Understanding Hepatitis E: Symptoms, Transmission, Treatment and Prevention

Overview

About Hepatitis E

Hepatitis E is a viral infection ( Infection with the hepatitis E virus ) that results in inflammation of the liver and damage to it. When bodily tissues are harmed or diseased, inflammation—which is swelling—occurs.

The Hepatitis E virus (HEV) is the primary etiological agent responsible for cases of acute viral hepatitis globally. Because of the lack of specific symptoms and the limited duration of the disease, it is not commonly identified. HEV comes from the Ortho Hepevirus genus that belongs to the Hepeviridae family.¹Overview| Researched based study from Nlm.nih.gov

It is usually not so severe, but it can be fatal for females who are pregnant. Most people who get hepatitis E can be treated completely.

How is Hepatitis E caused?

• The Hepatitis E virus (HEV) is an icosahedral virus which is non enveloped. It comes with a single-stranded RNA genome.

• The virus exhibits four distinct genotypes ie. 1, 2, 3, and 4. Genotypes 1 and 2 are exclusive to the human population. Genotypes 3 and 4 are present in pigs, wild boars, and deer.

• The virus is excreted in the feces of those who are infected and gains entry into the human body. The infection typically resolves spontaneously within a period of 2 to 6 weeks.

How widely is Hepatitis E spread?

• The World Health Organisation (WHO) reports that Hepatitis E virus (HEV) is responsible for approximately 20 million fresh infections and more than 55,000 deaths each year.

• HEV infection is distributed globally, with a greater prevalence seen in developing countries. HEV infection is most common in Asia, the Middle East, Africa and Central America.¹Overview| Researched based study from Nlm.nih.gov

Symptoms

Symptoms of Hepatitis E

Hepatitis E’s clinical features are like those of different types of acute viral Hepatitis and liver damage when they show up. The time it takes for a person to get sick after being exposed to the typical HEV is between 2 and 10 weeks.

There are three phases or stages of hepatitis E. The symptoms of hepatitis E differ according to the phase.

The phases are:

• Prodromal Phase
• Preicteric Phase
• Icteric Phase

Prodromal Phase

This phase is signified by the:

• Development of skin rash
• Fever
• Joint pain
• Edema (swelling)
• Arthritis

Preicteric Phase

This phase is signified by:

• Fatigue
• Anorexia (loss of appetite)
• Nausea
• Muscle pain or myalgia
• Vomiting
• Cough
• Diarrhea (loose stools)
• Abdominal pain
• Fever
• Dark urine
• Pale stool color

Icteric Phase

This phase is signified by:

• Worsening of vomiting
• Nausea
• Yellowing of skin and sclera of the eye known as jaundice
• Progressive skin lesions

Transmission

Transmission of Hepatitis E

Feco oral transmission

• The most common way for humans to get sick from HEV is through the feco oral route. It can be in the form of drinking contaminated water.

Foodborne transmission

• Also, HEV can be spread through food if you eat raw meat or meat products made from animals with the virus (HEV has been found in pig livers).

Blood transmission

• Blood or blood products that have been contaminated can cause Hepatitis E.

Donation of an organ

• HEV transmission risk during transplantation is seen in the United Kingdom and Spain. A recent study ²Transmission| Researched based study from Nlm.nih.gov found that the prevalence of HEV contamination in liver grafts is 0.95% (1 out of every 105 grafts).

Vertical transmission

• It means the Transfer of HEV from a pregnant woman ³Transmission| Researched based study from Nlm.nih.gov to her unborn child.

• Hepatitis E infection of genotype 1 in the third trimester is associated with a maternal mortality rate ranging from 15% to 25%.

Breastfeeding

• There isn’t enough information about how HEV can spread through breast milk, but HEV has been found in breast milk and blood titers were found to be similar.

From animals

• Yes. Hepatitis E has the ability to infect specific mammals. Humans may get the virus through the consumption of undercooked or uncooked meat or the organs from infected animals, resulting in foodborne transmission. HEV RNA genotypes 3 and 4 have been isolated from pork, deer meat and boar.

