TRANSFUSION COMPLICATIONS
Declining prevalence of hepatitis E antibodies among Danish
blood donors
Dorte K. Holm,1 Belinda K. Moessner,2 Ronald E. Engle,3 Hans L. Zaaijer,4 Jrgen Georgsen,1
Robert H. Purcell,3 and Peer B. Christensen2
BACKGROUND: The increasing incidence of reported
hepatitis E cases in Europe has focused attention on
hepatitis E virus (HEV) and the risk of transfusion-
transmitted hepatitis E. The aim of this study was to
investigate the prevalence of antibodies to HEV (anti-
HEV) among Danish blood donors in 2013 and to
compare it to previous studies in Denmark. In addition we
wanted to compare the relative reactivity of two different
assays.
STUDY DESIGN AND METHODS: Samples from 504
blood donors were collected and analyzed for anti-HEV
with an in-house assay developed at the National
Institutes of Health (NIH). In addition the samples were
analyzed with the Wantai anti-HEV assay. Demographic
information and possible HEV exposure was collected by
self-administered questionnaire.
RESULTS: Using the NIH assay the prevalence of anti-
HEV among Danish blood donors was 10.7% and with
the Wantai assay the prevalence of anti-HEV was 19.8%
(p < 0.001). In both cases the presence of anti-HEV was
significantly correlated with increasing age. In addition,
anti-HEV as measured by the Wantai test was
significantly associated with contact with children
(p 5 0.01), but in multivariate analysis only age was
associated with anti-HEV in both assays. By the NIH
assay, the prevalence had declined from 20.6% in 2003
to 10.7% in 2013.
CONCLUSIONS: Anti-HEV prevalence had decreased
by half among Danish blood donors over 10 years, but
was still highly prevalent. The difference in reactivity of
the two assays demonstrates the importance of using the
same assay when comparing the anti-HEV prevalence in
populations over time.
1662 TRANSFUSION Volume 55, July 2015
H
epatitis E is the most common cause of acute
hepatitis and jaundice worldwide.1 The virus
of hepatitis E is a small nonenveloped RNA
virus belonging to the Hepeviridae family.2
HEV consists of multiple genotypes and its classification
is being revised.3,4 Genotypes 1 and 2 are human viruses
and the most common cause of epidemic hepatitis E in
developing countries. Genotypes 1 and 2 are often associ-
ated with contaminated drinking water and fecal-oral
transmission. Genotypes 3 and 4 are associated with zoo-
notic infections with a porcine reservoir and other geno-
types have been found in birds.5 Genotypes 1 and 2
appear to be more virulent than Genotypes 3 and 4 in
humans and infect younger people than Genotypes 3 and
4. Based on the high prevalence of anti-HEV in Western
populations, infections with Genotypes 3 and 4 must be
subclinical in the vast majority of cases.6 It may have a
more serious course in elderly men and can lead to
chronic infection in immunocompromised patients.7
ABBREVIATION: S/CO 5 signal to cutoff.
From the 1Department of Clinical Immunology and the
2
Department of Infectious Diseases, Odense University
Hospital, Odense, Denmark; 3Laboratory of Infectious Diseases,
National Institute of Allergy and Infectious Diseases, National
Institutes of Health, Bethesda, Maryland; and the 4Department
of Blood-Borne Infections, Sanquin Blood Supply Foundation,
Amsterdam, the Netherlands
Address reprint requests to: Dorte Kinggaard Holm, M.Sc.,
Ph.D., Department of Clinical Immunology, Odense University
Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark; e-mail:
dorte.holm@rsyd.dk.
This work was supported in part by the Intramural
Research Program of the National Institute of Allergy and
Infectious Diseases, NIH.
Received for publication August 10, 2014; revision
received December 23, 2014; and accepted December 26, 2014.
doi:10.1111/trf.13028
C 2015 AABB
V
TRANSFUSION 2015;55;16621667

