Effect of Hepatitis E Virus RNA Universal Blood Donor Screening, Catalonia, Spain, 2017‒2020 Marta Bes, Maria I. Costafreda, Mar Riveiro-Barciela, Maria Piron, Angie Rico, Josep Quer, Lluis Puig, Silvia Sauleda processed pork meat (2,3). HEV genotype 7 has been Hepatitis E virus (HEV) is the major cause of acute identified mainly in camels but also an immuno- viral hepatitis in several countries in Europe. HEV is acquired mainly by consumption of contaminated pork compromised transplant patient (4). Several cases of but can also be transmitted through blood transfusion. transfusion-transmitted HEV infections have been HEV infection is usually self-limited but can become reported; these infections might cause chronic hepati- persistent in immunocompromised persons. During tis in immunosuppressed recipients (5) and were not the first 30 months of HEV RNA universal screening prevented by pathogen-reduction methods (6). of blood donations in Catalonia, Spain, we identified In Europe, most acute HEV infections are caused 151 HEV RNA–positive donations (1/4,341 blood do- by genotype 3 (7). Although these infections are usu- nations). Most infected donors reported consumption ally asymptomatic in immunocompetent persons, of pates and sausages, and 58% were negative for HEV infection poses a particular risk to persons who HEV IgM and IgG. All HEV isolates belonged to geno- have compromised immune systems because they type 3. All infected donors spontaneously resolved the might have persistent infection develop, with rapid infection, and no neurologic symptoms and reinfec- tions were observed after 1 year of follow-up. Since progression to cirrhosis, decompensation, and death the implementation of HEV RNA universal screening, (8). Moreover, HEV genotype 3 infection has been no new cases of transfusion-transmitted HEV infection related to several extrahepatic manifestations, such were reported. Our data indicate HEV screening of as Guillain-Barré syndrome, inflammatory polyra- blood donations provides safer blood for all recipients, diculopathy, bilateral brachial neuritis, encephalitis, especially for immunosuppressed persons. ataxia/proximal myopathy, and necrotizing myosi- tis (8). There is no proven treatment for chronic HEV H epatitis E virus (HEV; family Hepeviridae, ge- nus Orthohepevirus) (1) is an RNA virus that causes acute viral hepatitis in humans. Five HEV gen- infection, although ribavirin therapy or reduction of immunosuppression have been successful in achiev- ing HEV RNA clearance (9). otypes are known to infect humans. Genotypes 1 and A major systematic study assessing HEV trans- 2 are transmitted by the fecal–oral route and cause mission through blood transfusion was conducted in large waterborne outbreaks in developing countries. England during 2012–2013 (10). The study reported Genotype 3 and 4 cause zoonotic infections transmit- that 42% of recipients who received HEV RNA–con- ted from infected animals, such as pigs, deers, and taminated blood components showed evidence of wild boars, to humans. Transmission usually occurs infection, and progression to a chronic infection was through consumption of raw or inadequately cooked demonstrated in 50% of HEV-infected immunosup- pressed recipients. The study also observed a direct Author affiliations: Instituto de Salud Carlos III, Madrid, Spain correlation between HEV viral load and plasma (M. Bes, M.I. Costafreda, M. Riveiro-Barciela, M. Piron, A. Rico, transfused volume (HEV RNA infusion dose), and J. Quer, L. Puig, S. Sauleda); Vall d’Hebron Barcelona Hospital the capability to induce transfusion-transmitted HEV Campus, Barcelona, Spain (M. Bes, M.I. Costafreda, infection (10). M. Riveiro-Barciela, M. Piron, A. Rico, J. Quer, L. Puig, Moreover, a tertiary hospital in Catalonia, Spain, S. Sauleda); Banc de Sang i Teixits, Catalonia, Spain (M. Bes, reported 2 cases in immunocompetent patients who M.I. Costafreda, M. Piron, A. Rico, L. Puig, S. Sauleda) had acute hepatitis E resulting from HEV transmit- DOI: https://doi.org/10.3201/eid2801.211466 ted by erythrocyte concentrate or cryosupernatant Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 1, January 2022 157 RESEARCH plasma (11,12). The HEV infection resolved spontane- Archived Samples ously (11) or after ribavirin therapy (12). Some donors might have had a previous (archived) HEV RNA screening of blood donations has been blood donation within 6 months