Stages

Stages of Hepatitis E

Hepatitis E usually can be:

• Acute Hepatitis E
• Chronic Hepatitis E

Acute Hepatitis E

• Acute hepatitis E is an illness that doesn’t last long. Most of the time, the virus goes away because the body is able to heal and battle the illness. After a few weeks, most individuals become better on their own.

Chronic Hepatitis E

• Chronic hepatitis E is an uncommon infection that lasts a long time because your body can’t shed off the virus and it doesn’t go away.

• For example, hepatitis E can become chronic in people with HIV or AIDS or in people who have had an organ donation and are taking drugs that suppress their immune system.

Complications

Complications of Hepatitis E

Most of the time, hepatitis E doesn’t cause any problems.

Here are a few things that could go wrong:

• Liver failure
• Stillbirth, low birth weight, or birth before the due date
• Chronic Hepatitis E causes cirrhosis or liver failure

Risk factors

Risk factors of developing Hepatitis E

Common risk factors for hepatitis E development include:

• Water supply contamination
• Inadequate sanitation
• Consumption of undercooked meat and shellfish
• Travel to regions with endemic HEV

The following populations are at an elevated risk of hepatitis E virus infection:

• Individuals living in regions with ongoing community outbreaks.

• International travelers to regions where hepatitis E virus (HEV) is prevalent.

• Refugees living in densely populated temporary camps after disasters, particularly in Sudan, Somalia, Kenya, Ethiopia.

• People with chronic liver disease.

• People involved in the handling and care of pigs, sheep, cows and goats.

• People with glucose-6-phosphate dehydrogenase (G6PD) deficiency.

• Close touch with a sick person, like a family member, sexual partner, or someone who works in child care or a hospital.

Diagnosis

Diagnosis of Hepatitis E

Hepatitis E is not different from variants of other viral hepatitis in terms of how it marks its symptoms. But a diagnosis can often be firmly suspected in certain epidemiological situations.

Anti-HEV immunoglobulin M (IgM)

• Finding specific anti-HEV immunoglobulin M (IgM) antibodies to the HEV in a person’s blood is generally sufficient to confirm hepatitis E infection.

Reverse transcriptase polymerase chain reaction

• Reverse transcriptase polymerase chain reaction (RT-PCR) is another test that looks for RNA from the hepatitis E virus. A sample of blood and stool is taken and examined. For this test, you need special lab equipment. This test is especially important in places where hepatitis E is not widespread and in rare cases of long-term HEV illness.

Laboratory findings

• Increased Bilirubin serum concentration.
• Increased alanine aminotransferase.
• Increased aspartate aminotransferase.

Capsid antigen detection

• When a person has HEV, the viral capsid antigen can be found in their blood even before they show any symptoms, and it stays there for about 4 weeks.

Serological analysis

• In negative HEV PCR, serology might be a better choice. Serological testing isn’t as useful for people with weak immune systems who might not be able to make antibodies.

• In Europe, the 2018 EASL (European Association for the Study of the Liver) standards suggest both serology and NAT (nucleic acid amplification method) for diagnosing acute HEV infection and NAT for diagnosing chronic HEV infection.

Treatment

Treatment of Hepatitis E

Acute infection with the Hepatitis E virus (HEV) usually goes away on its own and only needs medical attention. Most of the time, the biochemical blood tests go away between one and six weeks after the illness starts. However, people who get fulminant liver failure need a liver replacement.

Medications

Antiviral therapy

• Antiviral treatment, like Ribavirin, may or may not help people with a weak immune system who have an acute HEV illness. Patients who are pregnant and have an acute HEV virus should not take ribavirin because it could cause birth defects.

• With ribavirin treatment, people with serious acute hepatitis E have shown signs of getting better. Few studies also proved that liver enzymes improve quickly when ribavirin is used.

Sofosbuvir

• Sofosbuvir is a nucleotide analogue that has changed how the hepatitis C virus is treated in a revolutionary way. It has been found to halt down the development of genotype 3 HEV in the lab.

