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Shipboard Medicine
Viral Hepatitis E during Offshore Deployment -A Case Report Surg Lt M. Indrakanth Reddy, Surg Lt Cdr Ushakiran Singh1, Surg Lt Arpit Upadhayaya INS Shishumar, COMCOS (W), Mumbai, 1Department of Anesthesiology, Armed Forces Medical College, Pune, Maharashtra, India
Abstract A 20-year-old young serving sailor presented with a two day history of loss of appetite, mild grade fever and yellow discoloration of both eyes and urine, while sailing, off the home port. He had icterus and tender Grade I hepatomegaly and was provisionally diagnosed as a case of clinical jaundice. As there was no facility for investigation on board, the severity of jaundice, as well as the type of infection were not known. The patient was isolated in a separate compartment and universal precautions were taken for the nursing members. Proper handwashing, chlorination of the water tanks, boiling of drinking water for the ships’ company and disinfection procedures for the sick bay were followed. The crew was educated on reporting to the sick bay whenever any signs or symptoms of jaundice appear in them. After five days, the sailor was referred to a tertiary care hospital when the ship reached the nearest port. He was found to be having high bilirubin level and his liver enzymes and PT/INR were deranged. He was positive for Hepatitis E. Prompt control measures undertaken by the Medical Officer of the ship ensured that there were no other cases of jaundice reporting from the ship. Keywords: Deployment, Hepatitis E, Navy, sailing, submarine, warship
Introduction
Case Report
Hepatitis E virus (HEV) is an enterically transmitted virus which is usually self‑limiting, but some cases may complicate to fulminant hepatitis (acute liver failure).[1] HEV was detected in 1983, when a researcher voluntarily ingested a pooled extract of feces from soviet soldiers suffering with acute hepatitis.[2] Since then HEV has caused large epidemics in developing countries including in India. An estimated 79,091 persons in the city of Kanpur were affected by hepatitis E during the period from 1990 to 1991[3] and was blamed to the mixing of drinking water by water from the Ganges. The HEV is shed in the stools of the infected person and enters the human body through enteric route. Definitive diagnosis of hepatitis E infection rests on detection of IgM and IgG anti‑HEV antibodies and detection of HEV RNA. Other advanced diagnostic modalities include reverse transcriptase polymerase chain reaction to detect viral RNA in the blood.[4] No specific treatment is presently used for altering the course of acute hepatitis E. However, hospitalization is mandatory for people with fulminant hepatitis. In complicated cases of hepatitis E, interferon or antiviral drugs such as ribavirin have also been used successfully.[5]
A 20‑year‑old young serving sailor, serving onboard a warship deployed off the home port for a considerable period, presented with a 2 days history of loss of appetite, mild grade fever, and yellowish discoloration of both eyes along with discoloration of urine. He embarked the ship along with the ships’ crew approximately 15 days prior and had no significant history of consumption of any food or fluids other than from known sources. On general physical examination, he was febrile, had icterus and tachycardia. Systemic examination revealed a tender Grade I hepatomegaly (2 cm below right costal margin). Based on these clinical findings, he was diagnosed as a case of jaundice for investigation. The patient was isolated in a compartment near to the sick bay and was managed conservatively. Medical and other staff nursing with the patient observed necessary universal precautions. Proper handwashing of all personnel onboard the ship was enforced, and disinfection procedures with 5% cresol ensured. Five days
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DOI: 10.4103/jmms.jmms_48_17
68
How to cite this article: Reddy MI, Singh U, Upadhayaya A. Viral hepatitis E during offshore deployment -A case report. J Mar Med Soc 2017;19:68-9.
© 2017 Journal of Marine Medical Society | Published by Wolters Kluwer ‑ Medknow
[Downloaded free from http://www.marinemedicalsociety.in on Friday, August 25, 2017, IP: 185.43.11.76] Reddy, et al.: Viral hepatitis during sailing
later, when the warship reached a foreign port, the patient was admitted to a tertiary care center. He had elevated serum bilirubin levels and liver enzyme levels besides a deranged prothrombin time/international normalized ratio. The patient was further diagnosed as a case of HEV‑related acute hepatitis. He was subsequently repatriated to India and was admitted to a tertiary care hospital of the Navy. The further period of hospitalization of the patient was uneventful, and the individual was discharged postfull recovery.
Discussion Hepatitis E is essentially transmitted by fecal–oral route through drinking of contaminated water.[6] Risks of contamination can arise from source water at the port or during loading, storage, or distribution onboard the ship which differ considerably from that of the water supply ashore. The infection may also arise from contaminated drinking water while eating out at unhygienic places, which cannot be ruled out in this case as the sailor contracted the infection 15 days after sailing out from the home port, thus being well within the incubation period of 2–10 weeks.[7] Water‑ and food‑borne diseases have been quite common in the Navy.[8] The pandemics of cholera were blamed to have spread through sea to several continents. In a ship or a submarine, environment is favorable for rapid and efficient transmission of HEV, particularly when levels of protection are suboptimal and immunity is low during prolonged sailing.[9] A single case of water‑ and food‑borne hepatitis E case can be transmitted relatively easily in view of the common food preparation areas and common water supply if control measures are not instituted. Our patient was managed as a case of clinical jaundice in the absence of confirmatory tests onboard. With so many different modes of transmission of viral hepatitis, control measures are difficult to be instituted in a ship or a submarine, especially when a confirmatory test is not available. Isolation is difficult in a space‑constrained environment, and management and transfer of the patients while on deployment would be a hideous task. Hepatitis A, also transmitted by water and food, was found in American sailors serving onboard ships during the Gulf War,[10] and the sailors were transferred to the hospital ship Mercy. The admission rates varied from 1.68% to 1.87%. The advantage of such a hospital ship during war for carrying the wounded and the sick is also not always available.
Conclusion This report highlights the importance of undertaking prompt preventive and control measures in jaundice cases as the mode of transmission is unknown till a final diagnosis of the nature of Hepatitis Virus is detected. The factors contributing to such outbreaks emphasize the need for sanitary handling of water by effective chlorination along the supply chain from source to consumption. A comprehensive approach to water safety onboard ships is essential which should include routine inspection of chlorination and regular maintenance of water pipes to prevent mixing of drinking water pipes with sewage pipes which run parallelly. Installation of water filters with ultraviolet technology and boiling of drinking water are also known effective measures against HEV.
Financial support and sponsorship Nil.
Conflicts of interest
There are no conflicts of interest.
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Journal of Marine Medical Society ¦ Volume 19 ¦ Issue 1 ¦ January-June 2017
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