Received: 20 April 2023 Revised: 5 June 2023 Accepted: 7 June 2023

DOI: 10.1111/vox.13487

ORIGINAL ARTICLE

Hepatitis E virus seropositivity in an ethnically diverse

community blood donor population

Jordan K. Mah 1 | MeiLe Keck 1,2 | Daniel Y. Chu 1,2 | Harini Sooryanarain 3 |
Malaya K. Sahoo 1 | Patrick Lau 1 | ChunHong Huang 1 | Jenna Weber 1 |
Geoffrey A. Belanger 2 | Zhenyong Keck 1 | Hua Shan 1 | Xiang-Jin Meng 3 |
Steven K. H. Foung 1 | Benjamin A. Pinsky 1,4 | Tho D. Pham 1,2

1
Department of Pathology, Stanford
University School of Medicine, Stanford, Abstract
California, USA
Background and Objectives: Hepatitis E virus (HEV) is an underrecognized and
2
Stanford Blood Center, Stanford Health Care,
Palo Alto, California, USA
emerging infectious disease that may threaten the safety of donor blood supply in
3
Virginia-Maryland College of Veterinary many parts of the world. We sought to elucidate whether our local community blood
Medicine, Virginia Polytechnic Institute and supply is at increased susceptibility for transmission of transfusion-associated HEV
State University, Blacksburg, Virginia, USA
4 infections.
Department of Medicine, Division of
Infectious Diseases and Geographic Medicine, Materials and Methods: We screened 10,002 randomly selected donations over an
Stanford University School of Medicine,
8-month period between 2017 and 2018 at the Stanford Blood Center for markers
Stanford, California, USA
of HEV infection using commercial IgM/IgG serological tests and reverse transcrip-
Correspondence tase quantitative polymerase chain reaction assays (RT-qPCR). Donor demographic
Tho D. Pham, Stanford Blood Center, 3373
Hillview Avenue, Palo Alto, CA 94304, USA. information, including gender, age, self-identified ethnicity, location of residence and
Email: thopham@stanford.edu recent travel, were obtained from the donor database and used to generate multivar-

Funding information
iate binary logistic regressions for risk factors of IgG seropositivity.
Stanford Blood Center; Stanford Department Results: A total of 10,002 blood donations from 7507 unique donors were screened,
of Pathology
and there was no detectable HEV RNA by RT-qPCR. The overall seropositivity rate
was 12.1% for IgG and 0.56% for IgM. Multivariate analysis of unique donors
revealed a significantly higher risk of IgG seropositivity with increasing age, White/
Asian ethnicities and residence in certain local counties.
Conclusion: Although HEV IgG seroprevalence in the San Francisco Bay Area is con-
sistent with ongoing infection, the screening of a large donor population did not
identify any viraemic blood donors. While HEV is an underrecognized and emerging
infection in other regions, there is no evidence to support routine blood screening
for HEV in our local blood supply currently; however, periodic monitoring may still
be required to assess the ongoing risk.

Keywords
blood donor supply safety, diverse blood donor population, hepatitis E, transfusion, transfusion-
transmitted infections

Jordan K. Mah, MeiLe Keck and Daniel Y. Chu contributed equally; they are listed reverse-alphabetically.

Vox Sanguinis. 2023;1–7. wileyonlinelibrary.com/journal/vox © 2023 International Society of Blood Transfusion. 1

 14230410, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vox.13487 by University Of Wisconsin - Madison, Wiley Online Library on [03/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
2 MAH ET AL.

Highlights
• There was no detectable hepatitis E viraemia in 10,002 blood donations from a diverse,
multi-ethnic blood donor population that was screened.
• There was a significantly higher risk of hepatitis E immunoglobulin G seropositivity with
increasing age, White and Asian ethnicities and residence in certain counties.
• While hepatitis E virus (HEV) is an underrecognized and potentially emerging infection in
other countries, there is no evidence to support routine blood screening at the current time
for HEV in the blood supply at Stanford Blood Center in Palo Alto, CA, USA.