Interferon (IFN)

• PEGylated Interferon (IFN) alpha is another choice for treating chronic hepatitis E. It has been shown to work in people with hemodialysis and liver transplants to achieve a stable virological response.

• In a case study, corticosteroids were linked to metabolic healing in HEV-infected patients.

Vaccine for Hepatitis E

• In the United States, there is no hepatitis E vaccine that has been approved by the FDA. But, in 2012, a recombinant vaccine was allowed for use in China.

• HAV is successfully prevented by a vaccination, however HEV is still not protected by a similar vaccine. Although there is only one serotype of HEV, passive immunization with high titre anti-HEV plasma ⁴Treatment| Researched based study from Nlm.nih.gov or serum has been proven to protect against many genotypes of HEV.

Treatment during pregnancy

• In developed countries, HEV infections brought on by genotypes 1 and 2 during pregnancy have been linked to bad results for both the mother and the baby. HEV was the main cause of a case of acute viral hepatitis and acute liver failure in women who were pregnant.

• At the moment, the main treatment for HEV illness during pregnancy is care. Due to the high risk of teratogenicity, pregnant women with HEV have not been tested with ribavirin and PEGylated IFN.

Prevention

Prevention of Hepatitis E

Here are a few preventive measures of Hepatitis E:

• Wash your hands for at least 20 seconds with water and liquid soap.

• When getting rid of or managing vomit and feces, wear gloves and a mask, and wash your hands well afterward.

• Use spoons and chopsticks to serve food.

• Choose safe raw materials.

• Keep food at a safe temperature.

• Only drink hot water from the tap or drinks in bottles from trusted sources.

• Avoid drinks with ice from a place you don’t know.

• Buy fresh food from reputable and clean places.

• Cook seafood (like shrimp), pork, and pork parts well. Don’t eat food that is raw or not fully cooked.

• Store the left out food in a container properly or put it in the fridge.

• Cut raw meat and organs into thin strips so they can cook all the way through.

• After touching an animal, wash your hands with water and liquid soap right away, and clean the area.

• If a sore shows up, clean the broken skin right away and cover it with a dry, sticky bandage.¹Prevention| Researched based study from Nlm.nih.gov

Lifestyle

Lifestyle modifications

Since hepatitis E affects your liver, you should eat foods that are easy on your liver and stay away from foods that make your liver work harder.

What to eat?

• Whole grains good for your liver are oats , whole-wheat bread, brown rice and corn.

• Fruits and veggies are healthy and easy to swallow. Try to eat fresh fruits and veggies and avoid starchy foods like potatoes.

• Consume the healthy fats in olive oil.

• Eat foods rich in proteins like lean meats, eggs, and soy foods.

When you have hepatitis, you should avoid these foods:

• Processed foods like fast food, cheese, and bread.

• Avoid foods that have a lot of saturated and trans fats. Change these oils to ones that are good for you.

• Avoid sugars that are hard for the liver to break down, like those in fake sweeteners and drinks.

• Avoid foods like canned foods and sauces that have a lot of salt in them.

• Try not to eat red foods.⁵Lifestyle| Researched based study from Nlm.nih.gov

When you have hepatitis, you should also make the following changes to your life:

• Avoid drinking alcohol

• Avoid cigarettes

• Avoid missing meals

• Lessen the number of times you overeat and space them out.

• Add more water to your diet

• Get enough rest

• Don’t take any vitamins or medicines you can get without first talking to your doctor.

Outlook

The Outlook

Hepatitis E is a viral infection that causes liver damage. It is the leading cause of liver damage. To help countries reach the world hepatitis removal goals set by the Sustainable Development Agenda, WHO is trying to:

• Spread knowledge, build relationships, and get people to help.
• Create policies and records that are based on facts.
• Improve health equity in the reaction to hepatitis.
• Prevent spread.
• Screening, care, and treatment programmes should be made bigger.

The World Health Organization (WHO) holds World Hepatitis Day on July 28th every year as one of its nine main health campaigns to raise awareness and knowledge about viral hepatitis.