In Europe and other Western countries the focus on
hepatitis E virus (HEV) has increased within the past decade
because of an increasing number of reported cases of HEV
infections. HEV transmission by blood transfusion is well
documented.8-11 Recently, a British study found 0.04% of
blood donors to be HEV RNA positive and that 42% of these
transmitted the infection to their recipients.12 Since HEV is a
nonenveloped virus, it is resistant to inactivation methods
including solvent/detergent treatment of plasma.13 Similarly,
HEV transfusion transmission from INTERCEPT Blood
System-treated plasma was recently shown in France.14
Several studies in Europe and the United States have
found not only a surprisingly high prevalence of anti-HEV
in the general population, but also a 10-fold difference in
prevalence depending on which assay was used.15,16 In
the Netherlands, among 5239 donors, the anti-HEV
immunoglobulin (Ig)G prevalence was 27% using the
Wantai assay (Beijing Wantai Biological Pharmacy
Enterprise Ltd., Beijing, China).16 A study among Scottish
blood donors using the same assay reported 4.7% anti-
HEV IgG prevalence.17 In France HEV IgG antibodies were
found in 52.2% of the blood donors (Wantai assay).18 In
children, only 3.7% were anti-HEV positive.
In Denmark an anti-HEV prevalence study was per-
formed in 2003 using an in-house assay developed at the
National Institutes of Health (NIH; Bethesda, MD).19
Among 461 blood donors the prevalence of anti-HEV was
20.6% in 2003 and had decreased from 32.9% in 1983. The
objectives of this study were to investigate the prevalence
of anti-HEV of Danish blood donors in 2013 and to com-
pare this to the prevalence in 2003.
MATERIALS AND METHODS
Study population
Unpaid, volunteer Danish blood donors (n 5 504) whose
records were collected in 2013 from the blood bank of
Odense University Hospital were recruited, and written
consent for the research was obtained. In addition to the
health history questionnaire completed for each donation,
the blood donors completed an additional questionnaire
with demographic information; hepatitis A vaccination
status; employment; and contact with animals, children,
and farming.
Laboratory analysis
Plasma samples from the blood donors were analyzed
with the two different HEV IgG assays. Anti-HEV was ana-
lyzed at the NIH with an in-house assay, as described else-
where.20,21 Briefly, a baculovirus vector containing a cDNA
fragment corresponding to the major part of ORF2 of the
Pakistani HEV strain SAR-55 was expressed in insect cells.
A purified 55-kDa antigen representing a truncated form
(Amino Acids 112-607) of the 660-amino-acid capsid
PREVALENCE OF ANTI-HEV AMONG DONORS
protein of HEV was coated on microtiter plates, and spe-
cific antibodies against this antigen were detected with
horseradish peroxidase (HRP)-labeled goat anti-human
IgG22 (KPL, 074-1006, 1.0 mg) used at 1 mg/mL. Samples
were tested at a 1:100 dilution (1% bovine serum albu-
min/0.5% gelatin). The assay was calibrated with a World
Health Organization anti-HEV standard to a detection
limit of 1.6 U/mL. The assay was found to have a sensitiv-
ity of 96% and a specificity of 98% and to be superior to
available commercial and in-house assays in a blinded
evaluation of serum panels in 1998.23 The NIH tests per-
formed in 2003 and 2013 were carried out with the same
capture antigen (two calibrated lots), reagents, standards,
and controls. The WHO anti-HEV standard (95/584) was
used to qualify an in-house secondary standard and serial
dilutions of this secondary standard were included in
every test. Routine evaluation of the secondary standard
revealed very little drift between 2003 and 2013.
At the Sanquin Blood Bank in Amsterdam, the plasma
samples were analyzed with the Wantai hepatitis E IgG
enzyme-linked immunosorbent assay (ELISA) kit (Beijing
Wantai Biological Pharmacy Enterprise Ltd.) according to
the manufacturers instructions. The Wantai HEV IgG assay
is an indirect ELISA method using synthetic HEV ORF2 and
three peptides precoated on a polystyrene microtiter plate.
Anti-HEVspecific antibodies were bound to the solid-
phase precoated HEV antigens. The wells were washed to
remove unbound serum proteins, and rabbit anti-human
IgG antibodies (anti-IgG) conjugated to HRP (HRP-conju-
gate) were then added. HRP-conjugated antibodies then
bound to any antigenantibody (IgG) complexes previously
formed, and the unbound HRP-conjugate was removed by
washing. For the Wantai assay the analytical sensitivity was
99.08% (package insert) and the specificity was 99.6%.24
At the Department of Clinical Immunology Odense
University Hospital Denmark the plasma samples were
tested for the presence of anti-hepatitis A virus (HAV) with
use of a commercial assay (Architect HAV IgG, Abbott
Diagnostics Division, Wiesbaden, Germany). The donor
samples were also tested for the presence of antibody to
human immunodeficiency virus (anti-HIV), hepatitis B
surface antigen, antibody to hepatitis C virus (anti-HCV),
HIV RNA, HBV DNA, and HCV RNA (and found to be
negative).
Ethics
Ethical approval for the study was granted by The
Regional Scientific Ethical Committees for Southern
Denmark (ID S-20130016).
Statistical analysis
Data processing and statistical analysis were performed
with the use of computer software (STATA, Version 13.0,
StataCorp, College Station, TX). Nonparametric tests were
used for univariate analysis; the chi-square test and Fishers
Volume 55, July 2015 TRANSFUSION 1663
HOLM ET AL.