I N T R O D U CT I O N Sample collection

Emerging infectious diseases represent an ongoing threat to the
safety of the blood supply [1]. Although some of these diseases origi-
nate outside of the United States, with increasing travel, immigration
and an ethnically diverse donor population, the safety of the blood
supply in the United States may be at risk. These concerns are particu-
larly relevant within the San Francisco Bay Area (SFBA), where the
nexus of several industries, including tech, biotech and academics,
brings together individuals from all over the world.
One such potential threat is hepatitis E virus (HEV), a non-
enveloped single-stranded RNA virus, comprising four genotypes
[2, 3]. Genotypes (G) 1 and G2 are water-borne diseases, similar to
hepatitis A virus, whereas G3 and G4 are zoonotic infections, com-
monly associated with swine exposure and consumption of under-
cooked pork [4–6]. Transfusion-transmitted HEV infection has been
documented in many countries, including Japan, the United Kingdom
and France [7, 8]. Though the evaluation of the risk of HEV to
the United States blood supply has previously been undertaken,
Northern California, which includes the SFBA, was notably under-
represented [9, 10].
At the Stanford Blood Center (SBC), with an annual whole-blood
collection volume approximating 45,000 donations, the donor popula-
tion travels extensively, with over 5000 donors per month reporting
travel outside the United States and Canada within the past 3 years.
Given that HEV transmission occurs primarily through swine contact,
or consumption of undercooked pork products or contaminated
water, the extensive travel habits in combination with the various
multinational origins of our donor base make HEV transmission a
potential threat that is unique to the local population.
The study seeks to quantify the transmission risk of HEV to the
local blood supply and provide the information necessary to commen-
surately undertake appropriate actions without compromising the
safety or availability of the blood supply.
MATERIALS AND METHODS
A total of 10,002 routine blood donations from 7507 unique donors
were collected at SBC (Palo Alto, CA) from May 2, 2017 to March
26, 2018. Specimens collected in BD Vacutainer serum blood collection
tubes at the time of blood collection were centrifuged at 1000  g for
10 min after clotting. Unopened serum samples were stored at 4 C for
7 days until no longer needed for blood centre operations. Serum was
then transferred into three separate vials for HEV RNA testing, anti-
HEV immunoglobulin G (IgG) and immunoglobulin M (IgM) antibody
screening and archival storage at 80 C, respectively.
HEV IgG and IgM ELISA
HEV IgG and IgM levels were tested using enzyme-linked immunosor-
bent assay (ELISA) kits (catalogue numbers WE-7296 and WE-7196,
respectively) manufactured by Beijing Wantai Biological Pharmacy
Enterprise CO., Ltd (Beijing, China). Following each diagnostic kit’s
instructions, all samples underwent the two-step incubation ELISA.
Samples were diluted 1:10 with the diluent provided (serum base,
casein and sucrose solution) and were added to pre-coated microwell
strips. The IgM kit strips were pre-coated with human anti-IgM μ
chain while the IgG kit was pre-coated with recombinant HEV. Initial
incubation lasted for 30 min and was followed by incubation with a
horseradish-peroxide conjugate for 30 min. Each plate had three neg-
ative controls and two positive controls (kindly provided by
Dr. Saleem Kamili, Division of Viral Hepatitis, Centers for Disease
Control and Prevention). Colour development was measured at
450 nm using a SpectraMax 190 microplate reader. Cut-off (C.O.)
values were determined according to the manufacturer’s instructions.
For IgM, the cut-off value was set at 0.26 plus the average optical
density (OD) of the negative controls. For IgG, the C.O. was set at
0.16 plus the average OD of the negative controls. The results were
calculated as a relation between the absorbance value (A) and the
C.O. The results of A/C.O. ≥ 1.0 were considered positive.