before HEV RNA in place for the last few years in the Netherlands, identification. We retested these archived plasma some blood banks in Germany, Ireland, the United samples by using the HEV RNA Procleix HEV assay Kingdom, France, Catalonia, and Japan (13). Howev- for individual samples. er, there is no international consensus on sensitivity required for HEV RNA. Therefore, blood banks have Follow-up of HEV–Infected Donors chosen to implement either individual or pool test- We collected age, sex, postal code, and country of ing. Furthermore, HEV RNA screening is exceptional birth for all HEV RNA–positive donors. All donors with respect to other screening markers in blood do- received a notification to follow-up on their HEV nations, for which a positive result (i.e., confirmed infection at the blood bank in 1 month. HEV RNA HIV antibodies, hepatitis B virus surface antigen, or tested individually, HEV IgG and IgM, and biochem- hepatitis C virus antibodies) permanently defers the ical parameters were reanalyzed for the follow-up donor. HEV RNA–positive blood donors are deferred sample. At the time of follow-up, donors completed for 6 months in Catalonia. a questionnaire evaluating symptoms of acute hepa- We report the results of routine screening for titis, meat consumption, type of meat products (sau- HEV RNA in Catalonia during November 2017–April sages, pates), type of dwelling (apartment, house, and 2020. We aimed to determine the prevalence of HEV farm), wastewater system (mains sewer, septic tank), among blood donors in Catalonia and to describe epi- and travel history outside Catalonia 2 months before demiology and progression of HEV acute infection in blood donation. immunocompetent and asymptomatic blood donors. In addition, donors who were still HEV RNA re- active at follow-up received the opportunity to visit Methods a clinician at the liver unit of Vall d’Hebron Hospital between 2 and 6 months after HEV RNA detection in Screening and Characterization of Donor Samples the blood bank. The clinician evaluated the hepatic During November 1, 2017–April 30, 2020, we tested and extrahepatic symptoms related to acute HEV 655,523 blood donations, plasma samples, and platelet infection, and another serum sample was obtained apheresis samples in Catalonia for HEV RNA by using to determine the presence of HEV RNA, HEV IgG the Procleix HEV assay (Grifols Diagnostic Solutions and IgM, and the biochemical parameters. If other- Inc., https://www.diagnostic.grifols.com/en/home) wise qualified, donors were reinstated for donation 6 in pools of 16 samples (95% of limit of detection 176 months after the last HEV RNA–positive result. IU/mL in individual donor when tested in pools of 16 samples). We analyzed individually all samples in re- Genotyping active pools by using the same assay (95% of limit de- We amplified a major fragment of reading frame 2 tection 11 IU/mL in individual samples) and selected (nt positions 5145–7127) by using a nested reverse HEV RNA–containing blood components. transcription nested RT-PCR. We performed reverse We assessed HEV RNA confirmation and viral transcription and the first PCR by using the Super- load by using an in-house quantitative reverse tran- Script III One-Step RT-PCR System with Platinum scription PCR (RT-PCR) for the open reading frame Taq DNA Polymerase (Invitrogen, https://www. 3 region adapted from Slot et al. (14). The lower limit thermofisher.com) and 0.35 nmol/L of each primer of detection (95% cutoff value) was 7.5 IU/mL for a (forward: 5′-CCGACAGAATTGATTTCGTCGGC-3′ 9.6-mL plasma volume and 45 IU/mL for a 1.6-mL and reverse: 5′-ACTCCCGRGTYTTACCYACCTT-3′). plasma volume. We calculated HEV viral loads by We performed a nested PCR by using Platinum Taq using a calibration curve based on the first World DNA Polymerase (Invitrogen), 0.32 nmol/L of each Health Organization International Standard for HEV primer (forward: 5′-TCGTCTCAGCCAATGGC- RNA (PEI code 6329/10; https://www.pei.de). We GAGCC-3′ and reverse: 5′-CASARAANGTCTTN- performed HEV serologic testing by using Mikrogen GARTACTGCT-3′), and 30 cycles of standard PCR IgM and IgG Detection Assays (https://www.mik- conditions. We loaded amplicons onto a 2% agarose rogen.de) and biochemical analysis (levels of direct gel, subjected the amplicons to electrophoresis, and bilirubin, total bilirubin, aspartate aminotransferase, purified specific bands by using the QIAquick Gel alanine