What is Hepatitis E?
Hepatitis E, sometimes called hep E or HEV, is a liver disease caused by the hepatitis E virus. A virus is a microscopic particle that needs to get inside living cells in order to reproduce (spread)6.
What is hepatitis?
Your liver responds to injury by becoming inflamed. Any inflammation of the liver is known as hepatitis7, whatever its cause. Sudden inflammation of the liver is known as acute hepatitis. Where inflammation of the liver lasts longer than six months, the condition is known as chronic hepatitis8.
Hepatitis can be caused by a number of things including:
- drinking too much alcohol (the most common cause of liver damage)
- a virus, such as hepatitis E or glandular fever
- the body’s own immune system – a liver disease called autoimmune hepatitis
- the side effects of some drugs and chemicals
- trauma/ injury to the body.
Inflammation is part of the process of repairing damaged tissue. In a similar way to a scab forming over a skin wound, a temporary fibrous ‘scaffold’ forms while liver cells regenerate9,10. If your liver is repeatedly injured, new liver cells cannot regenerate fast enough and the fibrous tissue remains as a scar10. This is called fibrosis and can take a variable amount of time to develop.
There are a number of viruses that infect the liver. The best known are hepatitis A, B, C, D and E. The ways in which they are transmitted (spread or passed on), how they cause liver damage and the effects they can have on your health are different. Of these viruses hepatitis B, C, D and E can cause chronic or long term disease.
Most people in the UK will not have heard of hepatitis E. Until very recently, it was thought to be a disease only found in developing countries. However, it is now accepted that the virus is also transmitted here11.
Hepatitis E is generally mild in its effect unless you have pre-existing liver disease or are pregnant12. Chronic infection (infection lasting over six months) caused by hepatitis E is very rare and usually only reported in patients with a suppressed immune system, for example in patients taking drugs to prevent rejection after an organ transplantation13.
There are four strains of hepatitis E called “genotypes.” Genotypes 1 and 2 are found in Asia and Africa; genotype 3 is found worldwide, including Europe and the UK; and genotype 4 is found in China and Japan14. In the UK, hepatitis E diagnosed in people who have travelled abroad is usually genotype 1, and in those who have not travelled it is genotype 3.
Among pregnant women there is a risk of the virus causing a severe and rapidly occurring form of hepatitis that can lead to liver failure. This is called fulminant hepatitis and can cause premature delivery and infant mortality in the third trimester15.Up to 25% of infected pregnant women can develop liver failure resulting in loss of life16to both mother and baby.
In patients with pre-existing liver disease the virus can also cause liver failure, which may be fatal17.
How is hepatitis E passed on?
The hepatitis E virus is spread in a way similar to hepatitis A, known as ‘faecal-oral’ transmission. This means that the virus is passed out in bowel motions (faeces) and finds its way into the mouth (orally), usually through contaminated food or water. This is one of the reasons why it is important to wash your hands after going to the toilet15. The illness does not usually spread easily within families, except when all members of the family have been drinking the same infected drinking water18 and/or contaminated food.
In European countries, such as the UK, the illness can also be caused by what is known as ‘zoonosis’. This means the virus can be found in animals such as pigs, wild boar, deer, rabbits and rats15. It does not cause the animals any illness, however, the virus can sometimes be passed from the animal to humans11,15. One way this can happen is by eating raw or undercooked meat16. In most cases the source and route of infection is unknown19.
Widespread outbreaks of the virus can occur frequently or constantly in overseas countries (referred to as ‘endemic areas’) where water supplies are contaminated with sewage after monsoons and flooding14.
Unlike hepatitis B, C or D, there is no evidence of the hepatitis E virus being transmitted through sharing needles, bodily fluids or through sexual contact20. However, there is a risk of transmission if there is mouth contact with the anal area21.
There have also been a number of cases reported where hepatitis E has been transmitted through blood transfusions and organ transplants22.
What are the symptoms of hepatitis E?
After the virus enters your body there may be no symptoms for a period of two to nine weeks. This is known as the incubation period23.
Symptoms of hepatitis E infection can include23:
- mild flu-like symptoms
- fatigue (extreme tiredness), this can continue for some time after clearing the virus
- change in urine colour – dark or brown
- abdominal pain
- fever (high temperature)
- loss of appetite
- nausea and vomiting (sickness)
- aching joints and muscles
- tingling, numbness and weakness in your arms and legs.