Ethics statement HEV reverse transcriptase quantitative PCR

This study was reviewed and approved by the Institutional Review Serum samples (1 mL) were extracted for total nucleic acids using the
Board of Stanford University (Protocol 13942). QIAsymphony DSP Virus/Pathogen Midi Kit on the QIAsymphony SP

HEV SEROPREVALENCE IN DIVERSE BLOOD DONORS
instrument (Qiagen, Germantown, MD) and eluted in a final volume of
60 μL. An internal control (IC) was added to each primary sample dur-
ing the extraction step. The Altona RealStar HEV RT-PCR Kit 2.0
(Hamburg, Germany) was performed according to the manufacturer’s
recommendations on a Rotor-Gene Q (Qiagen, Germantown, MD)
real-time PCR instrument. Briefly, 25 μL eluate was used in a 50 μL
reaction containing primers and probes for HEV and the IC. Cycling
 
conditions were as follows: 55 C for 20 min, 95 C for 2 min and
45 cycles of 95 C for 15 s, 55 C for 45 s and 72 C for 15 s. The fluo-
rescence signals for HEV and the IC were acquired at 55 C in the
FAM (green) and JOE (yellow) channels, respectively. For assay inter-
pretation, a signal threshold was set at 0.1 for FAM and 0.03 for JOE;
the sample was considered positive if the amplification curve crossed
the threshold before 40 cycles. Each RT-PCR run included a negative
control (RNA from Basematrix 53 defibrinated human plasma [DHP;
SeraCare, Milford, MA] extracted during each QIAsymphony run), a
positive control (RNA from an HEV positive stool sample [kindly pro-
vided by Dr. Saleem Kamili, Division of Viral Hepatitis, Centers for
Disease Control and Prevention]) and a no template control (nuclease-
free water). The analytical sensitivity of this test is 0.20 IU/μL (95%
confidence interval [CI], 0.12–0.45 IU/μL) [11].
Data acquisition and analyses
Donor demographic information is maintained on SafeTrace
(Haemonetics) database at SBC. All relevant donor demographic infor-
mation including gender, age, self-identified ethnicity, location of resi-
dence and recent travel were collected and analysed with the
serology and reverse transcriptase quantitative polymerase chain
reaction results. Binomial proportion CIs were calculated using the
Clopper–Pearson method. When comparing differences between and
among groups, we used Fisher’s exact or Chi-squared tests where
appropriate. To predict factors predictive of IgG seropositivity, we
used univariate and multivariate binary logistic regression to generate
odds ratios (ORs). Zip codes were used to categorize donors based on
the location of residence into the different Californian counties.
Donors resided primarily in Santa Clara, San Mateo, Santa Cruz, San
Francisco and Alameda counties; donors who resided in California,
but outside of these five counties were combined into the Other
County group. Reference groups were defined as the largest or most
normative groups of a population. Each donor was included only once
in the univariate and multivariate analyses; if there were multiple
donations from the same donor, only the first blood donation was
included in the analysis.
RESULTS
HEV antibody and RNA detection
There were 1210 HEV IgG seropositive donations accounting
for 12.1% (95% CI, 11.5%–12.8%) of total donations. In contrast,
14230410, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vox.13487 by University Of Wisconsin - Madison, Wiley Online Library on [03/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
3
there were 56 HEV IgM seropositive donations and 30 donations
positive for HEV IgM and IgG, accounting for 0.56% (95% CI,
0.4%–0.7%) and 0.3% (95% CI, 0.2%–0.4%) of total donations,
respectively. HEV RNA was not detected in any donation. The rela-
tively limited number of IgM-positive donations precluded the
detailed statistical analysis that was undertaken for IgG-positive
donations.
HEV IgG seropositivity is related to age but not gender
The proportion of IgG positivity increases with age. The proportion of
positivity in the oldest age groups, 61–70 and >70 years of age, was
23.08% and 35.57%, respectively (Table 1). Both the univariate and
multivariate models demonstrated that age was a strong predictor of
IgG seropositivity. The 61–70 and >70 years of age cohorts had multi-
variate OR of 10.96 and 20.40, respectively (Table 1). No significant
association was found with gender.
HEV IgG seropositivity is related to self-identified
ethnicity
The ethnic composition of the donations was determined based on
the donor’s self-reported ethnicity. The SBC donor population is com-
prised primarily of donors who self-identify as White (64.4%), fol-
lowed by self-identified Asians (20.5%). The third most prominent
ethnic population is Hispanic, comprising 9.6% of donations.
To evaluate for inadvertent sampling bias, these composite ethnicity
results were compared with the total blood donor population during
the study time frame. No significant difference from the overall donor
base was observed (data not shown).
We next investigated the rate of HEV IgG positivity within each
major ethnic group (Table 1). IgG seropositivity was highest among
Whites and Asians (12.47% and 11.42%, respectively). In contrast,
only 3.29% of Hispanics were HEV IgG positive. In the multivariate
model, compared with Whites, Asian ethnicity was associated with
IgG seropositivity with an OR of 1.76; whereas Hispanic and Black
ethnicities were less likely than Whites to be seropositive for IgG,
with ORs of 0.54 and 0.15, respectively.
HEV serostatus is associated with donor residence
We then addressed whether HEV exposure was related to a specific
locale within our donor base. Figure 1 shows HEV IgG seropositivity
mapped topographically according to donor residence. The highest
clusters of IgG seropositivity were located within Santa Clara and San
Mateo counties with a proportion of IgG positivity of 11.19% and
13.22%, respectively (Table 1). Santa Cruz, San Francisco and Alameda
counties had lower rates of IgG positivity; however, in the multivariate
model, only Alameda and other counties (residence in California, but
outside of the five major SFBA counties) reached statistical
 14230410, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vox.13487 by University Of Wisconsin - Madison, Wiley Online Library on [03/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 MAH ET AL.