aminotransferase, and γ-glutamyltransferase) Extraction Kit (QIAGEN, https://www.qiagen.com). for all HEV RNA–positive donations. We sequenced purified material by using the Sanger 158 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 1, January 2022 HEV RNA Universal Blood Donor Screening, Spain method and a 3130xL Genetic Analyzer System (Ap- individual reactive donation, which was confirmed plied Biosystems, https://www.thermofisher.com). by quantitative RT-PCR. During the 30-month period, we selected 151 HEV RNA–positive donations repre- Ethics senting an overall prevalence of 1 case/4,341 dona- We obtained signed consent for blood donation tions (95% CI 1 case/3,703 donations–1 case/5,004 from each donor at the time of donation. Donors donations). The prevalence of HEV RNA–positive who accepted the follow-up at the Liver Unit of Vall donations according to month of detection during the d’Hebron Hospital (Barcelona, Spain) signed an ad- 2.5 years of the study fluctuated, and no seasonality ditional research informed consent. The Clinical Re- of HEV cases was observed (Figure 1, panel A). search Institutional Review Board of Vall d’Hebron University Hospital in Barcelona approved the study Demographic Data for HEV RNA–Positive Donors (PR[BST]351/2017). Most (62.9%) donors with acute HEV infection were men; mean age ± SD was 41.5 ± 12.9 years, and 92.7% Statistical Analysis were born in Spain (Table 1). A significantly high- Prevalence was expressed as percentages and 95% CIs. er proportion of men were infected than women Quantitative variables were expressed as means, medi- (95/346,592 vs. 56/308,931; p = 0.0168). Although ans, and SDs. We compared percentages by using the HEV RNA was detected in all donor age groups, the χ2 test. p values <0.05 were considered significant. highest rate was observed in persons 56–65 years of age (Figure 1, panel B). Results HEV-infected blood donors were evenly distrib- uted by province: 107 donors in Barcelona, 18 in Tar- Prevalence of HEV Acute Infections in Blood Donors ragona, 14 in Girona, and 12 in Lleida (Figure 2, panel During November 1, 2017–April 30, 2020, we A). The prevalence of HEV RNA per 10,000 donations screened 655,523 blood donations HEV RNA in pools varied from 1.78 in Girona to 2.67 in Lleida (Figure 2, of 16 samples. All reactive pools were resolved to an panel B). Figure 1. Rate of HEV RNA– positive donations, Catalonia, Spain, November 2017–April 2020. A) All donations; B) by age group during the same period. HEV, hepatitis E virus. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 1, January 2022 159 RESEARCH Table 1. Characteristics for 151 HEV RNA‒positive blood (Figure 3). Two isolates were 100% homologous donors, Catalonia, Spain* and obtained from members of the same family Characteristic Value who were probably infected simultaneously and Sex M 95 (62.9) from the same source inoculum. F 56 (37.1) Mean ± SD age, y 41.5 ± 12.9 Serologic and Biochemical Parameters for HEV Country of birth RNA–Positive Donors Spain 140 (92.7) Argentina 4 (2.6) At the time of donation, 63 (42%) of HEV RNA– Uruguay 2 (1.3) positive donors were positive for HEV IgM and 45 Romania 2 (1.3) (30%) were positive for HEV IgG/IgM (Table 1). In- Germany 1 (0.7) Portugal 1 (0.7) creased levels of bilirubin were found in 4 (2.6%) of France 1 (0.7) these HEV-infected donors, increased levels of ala- Median viral load, IU/mL (range) 503 (40–999,340) nine aminotransferase in 10 (6.6%), and increased HEV IgM/IgG HEV IgM positive 63 (42.0) levels of aspartate aminotransferase (AST) in 15 HEV IgG positive 45 (30.0) (9.9%). Twenty-four donors also had increased lev- Biochemical parameters els of γ-glutamyltransferase at the time of donation Bilirubin >1.1 mg/dL 4 (2.6) (Table 1). AST >80 U/L 10 (6.6) ALT >80 U/L 15 (9.9) -glutamyltransferase > 55 U/L 24 (15.9) Clinical Symptoms and Donor Risk Factors for *Values are no. (%) unless indicated otherwise. ALT, alanine HEV Infection aminotransferase; AST, aspartate aminotransferase; HEV, hepatitis E virus. A total of 111 (73.5%) HEV RNA–positive donors completed the questionnaire with information Virologic Parameters for HEV RNA–Positive Donors about clinical symptoms, diet, type of housing, and The median viral load was 503 IU/mL (range travel history to determine possible routes of HEV 40–999,340 IU/mL) (Table 1). All HEV isolates acquisition. Only 2 donors reported symptoms of that were