exact test for nominal variables and the Mann-Whitney U test for continuous variables were used for comparison between the two groups. Comparisons between anti-HEV IgM positivity in a specific day meal intake group and non-intake group were analyzed using RR. Univariate and multivariate analyses were performed using logistic regression to identify independent variables related to anti-HEV IgM positivity, and odds ratios (OR) with 95% confidence intervals (CI) were calculated. Statistical analysis was performed using R (version x64 4.0.5; R Foundation for Statistical Computing, Vienna, Austria) and SPSS version 21 (IBM Corp., Armonk, NY, USA), and p<0.05 was considered statistically significant.
Among 646 employees, the HEV-IgM positivity rate was 3.7% (n=24). In-depth interviews with the 24 employees showed that eight people had a history of eating undercooked meat or salted fish/shellfish (beef tartare in four, salted and fermented squid in four, salted pollack roe in one, and salted small octopus in one person). However, none of the patients showed symptoms of hepatitis. None visited the health management office in the facility or clinic because of hepatitis-related symptoms during the study period, which was confirmed by checking the Drug Utilization Review system. Eight patients had a history of hypertension or diabetes, and one person had been diagnosed with liver cirrhosis. Among the 10 patients who were tested for alanine aminotransferase, three showed mildly elevated alanine aminotransferase levels (45, 59, and 98 IU/L) (Table 1). Also, none of the anti-HEV IgM positivity cases showed hepatitis A virus infection in their test result, likewise four employees who tested positive for hepatitis A virus showed no HEV infection. There were no differences in terms of age, sex, affiliated workplace, and occupation between the anti-HEV positive and negative groups, as shown in Table 1. The median age was 42.5 years, 76.5% were men, and anti-HEV IgM positivity was not concentrated in a specific workplace.
Table 1 . Demographic Characteristics According to Anti-HEV IgM-Positivity.
| Variable | Total | Anti-HEV IgM positive (n=24) | Anti-HEV IgM negative (n=622) | p-value |
|---|---|---|---|---|
| Age, median (IQR), yr (n=638)* | 42.5 (34–52) | 43.0 (30–50) | 42.0 (34–52) | 0.579 |
| Age group, No. (%) (n=638)* | 0.072 | |||
| 20–29 yr | 82 (12.9) | 7 (29.2) | 75 (12.2) | |
| 30–39 yr | 180 (28.2) | 3 (12.5) | 177 (28.8) | |
| 40–49 yr | 173 (27.1) | 8 (33.3) | 165 (26.9) | |
| 50–59 yr | 162 (25.4) | 4 (16.6) | 158 (25.7) | |
| ≥60 yr | 41 (6.4) | 2 (8.4) | 39 (6.4) | |
| Sex, No. (%) (n=638)* | 0.505 | |||
| Male | 488 (76.5) | 17 (70.8) | 471 (76.7) | |
| Female | 150 (23.5) | 7 (29.2) | 143 (28.3) | |
| Affiliation, No. (%) | 0.168 | |||
| Factory | 414 (64.1) | 12 (50.0) | 402 (64.6) | |
| Company A | 113 (17.5) | 6 (25.0) | 107 (17.2) | |
| Company B | 11 (1.7) | 1 (4.2) | 10 (1.6) | |
| Company C | 39 (6.0) | 3 (12.5) | 36 (5.8) | |
| Contractor | 69 (10.7) | 2 (8.3) | 67 (10.8) | |
| Job position, No. (%) | 0.901 | |||
| Production worker | 223 (34.5) | 8 (33.3) | 215 (34.6) | |
| Non-production worker | 423 (65.5) | 16 (66.7) | 407 (65.4) | |
| Institutional group meal intake at least once | 508 (78.6) | 10 (41.7) | 498 (80.1) | 0.000 |
| Total bilirubin level, mean±SD, mg/dL (n=101) | 1.0±1.7 | 0.8±0.2 | 1.0±1.8 | 0.458 |
| AST, mean±SD, IU/L (n=223) | 25.7±12.7 | 25.7±11.5 | 25.6±12.8 | 0.994 |
| ALT, mean±SD, IU/L (n=222) | 27.9±21.6 | 33.1±27.2 | 27.6±21.6 | 0.468 |
HEV, hepatitis E virus; IgM, immunoglobulin M; IQR, interquartile range; AST, aspartate aminotransferase; ALT, alanine aminotransferase..