TABLE 2. S/CO values of the three donors

represented in both studies
Donor NIH 2003 NIH 2013 Wantai 2013
1 1.19 0.62 1.51
2 3.0 1.14 4.95
3 1.6 0.92 1.29

was not changed by backward stepwise elimination of

insignificant variables (data not shown).
Using the Wantai assay a total of 100 of the 504 donors
(19.8%; 95% CI, 16.4-23.6) were reactive for anti-HEV IgG.
All 54 anti-HEVpositive donors in the NIH assay were reac-
tive when using the Wantai assay (Tables 1 and 2). The
signal-to-cutoff (S/CO) range for the samples only reactive
in the Wantai assay is shown in Table 1. The presence of
Fig. 1. Prevalence of anti-HEV IgG in 504 Danish blood anti-HEV IgG in the Wantai assay was associated with
donors in 2013 when tested in the NIH assay () and the increasing age (p < 0.001) and contact with children
Wantai assay (). (p 5 0.01). The prevalence of anti-HEV was numerically
higher among donors living in the countryside, but did not
reach significance (Table 3 and Fig. 1). However, both of
these factors were significantly associated with increasing
TABLE 1. 2 3 2 table showing reactive comparisons age. In multivariate analysis Wantai anti-HEV was associated
between the assays*
with increasing age and negatively associated with contact
Wantai
to sheep in the full model. By backward elimination only
NIH Negative Positive Total Percent
age remained independently associated (data not shown).
Negative 404 46 450 89.3
Among the 504 donors from the current study, 13 had
Positive 0 54 54 10.7
Total 404 100 504 been tested in 2003.19 Three of the 13 reactive in 2003
Percent 80.2 19.8 remained reactive in 2013 using the Wantai assay, whereas
* Fishers exact < 0.0001. only one of the three was weakly reactive (borderline)
S/CO range: minimum, 1.12; maximum, 11.64; mean, 3.2.
using the NIH assay. The initial S/CO values of the three
samples (2003) as well as the current S/CO values (2013)
are shown in Table 2.
exact test were used as appropriate. Statistical significance
Earlier anti-HEV prevalence studies among Danish
was set at p values of less than 0.05. Independent factors
blood donors have shown a strong birth cohort effect.
associated with anti-HEV were identified by logistic regres-
This cohort effect was still present and explains the overall
sion analysis in separate analysis for the NIH and Wantai
decline in NIH anti-HEV prevalence over the past decade
assays. From a full model we eliminated insignificant varia-
(Fig. 2). The median birth year of the 2013 donors was
bles based on the Wald statistic (backward elimination),
1969 and had increased 1 year compared to the 2003
until all variables remaining in the model were significant.
donors (1958).
We compared the anti-HEV prevalence of blood
donors in Denmark based on the results obtained from
the Wantai assay with recently reported anti-HEV preva-
RESULTS
lences of blood donors in other Western countries also
Blood samples and questionnaire information were obtained from analysis using the Wantai assay (Table 4).
obtained from the 504 consecutive blood donors. All were The anti-HEV prevalence of Danish blood donors was
tested for anti-HEV in both the NIH assay and the Wantai similar to that of England and Wales, the Netherlands, and
assay. the United States; higher than in Scotland; and lower than
Using the NIH assay a total of 54 of 504 donors in Southwest France.
(10.7%; 95% confidence interval [CI], 8.2-13.7) were reac-
tive for anti-HEV IgG. In univariate analysis anti-HEV IgG
DISCUSSION
was only associated with increasing age (p 5 0.001; Fig. 1).
In the full model anti-HEV was positively associated with In this study we found that anti-HEV was still very preva-
increasing age and anti-HAV positivity and negatively lent among Danish blood donors. Using the same NIH
associated with travel outside the European Union. This assay among Danish blood donors the prevalences of