TABLE 1 Univariate and multivariate analyses of hepatitis E virus immunoglobulin G (IgG) seropositivity.

Potential risk factor or exposure %, proportion of IgG positive Univariate OR (95% CI) p value Multivariate OR (95% CI) p value
Gender
Female 11.05 (328/2968) 1.00 (Reference) – 1.00 (Reference) –
Male 10.82 (489/4521) 0.98 (0.85–1.14) 0.819 0.96 (0.82–1.12) 0.600
Age
<20 2.48 (28/1128) 1.00 (Reference) – 1.00 (Reference) –
21–30 3.80 (43/1131) 1.55 (0.96–2.52) 0.074 1.31 (0.80–2.13) 0.288
31–40 6.58 (72/1095) 2.77 (1.77–4.31) <0.001 2.45 (1.43–3.52) <0.001
41–50 8.71 (101/1159) 3.75 (2.45–5.75) <0.001 3.04 (1.97–4.70) <0.001
51–60 13.11 (211/1610) 5.93 (3.96–8.86) <0.001 5.29 (3.50–8.00) <0.001
61–70 23.08 (240/1040) 11.79 (7.89–17.62) <0.001 10.96 (7.21–16.65) <0.001
>70 35.57 (122/344) 21.59 (13.97–33.37) <0.001 20.40 (12.96–32.12) <0.001
Ethnicity
White 12.47 (568/4554) 1.00 (Reference) – 1.00 (Reference) –
Asian 11.42 (191/1672) 1.016 (0.65–1.59) 0.944 1.76 (1.45–2.15) <0.001
Black 1.36 (2/152) 0.92 (0.58–1.46) 0.722 0.15 (0.04–0.71) 0.015
Hispanic 3.29 (28/851) 0.10 (0.02–0.41) 0.002 0.54 (0.36–0.81) 0.003
Islander 4.65 (2/43) 0.24 (0.14–0.43) <0.001 0.62 (0.14–2.65) 0.514
Native 6.25 (3/48) 0.35 (0.08–1.54) 0.163 0.74 (0.223–2.47) 0.628
Unknown 12.30 (23/187) 0.48 (0.14–1.66) 0.243 1.04 (0.65–1.65) 0.880
Residence of blood donor
Santa Clara 11.19 (565/5051) 1.00 (Reference) – 1.00 (Reference) –
San Mateo 13.22 (147/1112) 1.15 (0.53–2.53) 0.725 1.00 (0.82–1.23) 0.968
Santa Cruz 8.62 (15/174) 1.39 (0.63–3.10) 0.417 0.68 (0.39–1.18) 0.168
San Francisco 6.41 (10/156) 0.86 (0.34–2.21) 0.863 0.94 (0.48–1.83) 0.844
Alameda 5.92 (41/692) 0.63 (0.23–1.72) 0.364 0.71 (0.51–1.00) 0.049
Other county 12.75 (32/251) 0.58 (0.25–1.34) 0.199 1.51 (1.00–2.27) 0.045
Another state 9.86 (7/71) 1.34 (0.56–3.17) 0.511 0.95 (0.45–2.33) 0.947
Self-reported travel (≤3 years)
No 10.70 (395/3692) 1.00 (Reference) – 1.00 (Reference) –
Yes 11.48 (409/3564) 1.08 (0.93–1.25) 0.007 1.01 (0.94–1.28) 0.232
Unknown 5.18 (13/251) 0.46 (0.26–0.81) 0.003 0.75 (0.42–1.36) 0.346