*Number of workers at the investigation time excluding resigned persons..
Serum HEV RNA was negative in 17 employees with anti-HEV IgM positivity. The blood sampling interval between anti-HEV and HEV RNA testing ranged from to 3–15 days. Moreover, HEV-RNA was not detected in any of the environmental samples, including six samples collected from water purifiers, washing water, and common objects in the factory; seven samples from groundwater wells used for washing equipment; and four from raw materials and products.
During the study period, four out of 340 meals (1.2%) showed a significantly higher proportion of anti-HEV positivity in the meal intake group than in the non-intake group (Table 2). The detailed menu of the four meals is as follows: stir-fried pork kimchi (lunch on February 2: RR, 3.95; 95% CI, 1.38 to 11.34), braised pork ribs, chicken fillet (dinner on February 14: RR, 3.21; 95% CI, 1.31 to 7.85), pork cutlet (dinner on February 17: RR, 3.55; 95% CI, 1.24 to 10.21), and fried chicken (dinner on February 18: RR, 3.78; 95% CI, 1.32 to 10.86), although all dishes were completely cooked by boiling or deep frying. HEV-anti-IgM test results were negative for all nine food handlers.
Table 2 . Summary of Significantly Higher RRs of Anti-HEV Positivity in the Eaters of Institutional Group Meals Compared to the Non-eaters.
| Date | Type | Exposed (eaters) | Unexposed (non-eaters) | RR (95% CI) | p-value | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Subtotal | Anti-HEV IgM+ | Prevalence rate | Subtotal | Anti-HEV IgM+ | Prevalence rate | |||||
| February 2 | Lunch | 51 | 5 | 9.8 | 363 | 9 | 2.5 | 3.95 (1.38–11.34) | 0.02 | |
| February 14 | Dinner | 64 | 6 | 9.4 | 582 | 17 | 2.9 | 3.21 (1.31–7.85) | 0.02 | |
| February 17 | Dinner | 56 | 5 | 8.9 | 358 | 9 | 2.5 | 3.55 (1.24–10.21) | 0.04 | |
| February 18 | Dinner | 53 | 5 | 9.4 | 361 | 9 | 2.5 | 3.78 (1.32–10.86) | 0.03 | |
RR, relative risk; HEV, hepatitis E virus; IgM, immunoglobulin M; CI, confidence interval..
Among the 24 HEV antibody-positive and 522 HEV IgM-negative employees, COVID-19 infection and vaccination before anti-HEV testing were investigated using the national COVID-19 management system. We identified no significant difference in the cumulative COVID-19 infection rate (45.8% vs 40.9%) or 90-day COVID-19 infection rate before anti-HEV testing (29.2% vs 35.5%) between the anti-HEV IgM-positive and -negative groups (Table 3). More than 97% of the employees were vaccinated at least once against COVID-19. However, the anti-HEV IgM positive group showed a significantly higher rate of COVID-19 vaccination more than two times (83.3% vs 48.7%, p=0.021), as well as a higher rate of recent vaccination within 90 days before anti-HEV testing (45.8% vs 19.7%, p=0.008). Interestingly, a significant difference was found in the most recent COVID-19 vaccine used; namely, the Moderna vaccine was more commonly used in the anti-HEV IgM positive group (75.0%) than in the negative group (14.5%) (p<0.001) (Table 3).
Table 3 . Comparison of the Rates of COVID-19 Infection and Vaccination before HEV Antibody Testing Date between the Anti-HEV Positive and Negative Groups.