successfully genotyped (91, 60.9%) acute hepatitis, such as pain/aches or abdominal belonged to genotype 3. Phylogenetic analy- pain. However, 24.3% of HEV RNA donors report- sis showed that most (73, 80.2%) isolates clus- ed general unrest and 15.3% reported dark urine or tered with HEV subgenotype 3f, whereas 18 light stools during 1 or 2 weeks before or after do- (19.8%) isolates clustered with subgenotype 3c nation (Table 2). Figure 2. Geographic distribution of HEV-infected blood donors, Catalonia, Spain, November 2017–April 2020. A) All donations (n = 151). B) HEV RNA detection rate (per 10,000 analyzed blood donations), by province (Barcelona, Girona, Lleida, and Tarragona). Maps were created by using Tableau Software (https://www.tableau.com). HEV, hepatitis E virus. 160 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 1, January 2022 HEV RNA Universal Blood Donor Screening, Spain One HEV RNA–positive donor was vegetarian, In addition, 2 HEV RNA–positive donors consumed and no risk factor could be associated with HEV infec- game meat 1 month before blood donation. tion. However, most HEV-infected donors consumed Regarding travel history, 26 HEV-infected donors undercooked meat, especially pork (42.3%); liver pate traveled outside Spain in the 2-month period before or sausages (65.6%); or shellfish, especially mollusks blood donation. Moreover, 11 persons visited farms (63%), 2 months before blood donation. Moreover, 2 months before blood donation, and 20 persons lived 50% of them reported consuming nonbottled water. on a farm or in a rural area. Figure 3. Phylogenetic analysis of HEV isolates from HEV-positive blood donors identified, Catalonia, Spain, November 2017–April 2020 (n = 91). Evolutionary relationships of taxa. Evolutionary history was inferred by using the neighbor-joining method. Sequence analysis was performed by using MEGA 7 software (https://www.megasoftware.net) and HEV reference sequences described in Smith et al. (15), and additional HEV sequences from GenBank (labeled by accession number). Evolutionary distances were computed by using the maximum composite likelihood method, and the phylogenetic tree was constructed by using the neighbor-joining method. Colored dots indicate the HEV reference sequences used in the analysis (blue, HEV genotype 1; purple, HEV genotype 2; green, HEV genotype 3; gray, HEV genotype 4). Scale bar indicates nucleotide substitutions per site. HEV, hepatitis E virus. Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 1, January 2022 161 RESEARCH Table 2. Clinical characteristics and risk factors for HEV infection reported by HEV RNA‒positive donors, Catalonia, Spain* Characteristic No. (%) responses, n = 111 Symptoms or clinical signs Symptom of acute hepatitis: aches, nausea, abdominal pain, vomiting 2 (1.8) General unrest 27 (24.3) Dark urine or light stool 17 (15.3) Information on diet: eating habits related with HEV acquisition Vegetarian or vegan 1 (0.9) Usual consumption of undercooked meat 47 (42.3) Consumption of liver pate or sausages in last 2 months† 63 (65.6) Consumption of seafood in last 2 months 70 (63.0) Consumption of nonbottled water† 51 (53.1) Consumption of bushmeat 2 (1.8) Visited a farm within 2 months before donation 11 (9.9) Lived in rural areas or on farms 20 (18) Traveled outside Spain within 2 months before donation 26 (23.4) *HEV, hepatitis E virus. †96 HEV RNA‒positive donors responded to these questions. HEV RNA–Positive Blood Donor Follow-up In this cohort of HEV RNA–positive blood do- During the first month after RNA detection, 127 HEV nors, the maximum duration of detection of RNA RNA–positive donors attended follow-up appoint- was 71 days after blood donation. Long-term follow- ments at a blood bank (Table 3). At this time, HEV up (6 months to >1 year) showed that none of the IgM was found in 75% and IgG in 78% of retested HEV RNA–positive donors showed development of donors; 37% had undetectable HEV RNA. All HEV chronic HEV infection, and 79% continued to be HEV RNA–positive donors with altered levels of transami- IgM positive 6 months after the HEV RNA–positive nases or bilirubin at the time of donation had levels donation. All these donors remained HEV IgG posi- that returned to standard levels at 1-month follow- tive, and none were reinfected with HEV. up, while 16 HEV RNA–positive donors with who Thirty archived samples obtained during the 6 had standard bilirubin or