Note: Statistically significant values are highlighted in bold text.

Abbreviation: OR, odds ratio.

significance and were associated with a lower and higher ORs of IgG travel was not predictive of seropositivity, with an OR of 1.01
seropositivity, 0.71 and 1.51, respectively (Table 1). (p = 0.232) in the multivariate model.

HEV seropositivity is not related to travel outside of DI SCU SSION

the United States or Canada
We obtained donor travel information in the recent 3-year period as
reported on the donor history questionnaire, recorded as an affirma-
tive or negative if the donor has travelled outside the United States or
Canada. Donors who travelled within the past 3 years had a similar
proportion of HEV IgG seropositivity than those who have not trav-
elled (11.48% vs. 10.70%). In the multivariate binary regression model,
In this study, we report the risk of HEV exposure in an SFBA commu-
nity blood donor population. Although there was no evidence of HEV
viraemia, we uncovered significant differences in HEV IgG seroposi-
tivity relating to age, ethnicity and location of residence.
The absence of HEV RNA in our set of 10,002 donations is con-
sistent with the limited number of viraemic donations identified in
several other studies of US donors. Out of a total of over 18,000

HEV SEROPREVALENCE IN DIVERSE BLOOD DONORS
F I G U R E 1 Topographical map of the San Francisco Bay Area with self-reported blood donor residence and immunoglobulin G (IgG)
seropositivity status. Each circle represents a donation, with anti-hepatitis E virus IgG seropositivity represented by red and seronegativity by
green.
donations over multiple geographic regions, Stramer et al. demon-
strated two donations with HEV viraemia in the Midwest region,
which accounted for 6500 donations [9]. Another study at the
National Institutes of Health by Xu et al. also demonstrated no HEV
viraemia in 1900 donors [11]. Work from Roth et al. studying source
plasma donors encompassing close to 130,000 donors throughout the
United States yielded three donors positive for HEV RNA; also identi-
fied in the Midwest region, which accounted for 46,000 dona-
tions [10]. The risk of infection in the Midwest has been attributed to
farming/zoonotic exposure. Though it is important to mitigate the risk
of transfusion-transmitted HEV infection for vulnerable patient popu-
lations, including those who are immunosuppressed, pregnant or with
chronic liver disease, we found no evidence to support HEV RNA
screening in our donor population.
The overall HEV IgM seropositivity found in our study (0.56%)
was similar to the results reported in other US studies; 0.4% [12],
0.5% [13] and 0.58% [9]. Although these individuals showed no
14230410, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vox.13487 by University Of Wisconsin - Madison, Wiley Online Library on [03/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
5
evidence of active infection, it raises the possibility of recent HEV
exposure and the need for ongoing surveillance.
We detected overall HEV IgG seropositivity of 12.1% of dona-
tions from the SFBA. In contrast, a previous study of 5000 donations
carried out in 1993–1994 reported a seroprevalence of just
1.2%–1.4% [14]. More recent studies in the United States report
overall HEV IgG seropositivity of 6.0%, 7.7% and 6.1%, which more
closely approximates our findings [9, 13, 15]. When analysed
regionally, a higher rate of IgG seropositivity was observed in the
Midwest (12.5% and 11.4%) in two studies [9, 16] and in the
Maryland/Washington, DC area (18.8%), in another [12]. Differences
in IgG seroprevalence may be attributed, in part, to the sensitivities
of the respective immunoassays used in these studies. The Wantai
HEV IgG ELISA, used in our study and Xu et al. [12] has been shown
to demonstrate higher sensitivity than other commonly used
methods [15, 17]. Nevertheless, the regional differences observed
with the same serological method, as in Stramer et al. [9], indicate