| COVID-19 infection or vaccination before HEV testing date | Anti HEV-IgM positive (n=24) | Anti HEV-IgM negative (n=552) | p-value |
|---|---|---|---|
| COVID-19 infection | |||
| Ever infected | 11 (45.8) | 226 (40.9) | 0.675 |
| Recent infection (<90 day) | 7 (29.2) | 196 (35.5) | 0.664 |
| COVID-19 vaccination | |||
| Ever vaccinated | 24 (100) | 535 (96.9) | 1.000 |
| No. of vaccination | 0.021 | ||
| 1 | 0 | 10 (1.8) | |
| 2 | 4 (16.7) | 256 (46.4) | |
| 3 | 20 (83.3) | 266 (48.2) | |
| 4 | 0 | 3 (0.5) | |
| Recent vaccination (<90 day) | 11 (45.8) | 109 (19.7) | 0.008 |
| Last vaccine manufacturer | <0.001 | ||
| Moderna | 18 (75.0) | 80 (14.5) | |
| Pfizer | 6 (25.0) | 411 (74.5) | |
| Janssen | 0 | 7 (1.3) | |
| AstraZeneca (AZ) | 0 | 3 (0.5) | |
| Novavax | 0 | 1 (0) | |
| Missing | 0 | 33 (6.0) | |
| Detailed vaccination profile | <0.001 | ||
| 1st | |||
| Pfizer | 0 | 5 (0.9) | |
| Janssen | 0 | 4 (0.7) | |
| Missing | 0 | 1 (0.2) | |
| 1st-2nd | |||
| Moderna-Moderna | 3 (12.5) | 161 (29.2) | |
| Pfizer-Pfizer | 1 (4.2) | 11 (2.0) | |
| Janssen-Pfizer | 0 | 10 (1.8) | |
| Janssen-Moderna | 0 | 39 (7.1) | |
| Others | 0 | 16 (2.9) | |
| 1st-2nd-3rd | |||
| Moderna-Moderna-Moderna | 13 (54.2) | 16 (2.9) | |
| Pfizer-Pfizer-Pfizer | 5 (20.8) | 192 (34.8) | |
| AZ-AZ-Moderna | 1 (4.2) | 16 (2.9) | |
| AZ-AZ-Pfizer | 1 (4.2) | 9 (1.6) | |
| AZ-Pfizer-Pfizer | 0 | 8 (1.4) | |
| Pfizer-Pfizer-Moderna | 0 | 2 (0.4) | |
| Missing | 0 | 22 (4.0) | |
| 1st-2nd-3rd-4th | |||
| AZ-AZ-Moderna-Novavax | 0 | 1 (0.2) | |
| AZ-AZ-Moderna-Pfizer | 0 | 1 (0.2) | |
| AZ-AZ-AZ-Pfizer | 0 | 1 (0.2) |
COVID-19, coronavirus disease 2019; HEV, hepatitis E virus; IgM, immunoglobulin M..
As shown in Table 4, univariate analysis revealed that the specific day group meal intake (lunch on February 2, dinner on February 14, and dinner on February 17), vaccination rate within 90 days of anti-HEV testing (OR, 3.44; 95% CI, 1.50 to 7.89; p=0.004), receiving over 3 doses of COVID-19 vaccination (OR, 5.26; 95% CI, 1.78 to 15.59; p=0.003), and Moderna vaccine use as the last vaccine (OR, 17.06; 95% CI, 6.57 to 44.30; p<0.001) were significantly related to HEV IgM positivity (Table 4). In four multivariable models, three or more COVID-19 vaccinations and the use of the Moderna vaccine as the last vaccine were consistently associated with anti-HEV IgM positivity, while specific day group meal intake was a significant factor in the model. Among the 24 individuals tested as anti-HEV positive, 17 were not exposed to any of the four related group meals (no exposure group), and seven had at least one of these meals (exposure group). Compared to the exposure group, the non-exposure group showed a significantly higher rate of COVID-19 vaccination over three times and a higher rate of the last vaccination within 90 days of anti-HEV testing (Table 5).
Table 4 . Results of Logistic Regression Analysis for Factors Associated with Anti HEV-IgM Positivity.
