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Hepatitis E: Source and Route of Infection, Clinical Manifestations and New Developments
L. Scobie and H. R. Dalton J Viral Hepat. 2013;20(1):1-11.

Abstract
Hepatitis E was previously thought to be a disease of developing countries causing significant morbidity and mortality in young adults, particularly among pregnant women and patients with pre-existing chronic liver disease. Recent studies have shown that hepatitis E is also an issue in developed countries. In this setting, hepatitis E is a zoonotic infection and causes acute infection mainly in middle-aged and elderly men; and chronic infection in the immunosuppressed. The scope and burden of disease are still emerging. The diagnosis of hepatitis E should be considered in any patient with hepatitis, irrespective of their age or travel history.

Classification
The hepatitis E virus (HEV) is a member of the Hepeviridae and a sole member of the Hepevirus family, which includes genotypes 14. HEV has a single strand of positive-sense RNA and is nonenveloped. The genome is approximately 7.2 kb in length, and a mature virus particle is 2734 nm in diameter The HEV genome contains a short 5' untranslated region (UTR), three partially overlapping reading frames and a 3' UTR that is terminated by a polyadenylated tail.[1,2] HEV consists of four genotypes. Genotype 1 is mostly found in Asia and Africa, and genotype 2 is found in Mexico and Africa.[2,3] HEV genotypes 1 and 2 are found only in humans. Genotypes 3 and 4 cause human disease in developed countries and are also found in the animal population throughout the world. All genotypes belong to one serotype.[4]

Sources and Route of Infection

Genotypes 1 and 2

Genotypes 1 and 2 are found in developing countries in areas of poor sanitation (Fig. 1). Transmission is by the faeco-oral route via contaminated water supplies. [5,6] In outbreaks, person-to-person spread is thought to be uncommon. However, recent studies from Uganda showed that household factors may be more important than previously thought.[7]

Figure 1. Worldwide distribution of hepatitis E virus (HEV) by genotype. Areas left blank are those with no or little data.

Genotypes 3 and 4

In most cases of autochthonous (locally acquired) hepatitis E in developed countries, the source and route of infection cannot be identified. However, the evidence suggests that most cases may be due to consumption of uncooked or undercooked infected pork or game (wild boar and deer) meat.[810] HEV genotypes 3 and 4 are found in pigs throughout the world. The pig is considered the primary host for HEV, and when infected has no symptoms. Hepatitis E virus has been documented in the food chain in a number of countries.[1115] HEV RNA was found in 11% of pig livers obtained from grocery stores in the United States and was found to be fully infectious.[13] In the UK, the presence of HEV has also been documented in retail pig liver[16] and recently was also found in 10% of pork sausages.[11] Studies from southern France

demonstrated HEV in figatelli pig liver sausage, a local delicacy that is often consumed without cooking. Consumption of figatelli has been linked to outbreaks of hepatitis E in this setting.[12] In Japan, the consumption of wild boar and deer has also demonstrated zoonotic transmission of HEV genotypes 3 and 4.[10] Of ten patients who contracted sporadic acute or fulminant hepatitis E between 2001 and 2002 in Hokkaido, Japan, nine had a history of consuming grilled or undercooked pig liver or intestine 28 weeks before the disease onset. Raw pig liver sold in grocery stores in Hokkaido was also tested for the presence of HEV. Two isolates from the livers had 100% identity with two of the patients suggesting that this may have been the source of infection.[9] The thermal stability of HEV has been investigated. HEV remains viable even after heating to 56 C for 60 min with 1% of infectious viral particles remaining.[17] Cooking to temperatures of 71 C for 20 min is required to fully inactivate the virus.[18] Evidence has also shown that direct contact with pigs is another possible route of transmission of HEV. Seroprevalence studies in the United States show that pig handlers and veterinarians are more likely to be anti-HEV IgG positive (indicating previous exposure), compared with the normal population.[19] The waterborne route of infection may also be important for HEV genotypes 3 and 4. HEV genotype 3 has been detected in untreated wastewater, swine manure, swine slurry storage facilities and river water.[2022] In one of these studies,[21] HEV found in environmental samples was shown to be viable and infectious. How long HEV can remain viable outside its primary host is not known. Factors that affect the viability of HEV in the environment are also unknown. The risk of using infected pig manure on farmland also remains to be determined. There is currently no evidence to suggest that person-to-person spread occurs with HEV genotypes 3 or 4.