transaminase levels at the months before the HEV RNA–positive donor iden- time of donation had increased bilirubin or transami- tification were analyzed by HEV RNA in individual nase levels at 1-month follow-up. sample (95% limit of detection 11 IU/mL). Twen- A physician at the Liver Unit of Vall d’Hebron ty-nine samples were HEV RNA negative in indi- Hospital reevaluated 29 persons who had detect- vidual sample testing, but 1 archived sample was able HEV RNA or altered bilirubin/transaminase positive. This sample corresponded to a platelet levels at the 1-month follow-up. At this point, all apheresis that had been collected, tested negative persons had shown seroconversion to HEV IgM (28 in minipools of 16 samples, and transfused. The vi- also to HEV IgG), 24.1% were still HEV RNA posi- ral load was ≈40 IU/mL. In this instance, the hospi- tive, only 1 person had an increased bilirubin level, tal that had received the HEV RNA–contaminated and all persons had standard levels of transami- platelet apheresis was informed of potential risks nases. Despite 2 patients who had mild weakness and advised to take appropriate action. The physi- when raising an arm, an electromyography ruled cian informed the blood bank center that no signs out proximal myopathy. The remaining persons of acute hepatitis E were observed, and 3 months did not have signs of acute hepatitis E or any extra- after the transfusion, the recipient was negative for hepatic manifestation. HEV RNA and HEV IgG/IgM. Table 3. Follow-up of HEV RNA positive blood donors, Catalonia, Spain* Characteristic Baseline 1-month follow-up 2-month follow-up 6-month follow-up >1 year follow-up No. persons 151 127 29 38 20 Interval between tests, d (range) NA 20 (8–61) 53 (36–90) 242 (110–364) 534 (371–945) HEV RNA positive 151 (100.0) 80 (63.0) 7 (24.1) 0 0 HEV IgM positive 63 (42.0) 95 (74.8) 29 (100.0) 30 (78.9) 12 (60.0) HEV IgG positive 45 (43.0) 99 (78.0) 28 (96.6) 38 (100.0) 18 (90.0) Biochemical parameters Bilirubin >1.1 mg/dL 4 (2.6) 4 (3.1) 1 (3.4) NA NA AST >80 U/L 10 (6.6) 6 (4.7) 0 NA NA ALT >80 U/L 15 (9.9) 12 (10.2) 0 NA NA -glutamyltransferase > 55 U/L 24 (15.9) 18 (15.7) 3 (10.3) NA *Values are no. (%) unless indicated otherwise. ALT, alanine aminotransferase; AST, aspartate aminotransferase; HEV, hepatitis E virus; NA, not applicable. 162 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 1, January 2022 HEV RNA Universal Blood Donor Screening, Spain Posttransfusion HEV Infection Surveillance establishments in Spain have implemented universal The Catalonia blood bank provides all blood com- HEV RNA screening: the blood bank of Asturias in ponents (plasma, platelets, and erythrocyte concen- northern Spain (implemented during 2020) and the trates) to all hospitals in Catalonia. Half of blood com- blood bank in Catalonia. Our results indicate that ponent recipients are immunocompromised patients. Spain should be considered an area of medium to Because we implemented the HEV RNA universal high endemicity for HEV, comparable with the rest of screening in minipools of 16 samples during Novem- Europe, and universal or selective screening for HEV ber 2017, no new cases of transfusion-transmitted RNA should be carefully considered. hepatitis E have been reported in Catalonia. HEV-infected donors were distributed around Catalonia, and no outbreaks were observed. The high- Discussion est HEV RNA prevalence among donors in Catalo- In Spain, universal screening of blood donations for nia was observed in the 56–65 year-old persons (2.85 HEV is not mandatory. During 2013, the prevalence cases/10,000 donations), in contrast to what was pre- of HEV RNA in blood donations in Catalonia was 1 viously reported in England and Ireland, where the case/3,333 donations, tested individually, whereas highest incidence was seen in young donors (18–24 HEV IgG seroprevalence was 20% (16). Another years of age) (13,19). study conducted in south-central Spain during 2017– As in the United Kingdom, HEV RNA–positive 2018 showed a similar prevalence of HEV infection donors in Catalonia are deferred for 6 months (19). In among blood donors (1 case/2,828 donations) (17). the immunocompetent population, the course of HEV Furthermore, 2 cases of HEV transfusion-transmitted is usually asymptomatic, with an estimated manifesta- infection by supernatant of cryoprecipitate and eryth- tion index of 13% (22). In our study, 15 of 151 HEV- rocyte concentrate