| Univariate model | Multivariate model 1 | Multivariate model 2 | Multivariate model 3 | Multivariate model 4 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | |||||
| Age | 0.99 (0.95–1.03) | 0.611 | ||||||||||||
| Female sex | 1.36 (0.55–3.34) | 0.507 | ||||||||||||
| Production worker | 0.95 (0.40–2.25) | 0.901 | ||||||||||||
| Group meal (lunch on February 2) | 2.92 (1.05–8.15) | 0.041 | 2.93 (0.88–9.74) | 0.079 | ||||||||||
| Group meal (dinner on February 14) | 3.21 (1.23–8.41) | 0.017 | 3.04 (0.99–9.32) | 0.052 | ||||||||||
| Group meal (dinner on February 17) | 3.55 (1.35–9.32) | 0.010 | 3.26 (1.03–10.31) | 0.044 | ||||||||||
| Group meal (dinner on February 18) | 2.74 (0.99–7.64) | 0.053 | 2.34 (0.71–7.63) | 0.161 | ||||||||||
| COVID-19 infection within 90 day of HEV antibody testing | 0.90 (0.36–2.20) | 0.808 | ||||||||||||
| COVID-19 vaccination within 90 day of HEV antibody testing | 3.44 (1.50–7.89) | 0.004 | 2.07 (0.74–5.81) | 0.169 | 1.78 (0.64–4.91) | 0.267 | 1.71 (0.61–4.75) | 0.305 | 1.78 (0.65–4.91) | 0.264 | ||||
| More than 3 time of COVID-19 vaccination | 5.26 (1.78–15.59) | 0.003 | 4.22 (1.20–14.86) | 0.025 | 4.59 (1.31–16.11) | 0.018 | 4.46 (1.28–15.59) | 0.019 | 4.51 (1.29–15.71) | 0.018 | ||||
| Moderna vaccination | 17.06 (6.57–44.30) | <0.001 | 18.90 (7.05–50.67) | <0.001 | 19.56 (7.26–52.70) | <0.001 | 19.69 (7.30–53.09) | <0.001 | 19.13 (7.15–51.10) | <0.001 | ||||
HEV, hepatitis E virus; IgM, immunoglobulin M; OR, odds ratio; CI, confidence interval..
Table 5 . Comparison of the Rates of COVID-19 Infection and Vaccination before HEV Antibody Testing According to Exposure to the High-Risk Group Meal* in the Anti-HEV Positive Group.
| Anti-HEV positive persons (n=24) | p-value | ||
|---|---|---|---|
| No exposure (n=17) | Exposure (n=7) | ||
| COVID-19 infection | |||
| Ever infected | 7 (41.2) | 4 (57.1) | 0.476 |
| Recent infection (<90 day) | 5 (29.4) | 2 (28.6) | 0.967 |
| COVID-19 vaccination | |||
| Ever vaccinated | 17 (100) | 7 (100) | 1.000 |
| No. of vaccination | 0.027 | ||
| 2 | 1 (5.9) | 3 (42.9) | |
| 3 | 16 (94.1) | 4 (57.1) | |
| Recent vaccination (<90 day) | 10 (58.8) | 1 (14.3) | 0.047 |
| Last vaccine manufacturer | 0.195 | ||
| Moderna | 14 (82.4) | 4 (57.1) | |
| Pfizer | 3 (17.6) | 3 (42.9) | |
| Detailed vaccination profile | 0.011 | ||
| 1st-2nd | |||
| Moderna-Moderna | 1 (5.9) | 2 (28.6) | |
| Pfizer-Pfizer | 0 | 1 (14.3) | |
| 1st-2nd-3rd | |||
| Moderna-Moderna-Moderna | 13 (76.5) | 0 | |
| Pfizer-Pfizer-Pfizer | 3 (17.6) | 2 (28.6) | |
| AZ-AZ-Moderna | 0 | 1 (14.3) | |
| AZ-AZ-Pfizer | 0 | 1 (14.3) | |
COVID-19, coronavirus disease 2019; HEV, hepatitis E virus; AZ, AstraZeneca..
*Definition of high-risk group meal: patient who had exposure to lunch on the February 2, dinner on the February 14, dinner on the February 17, or dinner on the February 18..
This epidemiological investigation of 24 cases of anti-HEV IgM positivity initially presumed to be an HEV outbreak showed that anti-HEV IgM positivity may be a false-positive result related to COVID-vaccination over three times and use of the Moderna vaccine, while a portion of true HEV infection may not be excluded because a certain-day group meal intake was significantly associated with anti-HEV IgM positivity in multivariate analysis. This peculiar experience should raise awareness regarding the COVID-19 pandemic and widespread COVID-19 vaccination.