Clinical Manifestations
Genotypes 1 and 2

Hepatitis E is the commonest cause of acute viral hepatitis worldwide.[23] In many developing countries, HEV is hyperendemic and causes outbreaks often involving hundreds or thousands of individuals, as well as sporadic cases (Fig. 1). HEV usually causes a self-limiting hepatitis in young adults (typical age range 1530 years). The overall mortality is <1%, with the majority of deaths occurring in pregnant women. The mortality in pregnant women is approximately 25%, with most deaths in the third trimester.[24,25] Deaths are caused by obstetric complications such as eclampsia and haemorrhage, with or without acute liver failure, usually resulting in loss of the foetus. The excess mortality seen in

pregnancy does not occur with other causes of viral hepatitis and appears to be unique to HEV genotypes 1 and 2. The pathophysiological mechanisms are unknown. In developing countries, hepatitis E genotype 1 also causes increased mortality in patients with pre-existing chronic liver disease. In a large study from Delhi, India, patients with chronic liver disease who decompensated due to acute HEV infection had a 12-month mortality approaching 70%, with most deaths occurring within the first 3 months following infection. The mortality in this group was significantly higher than a group of patients with chronic liver disease who had decompensated for reasons other than HEV infection.[26]
Genotypes 3 and 4

HEV genotypes 3 and 4 are zoonotic infections and cause sporadic cases of hepatitis E in developed countries (Fig. 1). Cases of hepatitis caused by genotype 3 have been found in North America,[27] Europe [28, 29], Japan[30] and New Zealand.[31] Human infection with genotype 4 is found in China and Japan, but there have been a small number of cases also recently reported in Europe.[32]
Acute HEV Infection

In contrast to genotypes 1 and 2, HEV genotypes 3 and 4 cause clinically apparent hepatitis in the middle-aged and elderly, and men are much more commonly affected than women (M:F ratio is about 4:1).[33] This is a consistent and intriguing observation, as no other known virus has such a predilection for middle-aged/elderly men. The reason for this unusual demography is not known. It might be that for some reason, older men are more likely to be exposed to higher viral loads, and so more likely to develop clinically apparent disease. However, the evidence suggests asymptomatic infection with HEV is common and that exposure to HEV is independent of age and sex. This suggests that host risk factors must be important in clinical disease expression. Two studies show that hepatitis E is more common in individuals who drink excessive amounts of alcohol.[34,35] It has been hypothesized that subclinical hepatic steatosis/fibrosis could be a host risk factor for clinical disease expression in patients exposed to HEV. Autochthonous hepatitis E causes a range of severity of illness in humans, from asymptomatic infection to acute or subacute liver failure (). Symptoms are nonspecific, and usually indistinguishable from other forms of viral hepatitis, and include jaundice, fever, flu-like symptoms, abdominal pain, vomiting, anorexia and weight loss, and myalgia.[33] In a minority of patients, neurological symptoms dominate the clinical picture, as HEV appears to be neuropathogenic.[36] Physical signs are also similar to those found in other forms of acute viral hepatitis, with

jaundice in most and hepatomegaly in a minority.