1664 TRANSFUSION Volume 55, July 2015

 PREVALENCE OF ANTI-HEV AMONG DONORS

TABLE 3. Prevalence of anti-HEV IgG in Danish blood donors related to activities*

HEV IgG positive by NIH HEV IgG positive by Wantai
Yes No Yes No
Activity Percent n/N Percent n/N p value Percent n/N Percent n/N p value
Traveling out of Europe 10 33/329 12.2 20/164 0.537 19.5 64/329 20 33/165 0.905
Daily contact with small children 11.5 45/393 9.3 10/108 0.604 22.3 88/394 11.2 12/107 0.010
Contact with mentally disabled 7 4/57 11.4 51/446 0.376 19.3 11/57 20 89/446 1
Contact with cats 11.5 38/330 9.8 17/173 0.653 22.1 73/330 15.6 27/173 0.099
Contact with dogs 11.4 42/367 9.6 13/135 0.631 21.3 78/367 16.3 22/135 0.257
Contact with pigs 16.7 10/60 10.2 45/440 0.183 25.4 15/59 19.3 85/441 0.298
Contact with horses 11.2 10/89 11 45/411 1 22.5 20/89 19.2 79/411 0.467
Contact with cows 13.6 9/66 10.6 46/434 0.525 24.6 16/65 19.1 83/435 0.317
Contact with sheep 7.7 3/39 11.3 52/460 0.789 10.3 4/39 20.4 94/460 0.145
Living in the countryside 11.3 33/291 10.5 22/209 0.885 23 67/291 15.8 33/209 0.054
Working in the countryside 14.6 12/82 10.3 43/419 0.249 24.4 20/82 19.1 80/419 0.291
Working with raw meat 13.4 25/187 9.7 30/311 0.237 23.1 43/186 18.3 57/312 0.204
HAV IgG positive 12.8 21/164 10 34/339 0.363 18.9 31/164 20.1 68/339 0.812
* A nonparametric test was used for univariate analysis of donor activities associated with HEV IgG.
n 5 number of donors; N 5 total number of donors.

NIH assay, while the 2009 to 2010 survey used a commer-

Fig. 2. Prevalence of HEV IgG in Danish blood donors, who
had samples obtained in 2013, compared with donors and
farmers, who had samples obtained in 2003 and 1983. In
2013 the HEV IgG assay from NIH and the Wantai IgG HEV
assay were used in parallel. The NIH HEV IgG assay was the
only assay used in 2003 and 1998.
anti-HEV were 32.9% in 1983, 20.6% in 2003, and 10.7% in
2013.19 This indicates a strong birth cohort effect in anti-
HEV prevalence and suggests that the exposure to anti-
HEV has continued to decline over the past 30 years. A
similar decrease was found in a study performed in the
United States, where the anti-HEV prevalences were
21.8% in 2006 and 16% in 2012.25 In the general US popu-
lation the anti-HEV prevalence decreased from 21% in the
1988 to 1994 NHANES survey to 6% in the 2009 to 2010
survey, comparable to the decrease observed in our
study.26,27 However, the results may not be directly com-
parable, as the 1988 to 1994 study and our study used the
cial assay (Diagnostic Systems, Soronno, Italy).
In England,28 a similar cohort effect was found. We
do not know how long anti-HEV persists in the absence of
new exposure, but our finding that two of three donors
who tested positive in 2003 were no longer anti-HEV posi-
tive 10 years later using the NIH assay indicates that anti-
HEV levels may decay over time. The inability of the NIH
assay to detect all three anti-HEV IgGpositive donors
from 2003 could not be explained by migration of the per-
formance of the assay, since serial dilutions of an in-
house secondary standard were included in every test.
However, some IgG assays lack the ability to detect mature
antibodies from distant infections,24 and this may be an
explanation why anti-HEV IgG was not detected in those
three donors.
The difference in the prevalence of anti-HEV between
the two assays indicated that the sensitivity of the Wantai
assay, compared to the NIH assay, is much higher, or
theoreticallythat the specificity of the Wantai assay is
much lower. If we had used only the Wantai assay in this
study, we would have concluded that the prevalence was
stable the past 10 years, instead of the 48% decline
observed with the NIH assay. This suggests that compari-
sons between different populations and different points in
time require the same assay used in both populations. We
speculate whether the variation could be solved by speci-
fying a detection limit in WHO anti-HEV units, when used
in population surveys. In a recent study comparing the
diagnostic performance of eight different commercial
assays,29 the Wantai assay was the most sensitive assay.
However, we acknowledge that as a gold standard con-
firmatory test for anti-HEV is not available, interassay
comparison is difficult and reactivity may not reflect hep-
atitis E exposure in all cases.