were documented in Catalonia positive blood donors showed moderate and transient during 2015 and 2017 (11,12). The most comprehen- increases of alanine aminotransferase levels, although sive study in transfusion-transmitted HEV infection none had hepatic or extrahepatic manifestations either was conducted in the United Kingdom and showed at the time of donation or at 6-month follow-up. In our an HEV transfusion-transmitted rate of 42% (10). Tak- study, HEV RNA clearance in infected donors was ing into account all these results, the blood bank of achieved after a maximum of 71 days, similar to what Catalonia implemented universal HEV RNA screen- was observed in another study in Spain (17). None of ing in pools of 16 samples during November 2017. the infected donors showed development of chronic HEV RNA screening of 653,800 blood donations HEV infection, and none were reinfected at follow-up. during 2017–2020 showed a high prevalence of HEV These observations are in concordance with the clini- infection in Catalonia. We detected 151 HEV RNA– cal guidelines by which spontaneous viral clearance in positive donations, corresponding to a prevalence immunocompetent subjects typically occurs in the first of 1 case/4,341 donations, which is consistent with 3 months of infection, and infection persisting beyond the prevalence reported in the same cohort during this period is recommended to be considered a chronic 2013, although in this study, HEV RNA was detected infection (24). A total of 58% of HEV RNA–positive do- in individual samples (16). This proportion of HEV- nors were seronegative at the time of donation, which infected donors is similar to those reported by Can- contributes to transmission because the antibody sta- ada (1 case/4,615 donations) and many countries in tus of the donor could be a determinant in preventing Europe, including England (1 case/2,848 donations HEV transfusion transmission (10). Finally, HEV IgM 1 case/4,781 donations), Ireland (1 case/4,745 dona- was detected 1 year after the HEV exposure in immu- tions), Austria (1 case/5,369 donations), and Belgium nocompetent persons, indicating that this detection (1 case/5,448 donations) (13,17–20). Although we ob- is not a good clinical biomarker of acute HEV infec- served lower prevalence than Germany (1 case/1,241 tion and that nucleic acid amplification testing (NAT) donations), France (1 case/1,317 donations), and the should be performed (25). Netherlands (1 case/1,987 donations) (21–23), the re- Our study also demonstrates the diversity of sults cannot be compared directly because different HEV strains circulating in Catalonia. On the basis pool size and methods have been used. The United of phylogenetic analysis of 91 HEV isolates, we de- Kingdom, the Netherlands, and Ireland have imple- termined that all infections were caused by HEV mented universal HEV screening, whereas other genotype 3 and showed the dominance of subgeno- countries, such as Germany and France, have imple- type 3f variants (80%). Genotype 3 virus causes zoo- mented selective HEV RNA screening for use in high- notic infections in pigs, wild boars, and deer. It is risk patients. Currently, only 2 of 17 blood regional clear that most HEV infections are acquired in Spain Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 28, No. 1, January 2022 163 RESEARCH because only 33% of donors reported travel abroad in none showed development of chronic HEV infection, the 2-month period before donation (26). and no HEV reinfection was observed. Our data sup- We identified consumption of undercooked meat port the suggestion that HEV RNA screening of blood or pork-derived foods (liver pate or sausages) in 42% donations provides safer blood for all recipients, es- and 66% of HEV-infected donors, respectively. A pecially for immunosuppressed patients. study analyzed the presence of HEV RNA in differ- ent organs and tissues of 45 apparently healthy pigs Acknowledgment from 9 slaughterhouses in Spain (27). The findings of We thank all technicians in the Transfusion Safety this study indicate that pig liver pate and sausages Laboratory for providing technical support. could be the route of HEV infection. In addition, 63% This study was supported by the Banc de Sang i Teixits. of HEV RNA–positive donors reported seafood con- sumption during the 2 months before donation. A re- cent study conducted in Galicia (northwestern Spain) About the Author