Table 1. Spectrum of clinical disease expression with HEV genotypes 3 and 4

Clinical expression Comments Asymptomatic Mild anicteric illness Mild-moderate hepatitis Neurological syndromes 6798% of infections are asymptomatic

Incidence uncertain. Patients have nonspecific flu-like symptoms and ma

The majority of clinically recognised infection in developed countries. Sy

HEV appears to be neuropathogenic. The clinical picture is dominated b often anicteric

Severe hepatitis Acute and subacute liver failure can occur, particularly in patients with un The differential diagnosis of autochthonous hepatitis E includes other causes of acute viral hepatitis including hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), EpsteinBarr Virus (EBV), and CMV and autoimmune hepatitis (). Acute HEV infection may be mistaken for drug-induced liver injury (DILI). In a study from the UK, 6 (13%) of 47 patients with 'criterion-referenced' DILI were misdiagnosed, as they had acute HEV genotype 3 infection.[37] These findings were confirmed by a more recent US study which showed that 9 (3%) of 318 patients with 'DILI' had HEV infection.[38] These studies suggest that a diagnosis of DILI is not secure without first excluding HEV infection, particularly in patients with a predominant transaminitis.
Table 2. Differential diagnosis of acute HEV

M: F rat io HEV 4. 0 0. 9 1. 25

Media n age (range ) 63 (54 81) 44 (20 61) 39 (20 60)

ALT (U/L) Median (range) 1387 (318 6357) 1056 (595 4122) 1858 (499 3856)

Bilirubin (mol/L) Median (range) 61 (8297)

Comments

ALT is often modest and very occasio

HAV

154 (42214)

HAV is becoming less common in mo

Acute HBV

122 (36355)

More common in IVDUs and high-risk

DILI

1. 0

65 (17 83) 64 (15 91)

398 (48 1456) 749 (22 2519)

199 (20651)

Diagnosis of DILI is not secure withou predominant transaminitis

Autoimmun 0. e hepatitis 3 EBV 1. 2

122 (32634)

Occurs at any age. Most cases prese >60 years

40 Occurs at any age. Symptoms of infec 395 (87 (18 74 (13165) a combination of lymphocytosis and s 1362) 68) >95% EBV, EpsteinBarr Virus; HAV, hepatitis A virus infection; HBV, acute hepatitis B virus infection; HEV, acute hepatitis E virus infection; DILI, drug-induced liver injury; IVDU, intravenous drug user; ALT, alanine aminotransferase (normal range, 1036 U/L), Bilirubin normal range: 317 mol/L. The values shown in this table are those at presentation to a rapid access jaundice clinic in SW England. [37,88] Most patients with autochthonous hepatitis E have a self-limiting illness that last 46 weeks.[3] Few infections have been documented in pregnant women, and excess mortality in this group does not occur. A minority of patients develop acute or subacute liver failure. Such patients usually have underlying chronic liver disease and, as in HEV genotype 1 and 2 infections, the mortality is high.[39,40] How commonly HEV causes decompensation in patients with chronic liver disease in developed countries is not known, as such patients are not routinely tested for HEV. This is an important question, as two studies have shown a strong relationship between pork consumption and deaths from chronic liver disease in developed countries[41] (Fig. 2). The reason for this relationship is not known, but one hypothesis is that this could be due to unrecognised HEV infection in patients with existing chronic liver disease, as HEV has been documented in pig products in the human food chain and may not be inactivated by light cooking.

Figure 2. Univariate regression analysis of the mean mortality from chronic liver disease for the years 1990, 1995, 1997, 1998, 1999 and 2000, compared with (a) alcohol consumption and (b) pig meat consumption in 18 developed countries using data derived from WHO and UN databases. The strength of the relationship between pork consumption and death from chronic liver disease (b) is similar to that for alcohol (a).

The incidence of HEV in most countries is not known, but studies have shown that locally acquired HEV is more common than HAV in the UK and Japan.[42,43] In some countries, HEV is a notifiable disease. In 2011, 454 cases of laboratoryconfirmed cases of HEV were documented in England and Wales (http://www.hpa.org.uk/hpr/archives/2012/news3212.htm#hev), and these were mostly locally acquired. The number of cases has risen substantially in 2011 and the first half of 2012. This appears to be a true increase in cases rather changes in case ascertainment due to increased testing (S. Ijaz, personal communication). The reason for this increase in cases is not known. As in all infectious diseases, the number of cases notified represents only a small minority of infections in a community. Using changes in seroprevalence data, the incidence of hepatitis E in the UK has been estimated at 0.2%.[44] This equates to over 120 000 cases per annum. This implies that most cases are either asymptomatic or currently unrecognised. A study from an outbreak of 33 cases of HEV genotype 3 on a cruise ship showed that 67% had no symptoms related to infection with HEV.[34] In the USA, the incidence of HEV infection has been calculated at 0.7%.[45] In this geographical setting, most cases of symptomatic hepatitis E infection are 'missed', as currently there are no FDA-approved diagnostic assays that are available for use in humans. This almost certainly accounts for the very small number of confirmed cases of locally acquired HEV in this country.
Chronic HEV Infection

