HIP conference, Oxford, July 2014 Laura Guerrero-Latorre (University - PowerPoint PPT Presentation

HIP conference, Oxford, July 2014 Laura Guerrero-Latorre (University of Barcelona) Rosina Girones (University of Barcelona) Simone Carter (OXFAM Intermon)

Session Contents Ø Hepatitis E Virus (HEV) characteristics & epidemiology Ø Current protocols for water disinfection in emergencies Ø Present results water disinfection treatments for HEV  Chlorine  UV  Flocculant-chlorine sachets Ø Environmental investigation South Sudan 2013

Hepatitis E Virus characteristics & epidemiology WHO 3.000.000 cases & 56,600 deaths per year Imunosuppressed patients 0,5% population 25% pregnant women

Hepatitis E Virus characteristics & epidemiology Reported outbreaks (until 2013)

Current protocols for WASH interventions in HEV epidemics WASH activities in HEV epidemics will focus on: -Water treatment - UNHCR recommends chlorination1 (0.8-1 mg/l at tapstands) - WHO recommends boiling or chlorination2 - MSF recommends UV treatment3 - Water quantity (20 liters/person/day) - Sanitation (1:20 latrines : people, reduce open defecation) -Hygiene promotion (basic hygiene measures at communal, household and individual levels) 1. UNHCR. Field Brief: Hepatitis E Response In Refugee Settings 2014 2. WHO. Manual on Response to Outbreaks of Hepatitis E in Limited Resource Settings (draft). 2013 3. MSF. Public Health Engineering in Precarious Situations. 2010

Problem: There is no existing Solution: Creation of evidence-based Standard evidence of which is the effective Operational Procedures for Hepatitis E Virus dosage and time of contact of Water Disinfection in Humanitarian Context disinfectant (nor for chlorine neither for UV) to inactivate Hepatitis E Virus in water matrices.

Water disinfection treatments for HEV Phase 1: In vitro model for testing infectious virus stability and infectivity Methodology Ø Viral strains Hepatitis E Virus - Sar55 Genotype 1 (experimentally infected rhesus macaque) - Kernow-C1 p6 Genotype 3 (patient infected) (kindly provided by Emerson S.) Cell culture lines - Caco-2 ( human epithelial colorectal adenocarcinoma cells) - HepG2/C3A ( human epithelial hepatocellular carcinoma) Surrogate viruses Human Adenovirus (HAdV) - Bacteriophage MS2 (MS2) -

Water disinfection treatments for HEV Phase 2: Describe kinetics of disinfection for Chlorine treatment, UV treatment and rapid flocculation + chlorination sachets . • Different water matrices assayed • Viral doses quantified by: - ImmunoFluorescence Assay (IFA) - Quantitative RT-PCR (qRT-PCR) - Plaque Assay ImmunoFluorescence Quantitative RT-PCR Assay ( IFA ) ( qRT-PCR )

Water disinfection treatments for HEV Chlorine treatment BDF water BDF water BDF water pH 8 pH 8 pH 8 + 1% sewage 1.97 x 103 ffu/mL2.04 x 104 ffu/mL 1.86 x 103 ffu/mL Hepatitis E Virus concentration Cell culture Pooled faeces Cell culture Hepatitis E Virus origin 7.3 mg/L 5.8 mg/L 23.1 mg/L Initial concentration FRC ( t0 ) 1.1 mg/L 1.1 mg/L 2.5 mg/L Residual concentration FRC ( t0.5 ) 0.9 mg/L 1.4 mg/L 1 mg/L Residual concentration FRC ( t30 ) 12 10 Chlorine decay 8 mg/L 6 4 2 0 minutes