6 MAH ET AL.
that regional donor demographic characteristics and risk factors also
impact HEV IgG seroprevalence.
Using a binary regression multivariate model, we showed that
HEV IgG seropositivity in the SFBA is strongly correlated with increas-
ing age, a finding that has been replicated by other studies [9, 12, 13,
15, 16]. This likely relates to the cumulative risk of lifetime exposure;
however, large differences in exposure or an age cohort effect are
possible [18–21]. No difference in IgG seroprevalence was associated
with gender, consistent with other work [12, 13, 15].
We also found that HEV IgG seropositivity was highest in Whites
and Asians and lower in Hispanics and Blacks (12.47% and 11.42%
vs. 3.29% and 1.36%, respectively). The largest study of US blood
donors did not examine the relationship of ethnicity with IgG seropos-
itivity [9], and other seroprevalence studies reported no difference in
IgG seropositivity between White and Hispanic ethnicities [12, 13].
Notably, these studies included limited numbers of Asian participants,
which comprise a substantial proportion of our local donor pool. Our
findings, however, are concordant with meta-analyses demonstrating
that many parts of Asia are endemic for HEV [22, 23]. Interestingly,
analysis of HEV IgG data from the 2009–2016 National Health and
Nutrition Examination Survey (NHANES) showed higher HEV IgG
seroprevalence in Asian participants than in other ethnicities [15].
We also stratified donors based on the location of residence and
found that donors residing in Alameda counties were less likely to be
seropositive compared with those from Santa Clara County while
those from other counties outside of the five major SFBA counties
had a higher probability of being seropositive. We speculate that
these differences could be due to differences in local exposure risks,
though further studies will be required to investigate this observation.
While birth outside of the United States has been shown to be a
risk factor for HEV exposure [13, 15], the effect of international travel
on HEV IgG seropositivity has not been investigated in US blood
donors. We found that travel outside of the United States and Canada
within the past 3 years was not associated with HEV IgG seropositiv-
ity; the OR was 1.01 in the multivariate model. It is important to note
that not all international travel carries the same HEV risk. Future stud-
ies may benefit from collecting more granular travel details including
dates, duration and exact location of travel, and whether the donor
engaged in any activities that might increase exposure risk. In addi-
tion, follow-up studies with HEV genotype-specific antibody assays, if
available, may help determine the relative contributions of travel-
related and locally acquired HEV infection to our seropositivity rates.
This study is limited by its retrospective design and the shortcom-
ings of the electronic donor database. For example, whether a donor
travelled internationally was not available for 3.0% of donations.
However, given that this represents a small fraction of the overall
data, the missing information is unlikely to impact our overall results
and conclusions. This study also did not collect data about potential
local exposures or other factors known to be associated with HEV IgG