In Korea, cases of acute hepatitis caused by HEV have rarely been reported since 2002; however, cases may still occur sporadically and can be accompanied by typical hepatitis symptoms. As a class 2 notifiable infectious disease the reported number of hepatitis E cases over the 2 years from July 2020 to June 2022 was 938. However, the HEV antibody prevalence (IgG anti-HEV) of individuals using blood samples from the National Health and Nutrition Survey in 2005 and during 2007 to 2009 showed an increase with age: less than 10% in individuals in their 30s, 10% to 20% in 40s, 20% to 30% in 50s, 40% in 60s or older, and 5.9% in the domestic population aged 10 to 55 years.10,11 The large gap between the number of cases and HEV seroprevalence suggests that the majority of HEV infections are asymptomatic, which is consistent with the results of this study.
In the present study, intake of the four groups of meats was higher in the anti-HEV IgM-positive group than in the negative group, and intake of dinner on February 18 was an independent factor associated with anti-HEV IgM positivity in multivariate analysis. This result was compatible with Hills criteria, including the intensity of association, temporal precedence, and biological plausibility. This indicates that group meal intake may be associated with HEV infection or anti-HEV IgM positivity, although we did not detect HEV RNA in the related foods. In addition, among the anti-HEV positive individuals, a subgroup that consumed the risk group meal showed a lower rate of COVID-19 vaccination than the non-intake group.
The examination of these 24 cases of anti-HEV IgM positivity was interesting as this was the second event of an HEV outbreak in South Korea. However, all cases were asymptomatic and all HEV RNA tests were negative. In addition, the anti-HEV IgM positivity rates among the tested employees in the same factory were 0% in 2018 to 2019, 0.8% in 2020, 1.7% in 2021, and 3.7% in 2022. Therefore, we believe that these peculiar findings may reflect a false-positive reaction of anti-HEV IgM related to widespread COVID-19 infection or COVID-19 vaccination. However, we found no significant difference in the cumulative COVID-19 infection rate or the rate within the 90 days prior to anti-HEV testing between the anti-HEV IgM-positive and -negative groups.
In our analysis, multiple vaccinations against COVID-19 (over three times) and the use of the Moderna vaccine were consistently associated with anti-HEV IgM positivity in our four multivariate analysis models. This suggests a false-positive reaction to anti-HEV IgM after the COVID-19 vaccination. COVID-19 infection causes liver injuries such as cholangiopathy and chronic cholestasis,12,13 and COVID-19 vaccination may induce autoimmune hepatitis. However, COVID-vaccination-induced false-positive HEV serology reaction was not yet reported. Because anti-HEV false positivity was observed in hepatitis A, Epstein-Barr infection, and autoimmune hepatitis, the assumed mechanism of false positivity in our study was a systemic inflammatory response generated by COVID-19 vaccination with predominantly RNA vaccines. Both the Pfizer and Moderna vaccines are lipid-formulated RNA vaccines. The vaccine adjuvant activity of the lipid formulation itself or modified or unmodified single-stranded RNA induces a strong innate immune response.14 Recent studies have shown that Moderna has a higher antibody titer, lasts longer, and prevents breakthrough infection better than the Pfizer vaccine,15 which may be related to differences in RNA amount, lipid nanoparticle composition, and vaccination interval.16 In fact, a recent study reported that false reactivity in common infectious disease serologies such as Epstein-Barr virus, measles, and rubella after mRNA vaccination and it was more likely to occur in those receiving the Moderna vaccine in a longitudinal cohort.17 These findings are consistent with our results showing a strong association between anti-HEV positivity and the use of Moderna vaccine. To the best of our knowledge, this is the first study to report an association between COVID-19 vaccination and anti-HEV positivity.
This study has several limitations including its retrospective cohort nature and the non-optimal timing of HEV RNA testing for blood and environmental samples. Furthermore, detailed laboratory results including complete blood count with differential were not available due to the epidemiological investigation setting. Finally, there is no standard diagnostic method for hepatitis E that is commonly used worldwide until now,18 and only one available test was performed in this study. Finally, there is a lack of basic studies and literature reports on the mechanisms for the false-positive results of anti-HEV IgM after COVID-19 vaccination.
In conclusion, the results of this study indicate that anti-HEV IgM positivity may be a false-positive result related to COVID-vaccination over three times and the use of the Moderna vaccine, while a portion of true HEV infection may not be excluded. Further studies on the mechanisms underlying these results are warranted.
