Hepatitis E
Hepatitis E is a liver infection caused by the hepatitis E virus (HEV). It is primarily a waterborne disease – hepatitis E outbreaks often happen due to contaminated drinking water in areas with poor sanitation. Hepatitis E is usually an acute, self-limiting illness like hepatitis A (it does not cause chronic infection in most people). In healthy individuals, it often resolves on its own. However, HEV can be very dangerous in certain populations, especially pregnant women, where it can cause severe liver failure. Globally, hepatitis E is a common cause of acute hepatitis in South Asia, East Asia, Africa, and parts of Mexico; it’s less common in developed countries (though sporadic cases occur, often linked to travel or consumption of undercooked pork/deer in the case of certain HEV strains).
Symptoms
The incubation period for hepatitis E is typically 2 to 6 weeks after exposure. Many cases, particularly in children or young adults, are asymptomatic or very mild. When symptoms do occur, they are similar to other acute hepatitis infections:
- Initial phase: Mild fever, reduced appetite, nausea, and vomiting for a few days. Sometimes there are aches or a rash.
- Followed by: Jaundice (yellowing of eyes and skin), dark urine, and pale stools, usually with right upper abdominal pain (from an enlarged tender liver).
- Other symptoms: Itching (pruritus) of the skin and sometimes joint pain.
These symptoms usually last from 1 to 6 weeks. Most people then fully recover. The illness is generally acute and self-limited.
A critical aspect of hepatitis E is its effect on pregnant women: Infection during pregnancy, especially in the 3rd trimester, can be severe. Pregnant women have a higher risk of developing fulminant hepatitis (acute liver failure) with HEV. This can lead to a fatal outcome in a significant proportion – up to 20-25% of pregnant women may die if infected with hepatitis E in the third trimester. This is a dramatically higher mortality rate than in the general population and makes hepatitis E a serious concern in pregnancy.
In those with weakened immune systems (such as organ transplant recipients on immunosuppressants), there have been rare cases of hepatitis E becoming chronic (mainly with HEV genotypes 3 or 4), but this is unusual.
Causes
Hepatitis E is caused by the hepatitis E virus, which has several genotypes. Genotypes 1 and 2 only infect humans and are transmitted by the fecal-oral route (similar to hepatitis A). Genotypes 3 and 4 primarily infect animals (such as pigs, deer, wild boar) and occasionally infect humans (zoonotic transmission) – usually through consumption of undercooked meat or organ meats from infected animals.
- Contaminated water: In developing regions, HEV is often spread by drinking water tainted with human feces containing the virus. Large outbreaks have been documented, often linked to monsoon floods or refugee camps with poor sanitation.
- Foodborne (zoonotic): In sporadic cases (especially with genotypes 3 and 4 in Europe, North America, East Asia), HEV can spread by eating raw or undercooked meat from infected animals (e.g., pork, venison, or shellfish). This is more relevant in developed countries.
- Person-to-person: Unlike hepatitis A, large outbreaks are uncommon. Transmission can happen through close household contact if hygiene is poor, but sustained person-to-person spread is rare. HEV more often causes point-source outbreaks from contaminated water.
- Blood transfusion: Possible if a donor is in the early phase of HEV infection. Not common, but some countries now screen blood donations for HEV RNA.
People at risk for hepatitis E are those living in or traveling to endemic areas with poor sanitation, especially if they drink untreated water. Additionally, consuming undercooked organ meats (like pork liver) has been identified as a risk in non-endemic countries for certain HEV strains.
Diagnosis
Clinically, hepatitis E infection cannot be distinguished from other acute viral hepatitis (A, B, or others) just by symptoms. Therefore, lab tests are needed:
- Blood tests for antibodies: The main test is detecting IgM antibodies to hepatitis E (anti-HEV IgM), which indicates a recent infection. IgG antibodies develop later and show past exposure. Rapid immunoassays are available in many settings.
- PCR testing: In developed countries or for confirmation, blood or stool can be tested by RT-PCR to detect HEV RNA. This specialized test can also determine the genotype.
- Liver enzymes: As in other hepatitis types, ALT and AST are often significantly elevated. Bilirubin is also elevated in jaundiced patients. These indicate hepatitis but not the cause.
- Epidemiological context: Important clues include outbreaks in the community, recent travel to endemic areas, or pregnancy with acute hepatitis. Such factors guide when to specifically test for HEV.
In summary, a positive HEV IgM blood test in a person with acute hepatitis symptoms confirms the diagnosis of hepatitis E.