The finding that HEV can become chronic in the immunosuppressed was a paradigm shift. Following this discovery, HEV became of interest to a wide range of health professionals, not least transplant physicians. To date, chronic infection has only been documented in HEV genotype 3 infections.

Chronic infection with HEV occurs in transplant recipients receiving immunosuppressive therapy, patients with haematological malignancies and individuals with HIV infection.[4651] Approximately 60% of immunosuppressed transplant recipients exposed to HEV develop chronic infection (defined as HEV PCR positive >6 months). Risk factors for developing chronic infection include the use of tacrolimus (rather than cyclosporin) and thrombocytopaenia. Chronic HEV infection has been found in a range of organ transplant recipients including renal, heart, lung and liver. Patients usually have no symptoms, and the only clue to the diagnosis is a modest elevation of alanine aminotransferase (ALT), usually in the 100200 IU/L range. Chronic inflammation and fibrosis occur within the hepatocytes and, untreated, progression to cirrhosis is rapid (10% in 2 years).[52,53] Chronic hepatitis E infection is common in the south-west of France. The prevalence of chronic hepatitis in other European transplant centres is around 1%.[54,55] A relatively small number of patients with HIV infection have also been documented with chronic infection with HEV, including two patients from the UK with established cirrhosis.[50,56] A casecontrol study suggests that sexual transmission of HEV in the HIV population is not an important route of infection.[57] All patients with HIV infection who have developed chronic HEV infection had CD4 counts <250. So far, chronic HEV infection in individuals with HIV has only been documented with HEV genotype 3.[50] How HEV and HIV interact in Africa and Asia (where both viruses are endemic) remains to be established and merits further study.
Neurological Complications of Hepatitis E

Neurological complications of HEV infection have been reported from Asia (genotype 1) and Europe (genotype 3). In the case of genotype 3 infections, neurological sequelae are seen in both acute and chronic infections. The range of neurological complications with HEV infection is wide and includes Guillain Barr syndrome, Bell's palsy, neuralgic amyotrophy, acute transverse myelitis, acute meningoencephalitis, inflammatory polyradiculopathy, bilateral brachial neuritis, encephalitis and ataxia/proximal myopathy.[3] In a study of 126 patients with acute and chronic HEV infection in France and the UK, 7 (5%) developed neurological complications.[36] In these cases, the neurological symptoms and signs dominated the clinical picture, as most patients were anicteric and the degree of transaminitis was modest. The incidence of neurological illness associated with HEV is not known, as most patients are likely to present to neurologists and are not currently tested for HEV. The pathophysiological mechanisms of HEV-associated neurological injury are not known. However, in some cases, HEV can be found in the CSF associated

with a CSF pleocytosis.[36] In one case of chronic HEV infection with predominantly lower-limb sensory neuropathy, symptom resolution was temporally related to viral clearance from the CSF with antiviral therapy.[58] HEV quasispecies compartmentalization has been found in the CSF.[59] Taken together, these findings suggest that certain quasispecies of HEV may be directly neuropathogenic.
Diagnosis of Hepatitis E