The authors extend their appreciation to the technical staffs, Song A Park, Sun-Whan Park, Deog-Yong Lee, at the Division of Viral Diseases, Korea Disease Control and Prevention Agency for their analysis in conducting the research. We also extend our appreciation to the study participants for their time and effort in providing the data for this research.
No potential conflict of interest relevant to this article was reported.
Study concept and design: S.H.J. Data acquisition: J.O., Y.C., J.K. Data analysis and interpretation: S.H.J., J.O., G.H.C. Drafting of the manuscript: S.H.J., J.O., G.H.C. Critical revision of the manuscript for important intellectual content: S.H.J., J.O., G.H.C. Statistical analysis: S.H.J., J.O., G.H.C. Administrative, technical, or material support; study supervision: K.P., H.Y., S.S., J.G. Approval of final manuscript: all authors.
Table 1 Demographic Characteristics According to Anti-HEV IgM-Positivity
| Variable | Total | Anti-HEV IgM positive (n=24) | Anti-HEV IgM negative (n=622) | p-value |
|---|---|---|---|---|
| Age, median (IQR), yr (n=638)* | 42.5 (34–52) | 43.0 (30–50) | 42.0 (34–52) | 0.579 |
| Age group, No. (%) (n=638)* | 0.072 | |||
| 20–29 yr | 82 (12.9) | 7 (29.2) | 75 (12.2) | |
| 30–39 yr | 180 (28.2) | 3 (12.5) | 177 (28.8) | |
| 40–49 yr | 173 (27.1) | 8 (33.3) | 165 (26.9) | |
| 50–59 yr | 162 (25.4) | 4 (16.6) | 158 (25.7) | |
| ≥60 yr | 41 (6.4) | 2 (8.4) | 39 (6.4) | |
| Sex, No. (%) (n=638)* | 0.505 | |||
| Male | 488 (76.5) | 17 (70.8) | 471 (76.7) | |
| Female | 150 (23.5) | 7 (29.2) | 143 (28.3) | |
| Affiliation, No. (%) | 0.168 | |||
| Factory | 414 (64.1) | 12 (50.0) | 402 (64.6) | |
| Company A | 113 (17.5) | 6 (25.0) | 107 (17.2) | |
| Company B | 11 (1.7) | 1 (4.2) | 10 (1.6) | |
| Company C | 39 (6.0) | 3 (12.5) | 36 (5.8) | |
| Contractor | 69 (10.7) | 2 (8.3) | 67 (10.8) | |
| Job position, No. (%) | 0.901 | |||
| Production worker | 223 (34.5) | 8 (33.3) | 215 (34.6) | |
| Non-production worker | 423 (65.5) | 16 (66.7) | 407 (65.4) | |
| Institutional group meal intake at least once | 508 (78.6) | 10 (41.7) | 498 (80.1) | 0.000 |
| Total bilirubin level, mean±SD, mg/dL (n=101) | 1.0±1.7 | 0.8±0.2 | 1.0±1.8 | 0.458 |
| AST, mean±SD, IU/L (n=223) | 25.7±12.7 | 25.7±11.5 | 25.6±12.8 | 0.994 |
| ALT, mean±SD, IU/L (n=222) | 27.9±21.6 | 33.1±27.2 | 27.6±21.6 | 0.468 |
HEV, hepatitis E virus; IgM, immunoglobulin M; IQR, interquartile range; AST, aspartate aminotransferase; ALT, alanine aminotransferase.
*Number of workers at the investigation time excluding resigned persons.
Table 2 Summary of Significantly Higher RRs of Anti-HEV Positivity in the Eaters of Institutional Group Meals Compared to the Non-eaters
| Date | Type | Exposed (eaters) | Unexposed (non-eaters) | RR (95% CI) | p-value | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Subtotal | Anti-HEV IgM+ | Prevalence rate | Subtotal | Anti-HEV IgM+ | Prevalence rate | |||||
| February 2 | Lunch | 51 | 5 | 9.8 | 363 | 9 | 2.5 | 3.95 (1.38–11.34) | 0.02 | |
| February 14 | Dinner | 64 | 6 | 9.4 | 582 | 17 | 2.9 | 3.21 (1.31–7.85) | 0.02 | |
| February 17 | Dinner | 56 | 5 | 8.9 | 358 | 9 | 2.5 | 3.55 (1.24–10.21) | 0.04 | |
| February 18 | Dinner | 53 | 5 | 9.4 | 361 | 9 | 2.5 | 3.78 (1.32–10.86) | 0.03 | |
RR, relative risk; HEV, hepatitis E virus; IgM, immunoglobulin M; CI, confidence interval.