Direct person to person transmission is uncommon; however, people who have the virus may be infectious for up to two weeks after their symptoms appear. During this period you should not prepare meals for others and, if possible, should limit contact with others, especially those who are pregnant or have a pre-existing chronic liver disease24.
If you become ill with hepatitis E, it is likely that you will develop a brief illness; most people will recover within a month15. Becoming infected with hepatitis E in the UK and Europe usually results in a full recovery with few or no symptoms. However, some patients with a suppressed immune system may fail to clear the virus and develop a persisting (chronic) infection. Such patients can develop cirrhosis of the liver25.
In some people, hepatitis E can affect the nervous system, and this can result in severe pain in the arms and legs. In some cases symptoms can clear completely within three to six months, but for other people there may be longer-lasting symptoms26.
If you have a pre-existing liver condition or you are pregnant, hepatitis E can cause you to be very ill27, often resulting in hospital admission15.
Symptoms of hepatitis E are non-specific, meaning they can be caused by a range of conditions. Initially medical staff may have to rule out other forms of hepatitis, although if you have travelled to areas where hepatitis E is common or where there has been a recent epidemic, you should inform your doctor.
Hepatitis E is detected by a blood test that looks for antibodies (protein substances) produced by your body’s immune system to fight the virus. The blood test for antibodies should distinguish your infection from hepatitis A or B.
A PCR test (see useful words section) may also be done on the blood sample given. The most accurate way of making a diagnosis is by using both tests together.
There is no specific treatment for hepatitis E infection lasting less than six months (acute). It is regarded as a self-limiting disease, meaning that it runs a defined or limited course. Most people who have hepatitis E will go on to recover completely within four weeks from the start of their symptoms.
If you have an existing liver problem you may become unwell. A small number of such patients have been treated successfully with anti-viral therapy using the drug Ribavirin28.
If you are pregnant or have a pre-existing liver condition and your doctor confirms you have hepatitis E, you should be referred to see a specialist urgently.
Currently there is no vaccine available for hepatitis E and, because of this, it is sensible to take precautions when you travel to endemic areas or areas where the virus is known to occur. You should practice good hygiene; always wash your hands properly after using the bathroom and before preparing or eating food. Use alcohol hand gel or ‘baby-wipes’ for cleaning hands if soap and water are not available.
When travelling to an area where hepatitis E is common you are advised to avoid12,15:
- drinking tap water (drink bottled water where possible)
- having ice cubes in your drinks
- cleaning your teeth with tap water
- drinking unpasteurised milk
- eating uncooked meat and shellfish
- eating unpeeled fruit and uncooked vegetables, including salads, that have not been prepared by you.
To reduce the risk of becoming infected with the virus in European countries, including the UK, you should ensure you thoroughly cook all meat, especially pork, before eating it. You should also wash your hands after touching uncooked meat or meat products.
If you suffer from a long standing liver disease, are pregnant or have a suppressed immune system, you should be particularly careful with raw meats, shellfish and pork products11, 23.
Looking after yourself
Alcohol is processed by your liver and, as a result, it can be dangerous for anyone with liver problems. If you have hepatitis E it is important that you stop drinking alcohol for the duration of infection (the whole time) as it can make your symptoms worse11.
Alcohol can accelerate the rate of liver damage in those with hepatitis B and C, and can limit the effectiveness of anti-viral treatment30. Therefore, it is recommended to avoid alcohol in these circumstances.
Smoking is dangerous to everyone’s health31, 32, 33. Smoking can increase the severity of liver damage34. People with liver disease are more vulnerable to infection and to general poor health, so smoking or exposure to passive smoking is not advisable. If you smoke, speak to your doctor about what help is available for cutting down and giving up.
Being overweight or obese can affect the progression, or treatment of, your liver condition. If you have a liver condition, there may be some special considerations you need to make in your diet to stay nutritionally well and to help manage your condition. Some of these are specific to certain liver diseases, others relate to how advanced your liver disease is (see our ‘Diet and liver disease’ publication).
For most people with hepatitis E there is no special diet, however, eating a good, balanced diet is one of the most important things you can do to keep yourself well. Regular low calorie meals containing protein (such as meat, fish or beans), starch (such as bread, potatoes or rice) and vitamins (in fruit and vegetables) is the best approach.
