Hepatitis E infection

1. HEPATITIS E
INFECTION
Dr.T.V.Rao MD
DR.T.V.RAO MD 1

2. WHAT IS VIRAL HEPATITIS E
• Hepatitis E is a viral hepatitis caused by
infection with a virus called hepatitis E virus
(HEV). HEV is a positive-sense single-stranded
RNA icosahedral virus with a 7.5 kilobase
genome. HEV has a fecal-oral transmission
route. It is one of five known hepatitis viruses: A,
B, C, D, and E. Infection with this virus was first
documented in 1955 during an outbreak in New
Delhi, India
DR.T.V.RAO MD 2

3. A TRUE STORY OF HEPATITIS E
INFECTION
• In 1983, Dr. Balayan was investigating an outbreak of non-A,
non-B hepatitis in a central Asian part of the Soviet Union.
Though he wanted to bring samples back to his Moscow
laboratory, he lacked refrigeration. So he made a shake of
yogurt and an infected patient’s stool, drank it, went back to
Moscow, and waited. When he became seriously ill a few weeks
later, he started collecting and analysing his own samples. In
these he found a new virus that produced liver injury in
laboratory animals and could be seen by electron microscopy. It
looked a lot like hepatitis A virus, but he could show that it was
not, because he already had antibodies against the hepatitis A
virus and these did not react with the new virus.
• ( National Institute of Allergy and Infectious Diseases )
DR.T.V.RAO MD 3

4. ROBERT PURCELL, ALBERT KAPIKIAN, AND STEPHEN FEINSTONE
WITH AN ELECTRON MICROSCOPE. (CREDIT: NIAID)
DR.T.V.RAO MD 4

5. HEPATITIS E - GENOME
• The genome is approximately 7200 bases in length, is a
polyadenylated single-strand RNA molecule that contains
three discontinuous and partially overlapping open
reading frames (ORFs) along with 5' and 3' cis-acting
elements, which have important roles in HEV replication
and transcription. ORF1 encode a methyltransferase,
protease, helicase and replicase; ORF2 encode the
capsid protein and ORF3 encodes a protein of undefined
function. A three-dimensional, atomic-resolution structure
of the capsid protein in the context of a virus-like particle
has been described. An in vitro culture system is not yet
available
DR.T.V.RAO MD 5

6. Hepatitis E - Clinical Features
 Incubation period: Average 40 days
Range 15-60 days
 Case-fatality rate: Overall, 1%-3%
Pregnant women,
15%-25%
 Illness severity: Increased with age
 Chronic sequelae: None identified
DR.T.V.RAO MD 6

7. Hepatitis E
Epidemiologic Features
 Most outbreaks associated with faecally contaminated drinking
water.
 Several other large epidemics have occurred since in the Indian
subcontinent and the USSR, China, Africa and Mexico.
 In the United States and other nonendemic areas, where
outbreaks of hepatitis E have not been documented to occur, a
low prevalence of anti-HEV (<2%) has been found in healthy
populations. The source of infection for these persons is unknown.
 Minimal person-to-person transmission.
DR.T.V.RAO MD 7

8. GEOGRAPHICAL DISTRIBUTION
• 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
DR.T.V.RAO MD 8

9. DR.T.V.RAO MD 9

10. DISTRIBUTION OF HEPATITIS E
INFECTION, 2010
DR.T.V.RAO MD 10

11. MORBIDITY AND MORTALITY
• 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.
DR.T.V.RAO MD 11

12. TRANSMISSION OF INFECTION
• 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
DR.T.V.RAO MD 12

13. DR.T.V.RAO MD 13

14. Prevention and Control Measures for
Travelers to HEV-Endemic Regions
 Avoid drinking water (and beverages with ice) of
unknown purity, uncooked shellfish, and uncooked
fruit/vegetables not peeled or prepared by traveler.
 IG prepared from donors in Western countries does not
prevent infection.
 Unknown efficacy of IG prepared from donors in
endemic areas.
 Vaccine?
DR.T.V.RAO MD 14

15. TRANSMISSION
• Foodborne 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 foetus.
DR.T.V.RAO MD 15

16. INCUBATION PERIOD
• 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.
DR.T.V.RAO MD 16

17. SYMPTOMS
• 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
DR.T.V.RAO MD 17

18. CLINICAL PRESENTATION
Jaundice
• anorexia (loss of appetite);
• an enlarged, tender liver (hepatomegaly);
• abdominal pain and tenderness;
• nausea and vomiting;
• fever.
DR.T.V.RAO MD 18

19. HEPATITIS E INFECTION AND
PREGNANCY
• 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.
DR.T.V.RAO MD 19

20. CHRONIC HEPATITIS E
INFECTION
• Cases of chronic
hepatitis E infection
have been reported in
immunosuppressed
people. Reactivation of
hepatitis E infection has
also been reported in
immunocompromised
people.
DR.T.V.RAO MD 20

21. DIAGNOSIS BY DETECTION OF ANTIBODIES
• Diagnosis of
hepatitis E
infection is
therefore usually
based on the
detection of
specific antibodies
to the virus in the
DR.T.V.RAO MD
blood. 21

22. NEWER METHODS IN DIAGNOSIS
• Reverse
transcriptase
polymerase chain
reaction (RT-PCR) to
detect the hepatitis E
virus RNA;
• Immune electron
microscopy to detect
the hepatitis E virus.
DR.T.V.RAO MD 22

23. TREATMENT
• There is no available treatment capable of
altering the course of acute hepatitis. Prevention
is the most effective approach against the
disease.
• 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.
DR.T.V.RAO MD 23

24. PREVENTION
Maintaining quality
standards for public
water supplies ;
Establishing proper
disposal systems to
eliminate sanitary
waste.
DR.T.V.RAO MD 24

25. PREVENTION
• Maintaining hygienic practices such as hand
washing with safe water, particularly before
handling food;
• Avoiding drinking water and/or ice of unknown
purity;
• Avoiding 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
DR.T.V.RAO MD 25

26. VACCINATION - UPDATE
• China has
produced and
licensed the first
vaccine to prevent
hepatitis E virus
infection, although
it is not yet
available globally.
DR.T.V.RAO MD 26

27. • Programme Created by Dr.T.V.Rao MD for
Medical and Paramedical Students in the
Developing World
• Email
• doctortvrao@gmail.com
DR.T.V.RAO MD 27