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Hepatitis E is found worldwide and different genotypes of the hepatitis E virus determine differences in epidemiology. For example, genotype 1 is usually seen in developing countries and causes community level outbreaks while genotype 3 is usually seen in the developed countries and does not cause outbreaks. Globally, 70 000 deaths and 3.4 million cases of acute hepatitis E are attributable to infection with hepatitis E virus genotypes 1 and 2.

The highest seroprevalence rates (number of persons in a population who test positive for the disease) are observed in regions where low standards of sanitation increase the risk for transmission of the virus. Over 60% of all hepatitis E infections and 65% of all hepatitis E deaths occur in East and South Asia, where seroprevalence rates of 25% are common in some age groups. In Egypt, half the population aged above five years is serologically positive for the hepatitis E virus.

Stages

There are three stages or phases of hepatitis E. The symptoms of hepatitis E vary as per the phase. The phases are as follows:

• Prodromal Phase: This phase is characterised by rash, fever, oedema (swelling), joint pain or arthritis.


• Preicteric Phase: This phase is characterised by fatigue, anorexia (loss of appetite), muscle pain or myalgia, nausea, vomiting, cough, abdominal pain, diarrhoea (loose stools), fever, light stool colour and dark urine.


• Icteric Phase: This phase is characterised by worsening of nausea, vomiting, anorexia, yellowing of skin and whites of the eye called jaundice, developing skin lesions, and chances of other symptoms subsiding.[1]

Symptoms

The incubation period following exposure to the hepatitis E virus ranges from three to eight weeks, with a mean of 40 days. The period of communicability is unknown.

The hepatitis E virus causes acute sporadic and epidemic viral hepatitis. Symptomatic infection is most common in young adults aged 15–40 years. Although infection is frequent in children, the disease is mostly asymptomatic or causes a very mild illness without jaundice (anicteric) that goes undiagnosed.

Typical signs and symptoms of hepatitis include:

• Jaundice (yellow discolouration of the skin and sclera of the eyes, dark urine and pale stools)


• Anorexia (loss of appetite)


• An enlarged, tender liver (hepatomegaly)


• Abdominal pain and tenderness


• Nausea and vomiting


• Fever

These symptoms are largely indistinguishable from those experienced during an acute phase of hepatic illness and typically last for one to two weeks.

In rare cases, acute hepatitis E can result in fulminant hepatitis (acute liver failure) and death. Overall population mortality rates from hepatitis E range from 0.5% to 4.0%. Fulminant hepatitis occurs more frequently during pregnancy. Pregnant women are at greater risk of obstetrical complications and mortality from hepatitis E, which can induce a mortality rate of 20% among pregnant women in their third trimester.

Cases of chronic hepatitis E infection have been reported in immunosuppressed people. Reactivation of hepatitis E infection has also been reported in immunocompromised people.

Causes And Risk Factors

Causes

Hepatitis E is a liver disease caused by the hepatitis E virus: a non-enveloped, positive-sense, single-stranded RNA virus. The hepatitis E virus is transmitted mainly through contaminated drinking water. It is usually a self-limiting infection and resolves within 4–6 weeks.

Occasionally, a fulminant form of hepatitis develops (acute liver failure), which can lead to death. Globally, there are approximately 20 million incidents of hepatitis E infections every year.

Risk Factors

The risk factors for hepatitis E are related to poor sanitation in large areas of the world and the shedding of the hepatitis E virus in faeces. The hepatitis E virus is transmitted mainly through the faecal-oral route due to faecal contamination of drinking water. Other transmission routes have been identified, which include:

• Food borne transmission from ingestion of products derived from infected animals


• Zoonotic transmission from animals to humans


• Transfusion of infected blood products


• Vertical transmission from a pregnant woman to her fetus.

Although humans are considered the natural host for the hepatitis E virus, antibodies to the hepatitis E virus or closely related viruses have been detected in primates and several other animal species. Hepatitis E is a waterborne disease, and contaminated water or food supplies have been implicated in major outbreaks. The ingestion of raw or uncooked shellfish has also been identified as the source of sporadic cases in endemic areas.

Prevention

The risk of infection and transmission can be reduced by:

• Maintaining quality standards for public water supplies


• Establishing proper disposal systems to eliminate sanitary waste

On an individual level, infection risk can be reduced by:

• Maintaining hygienic practices such as handwashing with safe water, particularly before handling food


• Avoiding drinking water and/or ice of unknown purity


• Avoid eating uncooked shellfish, and uncooked fruits or vegetables that are not peeled or that are prepared by people living in or travelling in highly endemic countries.

In 2011, the first vaccine to prevent hepatitis E infection was registered in China. Although it is not available globally, it could potentially become available in a number of other countries.

