Population-based estimates of hepatitis E virus associated mortality in Bangladesh

Background: Hepatitis E virus (HEV) is endemic in many resource-poor countries. Despite an available vaccine, data on HEV-associated mortality are scarce, hindering informed decisions. This study aims to estimate the population-based rate of HEV-specific mortality in Bangladesh. Methods During December 2014-September 2017, we conducted surveillance in six tertiary hospitals in Bangladesh. Patients aged ≥14 years with acute jaundice were recruited, tested for IgM anti-HEV, and followed up post-discharge. A mortality survey in the hospital catchment areas identified deaths associated with acute jaundice, including maternal, stillbirths and neonatal deaths delivered by a mother with acute jaundice during pregnancy, confirmed by two independent physicians reviewing verbal autopsy data. Findings Out of 1,925 patients with acute jaundice identified and enrolled in the surveillance hospitals, 302 died, with 28 (9%) testing positive for IgM anti-HEV. In the hospital catchment areas, the team identified 587 jaundice-associated deaths, including 25 maternal deaths. Combining hospital-based surveillance and mortality survey data, the study estimated 986 (95% CI: 599-1338) HEV-associated deaths annually among individuals aged ≥14 years in Bangladesh, including 163 (95% CI: 57-395) maternal deaths. Additionally, 279 (95% CI: 101-664) stillbirths and 780 (95% CI: 365-1,297) neonatal deaths were attributed to HEV infection annually. Interpretation Prior Global Burden of Disease studies presented wildly varying modeling estimates of HEV-associated annual deaths, ranging from 50,000 in 2013 to 1,932 in 2019. This study is the first to directly measure population-based estimates of mortality in Bangladesh, which can be used to determine the cost-effectiveness of hepatitis E vaccination and other interventions.