The key step in making a diagnosis of hepatitis E is to consider it as a diagnostic possibility. Acute HEV should be considered in any patient with clinical and/or biochemical evidence of hepatitis irrespective of their age or travel history. Chronic hepatitis E should be considered in any immunosuppressed patient with abnormal liver function tests. Finally, evidence of hepatitis E infection should be sought in any patient with unexplained neurological symptoms and abnormal liver function tests. The diagnosis of hepatitis E is established by a combination of serological and molecular techniques. Immunocompetent patients should be tested for anti-HEV IgM and IgG, and if positive for either, they should be tested for HEV by PCR. It should be noted that serological tests vary widely in their accuracy,[60] and users should ensure appropriately sensitive and specific assays are employed. Also, the period of viraemia can be quite brief, so a negative PCR does not exclude the diagnosis. In some patients, the IgM is negative, but the IgG and PCR are positive. These cases almost certainly represent re-infection with HEV. Re-infections with HEV have been shown to represent 20% of genotype 4 infections in eastern China.[3] Re-infections have also been documented in Europe with genotype 3, but the incidence is not known.[61] In patients who are immunosuppressed, HEV serology is less reliable.[50] PCR is mandatory for establishing the diagnosis and monitoring therapy.
Treatment and Prevention

Acute HEV is usually a self-limiting illness and requires no treatment. Patients with severe hepatitis, especially those with pre-existing chronic liver disease, should be considered for antiviral therapy. HEV appears to be very sensitive to ribavirin, which usually achieves viral clearance within a week or two. Ribavirin has been used successfully to treat a small number of patients with chronic liver disease and severe acute hepatitis E in both India[62] and Europe.[63] However, ribavirin is contraindicated in pregnancy. Chronic HEV infection has been treated with ribavirin and pegylated alpha interferon both as mono therapy and in combination.[6466] In transplant recipients,

the recommended treatment algorithm has been established by the Toulouse group. The first step is to wait a while, as a minority of patients will clear HEV spontaneously. In patients with on-going chronic infection, the next step is to reduce the amount of immunosuppression, if possible. This will clear HEV in 30% of cases.[53] Finally, if the above two manoeuvres are unsuccessful, then the patient should be treated with ribavirin monotherapy for 3 months. The above treatment algorithm will achieve viral clearance with a sustained virological response in the majority of individuals. The main way of preventing waterborne HEV infections in developing countries is by provision of secure supplies of clean drinking water. In developed countries, prevention strategies are more problematic as there are several possible routes of infection. Pork meat products should be handled and stored with appropriate care and cooked thoroughly. HEV vaccination is a possible solution in the future (see recent developments).

New Developments
Hepatitis E as an ancient disease

HEV was only discovered in developing countries 30 years ago. It has been described as an 'emerging infection', particularly in developed countries.[67] It would be more accurate to describe HEV as a disease that is emerging in human awareness. The reason for this is that HEV has almost certainly caused illness in humans for over 200 years. In a study of outstanding scholarship, Chong Gee Teo of the Centers for Disease Control and Prevention in Atlanta traced the historical origins of HEV-associated human disease.[68] Using historical accounts of deaths in pregnant women during outbreaks of icteric illness as a marker for HEV, the first recorded outbreak of HEV was in Ludenscheld, Germany, in 1794. This outbreak included 70 cases, including three pregnant women, two of whom died. In the nineteenth Century and early twentieth century, there were further outbreaks in the USA, Australia and a large one in Martinique in the Caribbean with 20 maternal deaths. However, most outbreaks occurred in Europe particularly in France, Germany and Italy. After the Second World War, reports of deaths in pregnant women with jaundice largely ceased in Europe, but started to appear in the Middle East, Asia and Africa. Biological time clock studies suggest that HEV diverged into its four genotypes over 500 years ago.[69] With the introduction of clean drinking water supplies and safe disposal of human sewerage in Europe in the late nineteenth and early twentieth centuries, ecological pressure may have forced waterborne HEV (genotypes 1 and 2) to move east into Asia and south into Africa, leaving HEV genotype 3 hidden in its primary host, the pig.