Volume 55, July 2015 TRANSFUSION 1665

HOLM ET AL.
TABLE 4. Anti-HEV IgG prevalence of different donor
populations in Europe and the United States tested
by the Wantai HEV IgG assay
Number of
samples Anti-HEV
Country tested IgG positive (%) References
Scotland 1559 4.7 Cleland et al.17
United States 1023 16.0 Xu et al.25
England and Wales 500 16.0 Dalton et al.
Denmark 505 19.8 This study
Netherlands 5239 26.7 Slot et al.16
Southwest France 512 52.2 Mansuy et al.18
Although the seroprevalence of anti-HEV seems to be
decreasing in Denmark, it is still high compared to the
number of clinical cases seen per year. Our current
hypothesis suggests that HEV infection is a zoonotic infec-
tion transmitted to humans from domestic animals.
However, like in the 2003 study, we found no indication
that direct contact with the animals is the route of trans-
mission. We found that anti-HEV IgG seroprevalence was
numerically higher among donors living in the country-
side. An unpublished study from Denmark has recently
shown that HEV was found in the drain water from fields
spread with swine manure,30 which indicates that there is
a potential risk of contamination of water reservoirs con-
nected to the drainage runoff. In the same study, HEV was
also found in the feces of pigs, as well as in organs such as
the liver and lungs. In the Netherlands, there was no asso-
ciation between anti-HEV positivity and living in the
countryside and contact with pig farms,16 whereas in
Southwest France living in the countryside (rural) and
hunting were highly associated with anti-HEV positivity.
Studies in several countries including France and the
United States have found HEV RNA in pig liver from com-
mercial butcher shops.31,32 This was recently also con-
firmed in a Danish study,30 but we found no association
between the handling of raw meat and anti-HEV presence
(Table 3). If infection took place in the kitchen, during
preparation of pork pate  (a Danish national dish), we
would have expected the anti-HEV prevalence to be
higher among women than men. However, if both prepar-
ing raw liver and outdoor activities are routes of transmis-
sion, this could produce an equal sex distribution.
In England, HEV infection recently has been docu-
mented in 42% of recipients of HEV RNApositive dona-
tions, of whom several developed chronic infection.
Interestingly, 71% of the implicated donors were negative
for HEV antibodies by the Wantai assay at the time of don-
ation, suggesting recent infection.12 Thus, transfusion-
transmitted HEV appears to be a significant issue requir-
ing consideration of an intervention.
In conclusion, our study shows that the HEV preva-
lence in Denmark has been rapidly decreasing over the
past decade, but remains high. This continues a trend
1666 TRANSFUSION Volume 55, July 2015
dating back at least four decades. Furthermore, our find-
ings suggest that studies of anti-HEV prevalence should
correct for the different sensitivity in available anti-HEV
assays, and ideally studies comparing populations over
space and time should use the same assay.
CONFLICT OF INTEREST
The authors have disclosed no conflicts of interest.
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