analyzed 168 shellfish samples from this region, and Dr. Bes is a senior researcher and physician at the Banc HEV RNA was detected in 41 (24.4%) samples, al- de Sang i Teixits, Catalonia, Spain. Her primary research though all isolates belonged to subgenotype 3e (28). interests are transfusion-transmitted diseases, such as In our study, none of HEV-infected donors had sub- hepatitis A, hepatitis B, hepatitis C, and hepatitis E and genotype 3e, suggesting that shellfish consumption HIV infections. was not a probable route for HEV transmission in our population. Finally, half of HEV-infected donors re- ported consumption of nonbottled water. Although References 1. Smith DB, Simmonds P, Jameel S, Emerson SU, Harrison TJ, HEV strains belonging to genotype 3 were frequently Meng XJ, et al.; Members Of The International Committee detected at low concentrations in urban sewage and On The Taxonomy Of Viruses Study Group. Consensus biosolids or sewage containing swine feces, they were proposals for classification of the family Hepeviridae. not detected in the river water samples or drinking J Gen Virol. 2014;95:2223–32. https://doi.org/10.1099/ vir.0.068429-0 water treatment plants studied in Spain (29,30). In ad- 2. Aggarwal R, Naik S. Epidemiology of hepatitis E: current dition, 2 persons reported consumption of game meat status. J Gastroenterol Hepatol. 2009;24:1484–93. (wild boar) shortly before donation. Because previous https://doi.org/10.1111/j.1440-1746.2009.05933.x studies detected HEV RNA subgenotypes 3f and 3c 3. Hoofnagle JH, Nelson KE, Purcell RH, Hepatitis E. N Engl J Med. 2012;367:1237–44. https://doi.org/10.1056/ in wild boars from Catalonia (25), they were the most NEJMra1204512 probable route of HEV acquisition for these 2 cases. 4. Spahr C, Knauf-Witzens T, Vahlenkamp T, Ulrich RG, We detected only 1 donation that was missed by Johne R. Hepatitis E virus and related viruses in wild, initial screening of minipools containing 16 samples. domestic and zoo animals: a review. Zoonoses Public Health. 2018;65:11–29. https://doi.org/10.1111/zph.12405 This donation had low viral load (<40 IU/mL) and 5. Kamar N, Selves J, Mansuy JM, Ouezzani L, Péron JM, did not cause a transfusion-transmitted HEV infec- Guitard J, et al. Hepatitis E virus and chronic hepatitis in tion in the recipient. A previous study estimated that organ-transplant recipients. N Engl J Med. 2008;358:811–7. the infectious dose is ≈20,000 IU of HEV RNA (10,21). https://doi.org/10.1056/NEJMoa0706992 6. Gallian P, Lhomme S, Morel P, Gross S, Mantovani C, For our case, because the apheresis platelet donation Hauser L, et al. Risk for hepatitis E virus transmission had a volume of 300 mL of plasma, the recipient re- by solvent/detergent-treated plasma. Emerg Infect Dis. ceived 12,000 IU of HEV RNA, which might not be 2020;26:2881–6. https://doi.org/10.3201/eid2612.191482 sufficient to induce an HEV infection. As a limitation 7. Doting MHE, Weel J, Niesters HGM, Riezebos-Brilman A, Brandenburg A. The added value of hepatitis E diagnostics of this study, although no additional transfusion- in determining causes of hepatitis in routine diagnostic transmitted HEV infections have been reported in settings in the Netherlands. Clin Microbiol Infect. Catalonia since implementation of HEV NAT in blood 2017;23:667–71. https://doi.org/10.1016/j.cmi.2017.02.026 donations, it is difficult to quantify the number of in- 8. Riveiro-Barciela M, Rodríguez-Frías F, Buti M. Hepatitis E virus: new faces of an old infection. Ann Hepatol. 2013; fections that have been prevented by NAT screening 12:861–70. https://doi.org/10.1016/S1665-2681(19)31290-6 because HEV infections are often underdiagnosed. 9. Kamar N, Abravanel F, Behrendt P, Hofmann J, Pageaux GP, In conclusion, 151 HEV infected donors have Barbet C, et al.; Hepatitis E Virus Ribavirin Study Group. been detected during 2.5 years of HEV RNA univer- Ribavirin for hepatitis E virus infection after organ transplantation: a large European retrospective multicenter sal screening strategy in Catalonia (minipools of 16 study. Clin Infect Dis. 2020;71:1204–11. https://doi.org/ samples), and no cases of HEV-transfusion-transmit- 10.1093/cid/ciz953 ted infection have been reported in our region. More- 10. Hewitt PE, Ijaz S, Brailsford SR, Brett R, Dicks S, over, most HEV-infected donors were asymptomatic, Haywood B, et al. 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