Table 3 Comparison of the Rates of COVID-19 Infection and Vaccination before HEV Antibody Testing Date between the Anti-HEV Positive and Negative Groups
| COVID-19 infection or vaccination before HEV testing date | Anti HEV-IgM positive (n=24) | Anti HEV-IgM negative (n=552) | p-value |
|---|---|---|---|
| COVID-19 infection | |||
| Ever infected | 11 (45.8) | 226 (40.9) | 0.675 |
| Recent infection (<90 day) | 7 (29.2) | 196 (35.5) | 0.664 |
| COVID-19 vaccination | |||
| Ever vaccinated | 24 (100) | 535 (96.9) | 1.000 |
| No. of vaccination | 0.021 | ||
| 1 | 0 | 10 (1.8) | |
| 2 | 4 (16.7) | 256 (46.4) | |
| 3 | 20 (83.3) | 266 (48.2) | |
| 4 | 0 | 3 (0.5) | |
| Recent vaccination (<90 day) | 11 (45.8) | 109 (19.7) | 0.008 |
| Last vaccine manufacturer | <0.001 | ||
| Moderna | 18 (75.0) | 80 (14.5) | |
| Pfizer | 6 (25.0) | 411 (74.5) | |
| Janssen | 0 | 7 (1.3) | |
| AstraZeneca (AZ) | 0 | 3 (0.5) | |
| Novavax | 0 | 1 (0) | |
| Missing | 0 | 33 (6.0) | |
| Detailed vaccination profile | <0.001 | ||
| 1st | |||
| Pfizer | 0 | 5 (0.9) | |
| Janssen | 0 | 4 (0.7) | |
| Missing | 0 | 1 (0.2) | |
| 1st-2nd | |||
| Moderna-Moderna | 3 (12.5) | 161 (29.2) | |
| Pfizer-Pfizer | 1 (4.2) | 11 (2.0) | |
| Janssen-Pfizer | 0 | 10 (1.8) | |
| Janssen-Moderna | 0 | 39 (7.1) | |
| Others | 0 | 16 (2.9) | |
| 1st-2nd-3rd | |||
| Moderna-Moderna-Moderna | 13 (54.2) | 16 (2.9) | |
| Pfizer-Pfizer-Pfizer | 5 (20.8) | 192 (34.8) | |
| AZ-AZ-Moderna | 1 (4.2) | 16 (2.9) | |
| AZ-AZ-Pfizer | 1 (4.2) | 9 (1.6) | |
| AZ-Pfizer-Pfizer | 0 | 8 (1.4) | |
| Pfizer-Pfizer-Moderna | 0 | 2 (0.4) | |
| Missing | 0 | 22 (4.0) | |
| 1st-2nd-3rd-4th | |||
| AZ-AZ-Moderna-Novavax | 0 | 1 (0.2) | |
| AZ-AZ-Moderna-Pfizer | 0 | 1 (0.2) | |
| AZ-AZ-AZ-Pfizer | 0 | 1 (0.2) |
COVID-19, coronavirus disease 2019; HEV, hepatitis E virus; IgM, immunoglobulin M.