seropositivity, such as birthplace outside the United States. Lastly,
given our unique population, the conclusions drawn from this study
may not be readily applicable to other centres with different donor
characteristics; local epidemiologic and seroprevalence studies may be
14230410, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vox.13487 by University Of Wisconsin - Madison, Wiley Online Library on [03/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
required to tailor HEV blood donor screening practices to a particular
community.
In this study, we report significant differences in HEV exposure in
our local donor population relating to age, self-identified ethnicity and
location of residence. Although there are modest rates of HEV sero-
positivity, there was no evidence of HEV viraemia in our population,
suggesting that the potential vulnerability of our local blood supply to
HEV transmission is low. Additional studies will be required to further
characterize specific donor behaviours that contribute to HEV expo-
sure. The small but detectable subpopulation of IgM seropositive
donors suggests possible recent HEV exposure and the need for peri-
odic monitoring.
AC KNOW LEDG EME NT S
The authors would like to thank Dr. Vivek Charu from the Department
of Pathology and Quantitative Sciences Unit, Stanford University
School of Medicine, for his input on the statistical analyses. The
authors would also like to thank Dr. Saleem Kamili from the Division
of Viral Hepatitis, Centers for Disease Control and Prevention, for
providing control of HEV RNA, as well as HEV IgG- and IgM-positive
sera. This study was funded by the Stanford Blood Center and the
Stanford Department of Pathology.
T.D.P., B.A.P. and S.K.H.F. conceived the project. M.K., D.Y.C.,
H.S., M.K.S., P.L., C.H., J.W., G.A.B., Z.K., H.S. and X.J.M. performed
the experiments. J.K.M., T.D.P. and B.A.P. performed data analyses
and interpretation of the data. J.K.M., T.D.P. and B.A.P. drafted the
manuscript. All authors provided a critical appraisal of manuscript
drafts. All authors critically revised the manuscript for important intel-
lectual content and gave final approval of the version to be published
and agreed to be accountable for all aspects of the work.
CONFLIC T OF INTER E ST STATEMENT
The authors declare no conflicts of interest.
DATA AVAILABILITY STAT EMEN T
The data that support the findings of this study are available on
request from the corresponding author, TDP. The data are not pub-
licly available due to restrictions from HIPPA that could compromise
the privacy of blood donors.
ORCID
Jordan K. Mah https://orcid.org/0000-0002-7552-4840
RE FE RE NCE S
1. Godbey EA, Thibodeaux SR. Ensuring safety of the blood supply in
the United States: donor screening, testing, emerging pathogens, and
pathogen inactivation. Semin Hematol. 2019;56:229–35.
2. Bi H, Yang R, Wu C, Xia J. Hepatitis E virus and blood transfusion
safety. Epidemiol Infect. 2020;148:e158.
3. Kamar N, Bendall R, Legrand-Abravanel F, Xia NS, Ijaz S, Izopet J,
et al. Hepatitis E. Lancet. 2012;379:2477–88.
4. Kim YH, Park BJ, Ahn HS, Han SH, Go HJ, Kim DH, et al. Detection
of hepatitis E virus genotypes 3 and 4 in pig farms in Korea. J Vet
Sci. 2018;19:309–12.