Diagnosis

The diagnosis of Hepatitis E is made with history taking, physical examination and identification of your symptoms. In history taking, your doctor will ask you about your travel history, any exposure to contaminated water or shellfish, your sexual activity, medication use, and intravenous drug use.

Certain blood test results that indicate increased levels of bilirubin, low white blood cell count, presence or increased levels of antibody (anti-HEV), and elevated enzymes in your blood can help your doctor identify whether you have hepatitis E.[1]

Two additional diagnostic tests require specialized laboratory facilities and are used only in research studies. These are:

• Reverse transcriptase polymerase chain reaction (RT-PCR) to detect the hepatitis E virus RNA;


• Immune electron microscopy to detect the hepatitis E virus.

Hepatitis E should be suspected in outbreaks of waterborne hepatitis occurring in developing countries, especially if the disease is more severe in pregnant women, or if hepatitis A has been excluded.

Treatment

There is no available treatment capable of altering the course of acute hepatitis. Prevention is the most effective approach against the disease. To speed up your recovery process, you can undertake the following steps:

• Have a Balanced Diet: Consuming a healthy balance of foods will help you on your road to recovery.


• Avoid Alcohol: Avoid consuming alcohol and illegal drugs as these can worsen liver issues.


• Increase Fluids: Increase your fluid intake with water, soup, and juices, as tolerated. This will help prevent dehydration.


• Reduce Your Activities: Slow down till your energy gets back and then get back to your routine.


• Consultations: Consult your doctor before taking any medicines, herbal products, over-the-counter medicines, or alternative therapy.[3] As hepatitis E is usually self-limiting, hospitalization is generally not required. However, hospitalization is required for people with fulminant hepatitis and should also be considered for infected pregnant women.

Lifestyle/management

As hepatitis E affects your liver, you need to follow a diet that is easy on the liver and avoid foods that increase the work of your liver. Following diet considerations should be followed:

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


• Fruits and vegetables are very beneficial as they are nutritious and easily digested. They also contain antioxidants that protect the cells of your liver from damage. Avoid vegetables high in starch, like potatoes, and try to consume fresh fruits and vegetables.


• Healthy fats present in olive oil are vital in hepatitis.


• Healthy proteins are important to maintain a healthy liver. These proteins are found in lean meats, eggs, and soy products.

Foods to be avoided in hepatitis are as follows:

• Processed foods like fast food items, cheese, and bread are hard for the liver to digest. They can delay recovery.


• Avoid foods that are high in saturated fats and trans-fats. Replace these oils with healthy oils.


• Avoid sugars that may be in the form of artificial sweeteners and juices that are difficult for the liver to digest.


• Avoid foods high in salt (sodium) like canned foods and sauces.


• Avoid eating red meats. If needed, consume lean meats but restrict their intake to once or twice a week.

Other lifestyle changes that should be borne in mind when you have hepatitis are as follows:

• Avoid alcohol


• Avoid cigarettes


• Avoid missing meals


• Reduce the frequency of meals and spread them through the day


• Increase your water intake


• Rest adequately


• Avoid taking any over-the-counter medications or vitamins without consulting your doctor.[4]

Prognosis And Complications

Prognosis

The prognosis of hepatitis E is usually good as most individuals recover completely. If you
are pregnant, the chances of death of the infant from hepatitis E are high, especially if you are in your third trimester. The prognosis is worse for individuals who already have chronic liver diseases, organ transplants, and those on immunosuppressive treatment. It can lead to liver disease and even death.[5]

Complications

Generally, hepatitis E has no complications. Few complications that may occur are as follows:

• Liver failure (liver suddenly stops functioning)


• Stillbirth, low birth weight or premature birth in case of mother and child


• Cirrhosis or liver failure caused due to chronic hepatitis E.[6]

References

1. Viral Hepatitis A and E. John Hopkins Medicine. Available at: https://www.hopkinsmedicine.org/health/conditions-and-diseases/hepatitis/viral-hepatitis-a-and-e. 2. Hepatitis E. British Liver Trust. Available at: https://britishlivertrust.org.uk/information-and-support/living-with-a-liver-condition/liver-conditions/hepatitis-e/.
3. Hepatitis E. University of Michigan Health. Available at: https://www.uofmhealth.org/health-library/abl2916.
4. Hepatitis Diet Recommendations- Foods to Eat and Avoid. Med India. Available at: https://www.medindia.net/patients/lifestyleandwellness/hepatitis-diet-recommendations-foods-to-eat-and-avoid.htm.
5. Hepatitis E. CDC. Available at: https://www.cdc.gov/hepatitis/hev/hevfaq.htm#section3. 6. Hepatitis E. NIH. Available at: https://www.niddk.nih.gov/health-information/liver-disease/viral-hepatitis/hepatitis-e#complications.