HEPATITIS E

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Hepatitis E, previously known as enterically transmitted non-A, non-B hepatitis, is an infectious viral disease with clinical and morphologic features of acute hepatitis. The disease was recognized first as a distinct clinical entity in the 1980s, when sera from persons affected during a large waterborne epidemic of viral hepatitis during 1955–1956 in Delhi, India116 and another epidemic in Kashmir were found to lack serologic markers of acute hepatitis A and B.56, 119 The first proof of the existence of a new viral hepatitis agent was obtained in 1983, when viruslike particles were detected by immune electron microscopy in feces collected from a volunteer infected with fecal material from patients who had suspected enterically transmitted non-A, non-B hepatitis.12 The disease was transmitted successfully to cynomolgus monkeys that excreted similar viruslike particles in their feces.12 The genome of this virus, known as hepatitis E virus (HEV),90 was cloned in 199093 and fully sequenced shortly thereafter.99, 104

The occurrence of the first recorded epidemic of hepatitis E as late as 1955 and the infrequency of this disease in developed countries suggest that hepatitis E is a new, emerging infectious disease. However, several epidemics of enterically transmitted hepatitis with epidemiologic features similar to those of hepatitis E outbreaks occurred in Europe and the United States in the 18th and 19th centuries.17, 28 It can be postulated, therefore, that HEV infection may have occurred in various parts of the world and only recently has become restricted to certain geographic areas, mostly underdeveloped with poor environmental sanitation.

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VIROLOGY

HEV virions are small, nonenveloped, 32- to 34-nm diameter particles with indentations and spikes on their surfaces similar in appearance to those of caliciviruses.19, 101 Analysis of electron micrographs of HEV particles by the Markham rotational method provided images that suggested an icosahedral symmetry for these virions.101 The HEV genome consists of a single-stranded, positive-sense, polyadenylated RNA molecule, approximately 7.5 kilobases (kb) in length.99 It contains short 5′ and 3′

Main Features

HEV infection is endemic in the Indian subcontinent and Southeast and Central Asia, and accounts for a substantial proportion of acute sporadic hepatitis in both children and adults. In disease-endemic areas, hepatitis E occurs as large outbreaks that affect several hundred to several thousand persons.56, 83, 116, 125 In India, HEV infection has been found to account for 50% to 70% of all patients with sporadic viral hepatitis.8, 62 A large outbreak of hepatitis E was identified in China

DIAGNOSIS

Current laboratory tests for the diagnosis of human HEV infection include serologic assays for identification of anti-HEV antibody of IgM or IgG class, and RT-PCR for detection of the virus in stool or serum.

Clinical and Biochemical Manifestations

The incubation period of hepatitis E is believed to range from 2 to 10 weeks based on data from volunteer inoculation experiments and epidemics with a short phase of water contamination.12, 14, 25, 116 Clinical manifestations of HEV infection are similar to those of infection with other hepatitis viruses and encompass a wide spectrum of symptoms, as follows:

  • •

    Incubation period 2–10 weeks

  • •

    Variable clinical manifestations, including

    • Icteric hepatitis

    • Severe hepatitis leading to

TREATMENT AND PREVENTION

Preventing hepatitis E in disease-endemic areas depends primarily on providing a clean drinking water supply, proper hygiene, and strict attention to sewage disposal. During an epidemic, steps to improve water quality can lead to rapid abatement of the occurrence of new cases.16 Boiling water before consumption appears to reduce the risk of acute hepatitis E.30 Isolation of affected persons is not indicated because person-to-person transmission is uncommon.3

The protective role of anti-HEV

SUMMARY

Hepatitis E, previously known as enterically transmitted non-A, non-B hepatitis, is an infectious viral disease with clinical and morphologic features of acute hepatitis. Its causative agent, hepatitis E virus, consists of small, 32- to 34-nm diameter, icosahedral, nonenveloped particles with a single-stranded, positive-sense, 7.5-kb RNA. The virus has two main geographically distinct strains, Asian and Mexican; recently, novel isolates from nonendemic areas and a genetically related swine HEV

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    Address reprint requests to K. Krawczynski, MD, PhD, Hepatitis Branch, NCID/DVRD, Mail Stop A33, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333, e-mail: [email protected]

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    Copyright © 2000 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.