New Animal Hosts and Routes of Infection

New Animal Hosts Recent studies have shown that HEV (or serological evidence of infection) can be found in an increasingly diverse number of animals ( ) including rats, sheep, ferrets, goats and rabbits. The importance of most of these animal reservoirs is currently uncertain. However, in a study from France, HEV RNA was found in 23% of farmed rabbit livers, with close sequence homology to HEV found in humans. Interestingly, the identification of a novel HEV within rabbits has shown to cross the species barrier.[70] This suggests that rabbits could be an important reservoir in terms of human disease. Other studies have shown the presence of HEV genotype 3 in the rat population, suggesting that this may be an alternative reservoir in the epidemiology and transmission of HEV [71]; however, so far, there is no evidence of cross-species infection.
Table 3. Identification of hepatitis E virus (HEV) and cross-species infection in animals examined to date

Species Human Swine Rat Rabbit Horse Cat Dog Goat Sheep Cow Avian Shellfish Mongoose Primate Deer Wild boar

Antibodies to HEV detected Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

HEV detected Y Y Y Y N N N N Ya Ya Y Y Y Y Y Y

Foodborne Proven N/A Y N N N N N N N N N N N N Y Y

Cross-specie transmission Y Y N Y N Y N N N N Y N N N Y Y

Ferrets

Y Y

N N

N N

Cut-throat N Trout *Only partial sequences are available.

Coastal Contamination and Waterborne Routes HEV genotype 3 has also been detected in mussels harvested in areas close to pig cutting plants/slaughterhouses.[72] The presence of a swine-like HEV genotype 3 in a freshwater bivalve has also been reported in Japan and in oysters in Korea and mussels in Italy.[73,74] Several recent reports have linked cases of HEV in humans to the consumption of shellfish. This includes a study of 33 passengers who developed hepatitis E genotype 3 on a cruise ship, which may have been caused by the consumption of shellfish.[34] A study in the UK has suggested that cases of hepatitis E genotype 3 are more commonly found in coastal and estuarine locations.[75] Provisional data from Cornwall have confirmed these findings. In a casecontrol study, 50% of cases of autochthonous HEV were found to live within 2 km of the coast.[76] The explanation for this observation is uncertain. It might be that individuals who live near the coast are more likely to consume shellfish. Another possibility is that coastal areas are more likely to be contaminated with HEV transported via watercourses from 'run-off' from pigs farms. An environmental study (including beach sampling) is currently in progress to determine the degree of coastal contamination with HEV. Waterborne transmission of HEV genotypes 3 and 4 may have a significant role in human infection. An example of this comes from a study from Canada that demonstrated HEV genotype 3 on strawberries, with infected irrigation water as the likely source of infection.[77] HEV and Blood Transfusion In developed countries, there have been reports of sporadic cases of HEV genotype 3 infection via blood transfusion from HEVinfected donors.[78] A recent study has shown that in Germany and Sweden, HEV genotype 3 is found surprisingly frequently in blood donors at the time of donation (one in 4525 and one in 7986 donors, respectively)[79] A study of London blood donors found 11% of donor sera to be HEV IgG reactive and 0.7% IgM reactive.[44] 0.7% of plasma minipools from English donors contained HEV RNA.[80] These studies suggest that parenterally acquired HEV infections occur quite commonly, the clinical consequences of which are currently uncertain.
HEV in the South of France

Over the last 20 years, there have been numerous seroprevalence studies in developed countries. These have produced a wide range of results. Many of the

earlier studies estimated the anti-HEV IgG seroprevalence in the 12% range.[81,82] In contrast, some studies have produced much higher results, including 16% in south-west England,[33] 20% in Denmark[83] and 21% in the USA.[84] In addition to differences in seroprevalence between countries, seroprevalence also varies within countries. In the UK, for instance, the seroprevalence in Cornwall is 16%, [61] in England 12%[85] and in Scotland 4.6% (unpublished observations). In France, there also appears to be a northsouth gradient in seroprevalence, as anti-HEV IgG seropositivity is four times higher in blood donors in the south of the country compared with the north. The reasons for the above geographical differences in seroprevalence are uncertain. One key issue when considering the literature on HEV seroprevalence is the sensitivity and specificity of the assay employed. Many of the assays employed are of very poor sensitivity, and one assay in common usage has been shown to underestimate the true seroprevalence by a factor of four.[61] For instance, in south-west France, the seroprevalence in blood donors was initially estimated at 16% using this assay. When this study was repeated using a highly sensitive and partially validated assay, the seroprevalence was found to be 52%.[86] This result suggests that HEV is hyperendemic in the Toulouse area (Fig. 1). However, these findings have caused some debate. Sceptics argue that a seroprevalence of 52% cannot possibly be accurate and merely reflects lack of assay specificity. However, the evidence suggests that this is not the case, as the seroprevalence in young children from the same area was very low (2%), and other adult populations have also shown very low seroprevalence when studied using the same assay.[31] In addition, clinically apparent HEV infections are very common in the south of France,[32] and the incidence of HEV in the Toulouse transplant population has been shown to be 3.2%. It is currently unknown whether there are other 'hot spots' of HEV hyperendemnicity in the rest of Europe or other developed countries.
HEV Vaccines