Treatment
For acute hepatitis E, there is no specific antiviral treatment that can alter the course of illness – much like hep A, it usually resolves on its own. Management is supportive:
- Rest and hydration: Patients should rest and drink plenty of fluids. Adequate nutrition is important, even though appetite may be reduced during the acute phase.
- Avoid liver stressors: Avoid medications that may harm the liver (e.g., acetaminophen/paracetamol or unapproved herbal supplements). Alcohol should be strictly avoided until full recovery.
-
Hospitalization: Most cases are managed at home, but admission is required if:
- There are signs of acute liver failure (confusion, very high bilirubin, coagulopathy).
- The patient cannot maintain hydration due to persistent vomiting.
- The patient is pregnant (close monitoring is advised due to higher risk).
In rare instances where hepatitis E leads to fulminant hepatic failure, the treatment would be intensive care support and possibly emergency liver transplantation (though this scenario is uncommon except in pregnant women with severe HEV or patients with underlying liver disease).
For chronic HEV infections (which have been observed mostly in immunosuppressed individuals like organ transplant patients), doctors have used antiviral therapy such as ribavirin off-label to try to clear the virus. Ribavirin has been shown to clear chronic HEV in many cases. This is a specialized scenario; the general public does not usually encounter chronic HEV.
FAQs
Both hepatitis A and E are transmitted via the fecal-oral route and usually cause acute, self-limited liver infections. However, hepatitis E tends to occur in large waterborne outbreaks in areas with poor sanitation (or sporadic cases from animal sources), whereas hepatitis A often spreads more via person-to-person or food. The most critical difference is in pregnancy – hepatitis E is notoriously severe in pregnant women, with a high risk of acute liver failure and death, whereas hepatitis A does not have such a high fatality in pregnancy. Also, hepatitis E is not as common in children (kids often get it but asymptomatically) and thus outbreaks often affect young adults. In terms of geography, hep A is worldwide; hep E is common in Asia, Africa, and parts of Mexico, with occasional cases elsewhere. Lastly, a vaccine exists for hep A (widely used), but for hep E, a vaccine is only approved in China and not broadly available.
Not widely, at least not yet. A vaccine (HEV 239, sold as Hecolin®) has been developed and is licensed in China for use in people ≥16 years old. It has shown high efficacy in clinical trials. However, this vaccine is not widely available globally and is not yet part of routine immunization in most countries. The World Health Organization has not issued a universal recommendation for hepatitis E vaccination, partly due to limited availability and data. In 2022, the vaccine was used experimentally in an outbreak response in Africa (South Sudan) with some success, which is promising. So, in the future, we may see broader use of the hep E vaccine, but as of now, if you’re outside of China, you likely cannot get vaccinated for hepatitis E.
Prevention mainly relies on clean water and good sanitation. If you are in an area with questionable water supply, stick to bottled or purified water for drinking and brushing teeth. Boiling water makes it safe. Avoid ice in drinks if the water source is uncertain. Practice good hand hygiene – wash hands with soap after using the bathroom and before handling food. Only eat foods that are cooked and served hot; avoid raw shellfish or undercooked meats in areas where HEV is prevalent (genotypes 3 and 4 can be in animals like pigs, so undercooked pork or game could carry the virus). Essentially, precautions similar to those for preventing “traveler’s diarrhea” or cholera will also protect against hepatitis E: boil it, cook it, peel it, or forget it when it comes to food and water. There’s currently no widely available vaccine, so these behavioral measures are key.
Pregnant women are at the highest risk – especially in the third trimester, hepatitis E can be devastating, with a maternal mortality rate of 20% or higher. So they are the single most vulnerable group. Apart from pregnancy, people with pre-existing chronic liver disease are at risk for more severe acute hepatitis (any acute hepatitis on top of chronic liver issues can precipitate liver failure). Also, individuals with weakened immune systems (like organ transplant patients or those on chemotherapy) might have difficulty clearing the virus, potentially leading to chronic infection, although that’s rare. In general, young healthy adults usually recover fully, but vigilance is needed in those high-risk categories.
In healthy individuals, no, hepatitis E does not linger – once the acute infection resolves, the virus is gone and it does not cause chronic hepatitis. The liver typically heals completely with no lasting damage. The exception is in people with severely weakened immune systems (such as patients on strong immunosuppressant drugs after organ transplants or those with certain blood disorders on chemotherapy). In those rare cases, HEV genotype 3 (the strain often seen in developed countries and zoonotic cases) has been known to cause a persistent infection that can become chronic. This is unusual. For the vast majority of people, hepatitis E is a one-time acute illness. It does not cause a carrier state like hep B can, and it doesn’t typically lead to conditions like cirrhosis on its own.