Table 4 Results of Logistic Regression Analysis for Factors Associated with Anti HEV-IgM Positivity
| Univariate model | Multivariate model 1 | Multivariate model 2 | Multivariate model 3 | Multivariate model 4 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | OR (95% CI) | p-value | |||||
| Age | 0.99 (0.95–1.03) | 0.611 | ||||||||||||
| Female sex | 1.36 (0.55–3.34) | 0.507 | ||||||||||||
| Production worker | 0.95 (0.40–2.25) | 0.901 | ||||||||||||
| Group meal (lunch on February 2) | 2.92 (1.05–8.15) | 0.041 | 2.93 (0.88–9.74) | 0.079 | ||||||||||
| Group meal (dinner on February 14) | 3.21 (1.23–8.41) | 0.017 | 3.04 (0.99–9.32) | 0.052 | ||||||||||
| Group meal (dinner on February 17) | 3.55 (1.35–9.32) | 0.010 | 3.26 (1.03–10.31) | 0.044 | ||||||||||
| Group meal (dinner on February 18) | 2.74 (0.99–7.64) | 0.053 | 2.34 (0.71–7.63) | 0.161 | ||||||||||
| COVID-19 infection within 90 day of HEV antibody testing | 0.90 (0.36–2.20) | 0.808 | ||||||||||||
| COVID-19 vaccination within 90 day of HEV antibody testing | 3.44 (1.50–7.89) | 0.004 | 2.07 (0.74–5.81) | 0.169 | 1.78 (0.64–4.91) | 0.267 | 1.71 (0.61–4.75) | 0.305 | 1.78 (0.65–4.91) | 0.264 | ||||
| More than 3 time of COVID-19 vaccination | 5.26 (1.78–15.59) | 0.003 | 4.22 (1.20–14.86) | 0.025 | 4.59 (1.31–16.11) | 0.018 | 4.46 (1.28–15.59) | 0.019 | 4.51 (1.29–15.71) | 0.018 | ||||
| Moderna vaccination | 17.06 (6.57–44.30) | <0.001 | 18.90 (7.05–50.67) | <0.001 | 19.56 (7.26–52.70) | <0.001 | 19.69 (7.30–53.09) | <0.001 | 19.13 (7.15–51.10) | <0.001 | ||||
HEV, hepatitis E virus; IgM, immunoglobulin M; OR, odds ratio; CI, confidence interval.
Table 5 Comparison of the Rates of COVID-19 Infection and Vaccination before HEV Antibody Testing According to Exposure to the High-Risk Group Meal* in the Anti-HEV Positive Group
| Anti-HEV positive persons (n=24) | p-value | ||
|---|---|---|---|
| No exposure (n=17) | Exposure (n=7) | ||
| COVID-19 infection | |||
| Ever infected | 7 (41.2) | 4 (57.1) | 0.476 |
| Recent infection (<90 day) | 5 (29.4) | 2 (28.6) | 0.967 |
| COVID-19 vaccination | |||
| Ever vaccinated | 17 (100) | 7 (100) | 1.000 |
| No. of vaccination | 0.027 | ||
| 2 | 1 (5.9) | 3 (42.9) | |
| 3 | 16 (94.1) | 4 (57.1) | |
| Recent vaccination (<90 day) | 10 (58.8) | 1 (14.3) | 0.047 |
| Last vaccine manufacturer | 0.195 | ||
| Moderna | 14 (82.4) | 4 (57.1) | |
| Pfizer | 3 (17.6) | 3 (42.9) | |
| Detailed vaccination profile | 0.011 | ||
| 1st-2nd | |||
| Moderna-Moderna | 1 (5.9) | 2 (28.6) | |
| Pfizer-Pfizer | 0 | 1 (14.3) | |
| 1st-2nd-3rd | |||
| Moderna-Moderna-Moderna | 13 (76.5) | 0 | |
| Pfizer-Pfizer-Pfizer | 3 (17.6) | 2 (28.6) | |
| AZ-AZ-Moderna | 0 | 1 (14.3) | |
| AZ-AZ-Pfizer | 0 | 1 (14.3) | |
COVID-19, coronavirus disease 2019; HEV, hepatitis E virus; AZ, AstraZeneca.
*Definition of high-risk group meal: patient who had exposure to lunch on the February 2, dinner on the February 14, dinner on the February 17, or dinner on the February 18.
pISSN 1976-2283
eISSN 2005-1212
Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE
| Yong Chan Lee |
Professor of Medicine Director, Gastrointestinal Research Laboratory Veterans Affairs Medical Center, Univ. California San Francisco San Francisco, USA |
| Jong Pil Im | Seoul National University College of Medicine, Seoul, Korea |
| Robert S. Bresalier | University of Texas M. D. Anderson Cancer Center, Houston, USA |
| Steven H. Itzkowitz | Mount Sinai Medical Center, NY, USA |
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