Two HEV vaccines have been developed. One of these vaccines has been withdrawn from the commercial 'pipeline', but the other vaccine (HEV 239) has been shown to be safe and efficacious in an enormous study in eastern China involving over 100 000 participants.[87] HEV 239 vaccine has recently been licensed for use in China. It is currently uncertain whether and when this vaccine will be available in other countries.
Worldwide Burden of Disease

Since its discovery 30 years ago, hepatitis E has been a neglected disease in terms of research funding. In fact, it has been so neglected that it does not even make the WHO list of 'neglected tropical diseases'. Lack of research funding has

made reliable data from many developing countries either scarce or absent. This makes it very difficult to accurately estimate the burden of disease. Bearing these constraints in mind, Rein and colleagues recently estimated the incidence of HEV genotypes 1 and 2 in nine of 21 world health regions to be 20 million cases per year, with 70 000 deaths and 3000 stillbirths.[24] This may be an underestimate, as a recent study suggests that in the country of Bangladesh alone, HEV may be responsible for over 1000 deaths per year in pregnant women.[25] An estimation of the burden of disease in developed countries has not yet been performed.

Conclusions
HEV should no longer be considered an uncommon, newly emerging virus of little interest or importance. Hepatitis E is a disease of global distribution, has significant morbidity and mortality and has been causing human disease for over 200 years. The scope and burden of disease continues to emerge, both in developed and developing countries. As these data emerge, it is hoped that WHO will update their list of neglected diseases.
References 1.

Emerson SU, Nguyen H, Graff J, Stephany DA, Brockington A, Purcell RH. In vitro replication of hepatitis E virus (HEV) genomes and of an HEV replicon expressing green fluorescent protein. J Virol 2004; 78 (9): 48384846. Okamoto H. Genetic variability and evolution of hepatitis E virus. Virus Res 2007: 127(2): 216228. Kamar N, Bendall R, Legrand- Abravanel F et al. Hepatitis E. Lancet 2012; 379(9835): 24772488. Aggarwal R, Naik S. Epidemiology of hepatitis E: current status. J Gastroenterol Hepatol 2009: 24(9): 14841493. Hazam RK, Singla R, Kishore J, Singh S, Gupta RK, Kar P. Surveillance of hepatitis E virus in sewage and drinking water in a resettlement colony of Delhi: what has been the experience? Arch Virol 2010: 155 (8): 12271233. Ippagunta SK, Naik S, Sharma B, Aggarwal R. Presence of hepatitis E virus in sewage in Northern India: frequency and seasonal pattern. J Med Virol 2007: 79(12): 18271831. Teshale EH, Grytdal SP, Howard C et al. Evidence of person-to-person transmission of hepatitis E virus during a large outbreak in Northern Uganda. Clin Infect Dis 2010: 50(7): 10061010.

2.

3.

4.

5.

6.

7.

8.