Water disinfection treatments for HEV Chlorine treatment Results Efficiency factor Hom (EFH) model was used to predict Ct values Equivalent to 1E+06 infective viruses C(t) = concentration x time in 100 ml mg/L min 1-log 2-log 3-log 4-log Initial Viral initial Virus Experimental free concentration R2 tested condition chlorine T90 C(t) T99 C(t) T99.9 C(t) T99.99 C(t) (FFU/ml) (mg/l) viruses from cell 1.97 x 103 7.3 0.61 0.02 0.15 NR NR NR culture viruses from pooled HEV 2.10 x 104 5.8 0.77 0.02 0.12 0.07 0.41 NR NR faeces +1% sewage 1.86 x 103 23.1 0.98 0.22 5.09 0.49 11.21 NR NR high viral load 7.20 x 105 2.7 0.96 0.27 0.73 0.35 0.95 0.44 1.19 0.61 1.65 viruses from cell HAdV2 1.40 x104 5 0.82 0.23 1.15 0.78 3.9 NR NR culture viruses from cell 1.40 x 104 2.2 0.89 0.36 0.79 NR NR NR culture

Water disinfection treatments for HEV UV treatment Assays performed in collaboration with Regina Sommer From the Medical University of Vienna Water matrix Water, pH 8, < 10 NTU 7.9 x 102 ffu/mL Hepatitis E Virus concentration Beaker 1 0-100-200-300-400- UV fluences 500-600-700-800- 1000-1400 m2/J 95.9 % reduction of infectious HEV MS2 bacteriophage Hepatitis E Virus 1000000000 10 100000000 GC or ffu / mL 10000000 1000000 100000 pfu/mL 10000 1000 100 10 1 1 0 200 400 600 800 1000 1200 1400 Fluence (J/m2) Fluence (J/m2) Infectivity Molecular quantification Infectivity

Water disinfection treatments for HEV Tap water River water Tap water River water pH 7, pH 9, pH 7, pH 9, NTU < 5 NTU > 30 NTU < 5 NTU > 30 Treatment WaterMaker PUR PUR WaterMaker Hepatitis E Virus concentration (GC/mL) 3.74 x 104 3.74 x 104 8.96 x 104 8.96 x 104 Reduction MS2 (5 assays) 99.18% 99.84% 99.58% 99.83% Reduction HEV 91.39% 79.58% 93.48% 91.51% PURTM Purifier of Water Contents: Fe2(SO4)3: 352 mg Fe(III); Ca(OCl)2 WaterMakerTM Contents: 1.4% available chlorine and approved flocculants

Water disinfection treatments for HEV Summary Treatment recommendations of 0.5 mg/l Free Residual Chlorine after 30 min of contact time will reduce HEV (infective particles) in at least 99% With an exposure to 100 J/m2 in a 253.7nm low pressure lamp HEV (infective particles) reduces in 95.9% After treatment with sachets in turbid water (> 30 NTU) HEV (viral particles) reduces : 79.6% (PURTM) and 91.5% (WaterMakerTM)

Environmental investigation South Sudan 2013

Environmental investigation South Sudan 2013 The environmental investigation focused on two camps : Jamam and Batil. Water samples at Surface Level (8), Groundwater Level (7), Household Water Level (8) and Household Food Level for testing on Human Adenovirus & Hepatitis E Virus Jamam camp Batil camp

Environmental investigation South Sudan 2013 J Water Health. 2011 Sep;9(3):515-24 . Results The presence of HAdV in some water sources studied indicate potential routes of faecal contamination for water-borne viruses

Results Environmental investigation elucidates the potential sources and patterns of HEV transmission in the affected camps during the study period showing …. High risk of transmission at Household level… Those results are independent of the potential role of flooding may have on the microbiological quality of water sources

Intermon Oxfam & University Barcelona Research Platform Acknoledgements Anna Carratalà, University of Barcelona Regina Sommer, Medical University of Vienna Suzanne Emerson, National Institutes of Health, USA Miquel Calvo, Statistics Department of University of Barcelona Joe Brown and Jeroen Ensink , London School of Hygiene and Tropical Medicine Peter Maes and William Ettiene, Mediciens Sans Frontieres Belgium Jose Dvorzak and Nina Egger-Bussing, Mediciens Sans Frontieres Holland Alberto Ibañez, Intermon Oxfam