Open Access Research article

Surveillance of hepatitis A virus in urban sewages and comparison with cases notified in the course of an outbreak, Italy 2013

Giuseppina La Rosa1*, Simonetta Della Libera1, Marcello Iaconelli1, Anna Rita Ciccaglione2, Roberto Bruni2, Stefania Taffon2, Michele Equestre3, Valeria Alfonsi4, Caterina Rizzo4, Maria Elena Tosti4, Maria Chironna5, Luisa Romanò6, Alessandro Remo Zanetti6 and Michele Muscillo1

Author Affiliations

1 Department of Environment and Primary Prevention, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy

2 Department of Infectious, Parasitic and Immune-Mediated Diseases, Istituto Superiore di Sanità, Rome, Italy

3 Department of Cell Biology and Neurosciences, Istituto Superiore di Sanità, Rome, Italy

4 National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy

5 Hygiene Section, Department of Biomedical Sciences and Human Oncology, University of Bari-Aldo Moro, Bari, Italy

6 Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy

For all author emails, please log on.

BMC Infectious Diseases 2014, 14:419  doi:10.1186/1471-2334-14-419

Published: 29 July 2014



Over the past 20 years, Hepatitis A notifications in Italy have been in decline. Since the beginning of 2013 however, Italy has been experiencing a foodborne hepatitis A outbreak caused by genotype IA, involving hundreds of cases. Consumption of frozen mixed berries was deemed the potential vehicle of infection.

We aimed to investigate the spread of hepatitis A virus (HAV) in Italy through the monitoring of urban sewages collected at Wastewater Treatment Plants (WTPs) and a subsequent comparison of environmental surveillance data with data from the clinical surveillance performed during the epidemic.


The study covered 15 months, from July 2012 to September 2013, comprising the outbreak and the preceding six months. Environmental surveillance consisted of the analysis of urban sewage samples collected at 19 WTPs in seven of the Italian regions most affected by the epidemic. HAV isolates were detected and typed using a nested RT-PCR targeting the VP1/2A junction. Parallel clinical surveillance was performed by the sentinel surveillance system for acute viral hepatitis (SEIEVA) and by the ministerial Central Task Force on Hepatitis A, established with the purpose of determining the source of the outbreak and adopting appropriate outbreak control strategies.


A total of 38/157 wastewater samples (24.2%) were positive for HAV, 16 collected in 2012 and 22 in 2013. Several HAV strains were detected, including the IA variant implicated in the outbreak and isolated from clinical cases over the same period. The vast majority of sequences belonged to genotype IB. Interestingly however, although these included variants related to strains that had been involved in past Italian epidemics, none were detected in recent clinical samples, probably due to underreporting or asymptomatic circulation. Conversely, a number of sequences were identified in clinical samples that were not found in wastewaters.


The percentage of sewage samples detected as HAV-positive in this study are consistent with the classification of Italy as a country with low/intermediate endemicity. A combined environmental/clinical surveillance is able to provide a more complete picture of the spread of HAV and of the genotypes circulating in the population, allowing a better understanding of changes in disease trends.

Hepatitis A; Surveillance; Genotyping; Environmental; Clinical