HEV SEROPREVALENCE IN DIVERSE BLOOD DONORS
5. Colson P, Borentain P, Queyriaux B, Kaba M, Moal V, Gallian P, et al.
Pig liver sausage as a source of hepatitis E virus transmission to
humans. J Infect Dis. 2010;202:825–34.
6. Tulen AD, Vennema H, van Pelt W, Franz E, Hofhuis A. A case-
control study into risk factors for acute hepatitis E in the
Netherlands, 2015–2017. J Infect. 2019;78:373–81.
7. Kimura Y, Gotoh A, Katagiri S, Hoshi Y, Uchida S, Yamasaki A, et al.
Transfusion-transmitted hepatitis E in a patient with myelodysplastic
syndromes. Blood Transfus. 2014;12:103–6.
8. Dreier J, Knabbe C, Vollmer T. Transfusion-transmitted hepatitis E:
NAT screening of blood donations and infectious dose. Front Med
(Lausanne). 2018;5:5.
9. Stramer SL, Moritz ED, Foster GA, Ong E, Linnen JM, Hogema BM,
et al. Hepatitis E virus: seroprevalence and frequency of viral
RNA detection among US blood donors. Transfusion. 2016;56:
481–8.
10. Roth NJ, Schafer W, Alexander R, Elliott K, Elliott-Browne W,
Knowles J, et al. Low hepatitis E virus RNA prevalence in a large-
scale survey of United States source plasma donors. Transfusion.
2017;57:2958–64.
11. Altona Diagnostics. Instructions for use: RealStar® HEV RT-PCR Kit
2.0. 2017 Accessed 5 June 2023. https://www.altona-diagnostics.
com/en/products/reagents/realstar-real-time-pcr-reagents/realstar-
hev-rt-pcr-kit-ce.html
12. Xu C, Wang RY, Schechterly CA, Ge S, Shih JW, Xia NS, et al. An
assessment of hepatitis E virus (HEV) in US blood donors and recipi-
ents: no detectable HEV RNA in 1939 donors tested and no evi-
dence for HEV transmission to 362 prospectively followed
recipients. Transfusion. 2013;53:2505–11.
13. Ditah I, Ditah F, Devaki P, Ditah C, Kamath PS, Charlton M. Current
epidemiology of hepatitis E virus infection in the United States: low
seroprevalence in the National Health and Nutrition Evaluation Sur-
vey. Hepatology. 2014;60:815–22.
14. Mast EE, Kuramoto IK, Favorov MO, Schoening VR, Burkholder BT,
Shapiro CN, et al. Prevalence of and risk factors for antibody to hep-
atitis E virus seroreactivity among blood donors in Northern Califor-
nia. J Infect Dis. 1997;176:34–40.
15. Pisano MB, Campbell C, Anugwom C, Re VE, Debes JD. Hepatitis E
virus infection in the United States: seroprevalence, risk factors and
14230410, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vox.13487 by University Of Wisconsin - Madison, Wiley Online Library on [03/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
7
the influence of immunological assays. PLoS One. 2022;17:
e0272809.
16. Zafrullah M, Zhang X, Tran C, Nguyen M, Kamili S, Purdy MA, et al.
Disparities in detection of antibodies against hepatitis E virus in US
blood donor samples using commercial assays. Transfusion. 2018;58:
1254–63.
17. Holm DK, Moessner BK, Engle RE, Zaaijer HL, Georgsen J,
Purcell RH, et al. Declining prevalence of hepatitis E antibodies
among Danish blood donors. Transfusion. 2015;55:1662–7.
18. van Gageldonk-Lafeber AB, van der Hoek W, Borlee F, Heederik DJ,
Mooi SH, Maassen CB, et al. Hepatitis E virus seroprevalence among
the general population in a livestock-dense area in the Netherlands:
a cross-sectional population-based serological survey. BMC Infect
Dis. 2017;17:21.
19. Mansuy JM, Saune K, Rech H, Abravanel F, Mengelle C, Homme SL,
et al. Seroprevalence in blood donors reveals widespread, multi-
source exposure to hepatitis E virus, southern France, October 2011.
Euro Surveill. 2015;20:27–34.
20. Hogema BM, Molier M, Slot E, Zaaijer HL. Past and present of hepa-
titis E in the Netherlands. Transfusion. 2014;54:3092–6.
21. Mahrt H, Schemmerer M, Behrens G, Leitzmann M, Jilg W,
Wenzel JJ. Continuous decline of hepatitis E virus seroprevalence in
southern Germany despite increasing notifications, 2003–2015.
Emerg Microbes Infect. 2018;7:133.
22. Raji YE, Toung OP, Mohd Taib N, Sekawi ZB. A systematic review of
the epidemiology of hepatitis E virus infection in south-eastern Asia.
Virulence. 2021;12:114–29.
23. Li P, Liu J, Li Y, Su J, Ma Z, Bramer WM, et al. The global epidemiol-
ogy of hepatitis E virus infection: a systematic review and meta-anal-
ysis. Liver Int. 2020;40:1516–28.
How to cite this article: Mah JK, Keck M, Chu DY,
Sooryanarain H, Sahoo MK, Lau P, et al. Hepatitis E virus
seropositivity in an ethnically diverse community blood donor
population. Vox Sang. 2023.