If you have hepatitis E, and are experiencing symptoms, you should try to take gentle exercise such as a regular walk or a gentle swim. You should avoid strenuous exercise until after your symptoms have gone.
Maintaining a healthy weight is vital for the health of your liver. Once you no longer have the symptoms of hepatitis E, continuing to take regular exercise will help you to maintain a healthy weight. The Department of Health recommends adults should take at least half an hour’s gentle exercise a day, leaving you warm and slightly out of breath. You can do this all at once or, if you find it easier, in shorter 10 minute bouts. If you are overweight, the amount of exercise you do may need to be increased from 30 minutes to 45-90 minutes a day to help you to lose weight35.
Finding an exercise that you enjoy will help; try walking, swimming, cycling or dancing. Make sure you start at a sensible rate with the aim to gradually build up the amount and intensity of exercise you do.
Complementary and alternative medicines and therapies
Many complementary and alternative medicines suggest they can ease the symptoms of liver disease. Before taking any medicine you should check with your doctor that it is safe to do so, as most of these are processed by the liver, so they can be toxic to people with liver conditions36. Some can damage the liver and make you more severely ill. At present, healthcare professionals are not clear on the role and place of some complementary medicines in managing liver disease; further research is needed on their use.
Licensing has been introduced for some traditional herbal medicines37; however, many herbal products are not classified as a medicine so there is no regulation of the product. This means you cannot be sure how much of the active ingredient you are getting or how pure it is. Unregulated products are not monitored or assessed for how effective or safe they are. Some remedies can damage the liver and make you more severely ill.
It is wise to be cautious about the claims made for herbal remedies, particularly those advertised on the internet, as they can offer false hope. It is important to discuss the use of these remedies with your doctor before taking them.
Some people choose to use complementary therapies alongside their conventional medical treatment, both to ease symptoms and emotional wellbeing. Such therapies may include massage, aromatherapy, meditation or acupuncture.
To ensure your chosen therapy does not adversely affect your health or medical treatment, you should discuss any therapies you are thinking of using with your doctor. Make sure your practitioner is registered with an accredited body; your doctor may be able to refer you to a locally recommended practitioner. Always inform your practitioner of your medical conditions as these may impact on the type of therapies that are safe for you.
Please visit the support section of our website for information on Support groups in your area or visit our Useful Links section for other organisations who may be able to offer information and support. Other organisations which may be able to offer information:
The National Travel Health Network and Centre (NaTHNaC)
A centre funded by the Department of Health to promote clinical standards in travel medicine. The NaTHNaC website provides general health information for people travelling overseas. Advice covers infectious and non-infectious health risks, where they are found, and links to other resources to help you plan your travel.
Fit For Travel
A website provided by the NHS (Scotland). It gives travel health information for people travelling abroad from the UK.
Download: Hepatitis E HEE/01/12
Reveiwed by: Professor Mark Thursz, Professor of Hepatology, Hepatology Section, Division of Medicine, Imperial College, London; Mrs Lorna Boyne (Specialist Nurse), RN, MN, DTM(Hon.), FFTM RCPSG, PG Cert.Med.Ed; Dr John Christie, Consultant Physician, Royal Devon & Exeter Hospital, Department of Gastroenterology, Exeter; Ms Amanda Clements, Hepatology Nurse Consultant Plymouth Hospital NHS Trust; Dr H R Dalton, Cornwall Gastrointestinal Unit and European Centre for Environment and Human Health, Peninsula College of Medicine and Dentistry, Cornwall; JG Hunter, Cornwall Gastrointestinal Unit and European Centre for Environment and Human Health, Peninsula College of Medicine and Dentistry, Cornwall; Dr Alisdair MacConnachie (Consultant Physician Infectious Diseases), MBChB, PHD, MRCP; RG Madden, Cornwall Gastrointestinal Unit and European Centre for Environment and Human Health, Peninsula College of Medicine and Dentistry, Cornwall; Dr Kali B Perrow (Speciality Grade Physician Infectious Diseases), MBChB, MRCP (Glas) MSc (International and Travel Health);Dr Roger Gajraj, Consultant in Communicable Disease Control, HPA West Midlands East Health Protection Unit, MBBS, FFPH