Tei S, Kitajima N, Takahashi K, Mishiro S. Zoonotic transmission of hepatitis E virus from deer to human beings. Lancet 2003: 362 (9381): 371373. Yazaki Y, Mizuo H, Takahashi M et al. Sporadic acute or fulminant hepatitis E in Hokkaido, Japan, may be food-borne, as suggested by the presence of hepatitis E virus in pig liver as food. J Gen Virol 2003: 84 (Pt 9): 23512357. Matsuda H, Okada K, Takahashi K, Mishiro S. Severe hepatitis E virus infection after ingestion of uncooked liver from a wild boar. J Infect Dis 2003: 188(6): 944. Berto A, Martelli F, Grierson S, Banks M. Hepatitis e virus in pork food chain, United kingdom, 2009 2010. Emerg Infect Dis 2012: 18(8): 13581360. Colson P, Borentain P, Queyriaux B et al. Pig liver sausage as a source of hepatitis E virus transmission to humans. J Infect Dis 2010: 202(6): 825834. Feagins AR, Opriessnig T, Guenette DK, Halbur PG, Meng XJ. Detection and characterization of infectious Hepatitis E virus from commercial pig livers sold in local grocery stores in the USA. J Gen Virol 2007: 88(Pt 3): 912917. Matsubayashi K, Kang JH, Sakata H et al. A case of transfusion-transmitted hepatitis E caused by blood from a donor infected with hepatitis E virus via zoonotic food-borne route. Transfusion 2008: 48(7): 1368 1375. Wichmann O, Schimanski S, Koch J et al. Phylogenetic and Case-Control Study on Hepatitis E Virus Infection in Germany. J Infect Dis 2008: 198 (12): 1732 1741. Banks M, Martelli F, Grierson S et al. Hepatitis E virus in retail pig livers. Vet Rec 2010; 166(1): 29. Emerson SU, Arankalle VA, Purcell RH. Thermal stability of hepatitis E virus. J Infect Dis 2005: 192(5): 930933. Barnaud E, Rogee S, Garry P, Rose N, Pavio N. Thermal inactivation of infectious hepatitis e virus in experimentally contaminated food. Appl Environ Microbiol 2012: 78(15): 51535159. Meng XJ, Wiseman B, Elvinger F et al. Prevalence of antibodies to hepatitis E virus in veterinarians working with swine and in normal blood donors in the United States and other countries. J Clin Microbiol 2002: 40(1): 117122. La Rosa G, Pourshaban M, Iaconelli M, Vennarucci VS, Muscillo M. Molecular

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

detection of hepatitis E virus in sewage samples. Appl Environ Microbiol 2010: 76(17): 5870 5873.
21.

Kasorndorkbua C, Opriessnig T, Huang FF et al. Infectious swine hepatitis E virus is present in pig manure storage facilities on United States farms, but evidence of water contamination is lacking. Appl Environ Microbiol 2005: 71(12): 78317837. McCreary C, Martelli F, Grierson S, Ostanello F, Nevel A, Banks M. Excretion of hepatitis E virus by pigs of different ages and its presence in slurry stores in the United Kingdom. Vet Rec 2008: 163(9): 261265. Purcell RH, Emerson SU. Hepatitis E: an emerging awareness of an old disease. J Hepatol 2008; 48(3): 494503. Rein DB, Stevens GA, Theaker J, Wittenborn JS, Wiersma ST. The global burden of hepatitis E virus genotypes 1 and 2 in 2005. Hepatology 2011: 55(4): 988997. Labrique AB, Sikder SS, Krain LJ et al. Hepatitis e, a vaccine-preventable cause of maternal deaths. Emerg Infect Dis 2012: 18(9): 14011404. Kumar A, Aggarwal R, Naik SR, Saraswat V, Ghoshal UC, Naik S. Hepatitis E virus is responsible for decompensation of chronic liver disease in an endemic region. Indian J Gastroenterol 2004: 23(2): 5962. Tsang TH, Denison EK, Williams HV, Venczel LV, Ginsberg MM, Vugia DJ. Acute hepatitis E infection acquired in California. Clin Infect Dis 2000: 30(3): 618619. Mansuy JM, Peron JM, Abravanel F et al. Hepatitis E in the south west of France in individuals who have never visited an endemic area. J Med Virol 2004: 74(3): 419 424. Dalton HR, Thurairajah PH, Fellows HJ et al. Autochthonous hepatitis E in southwest England. J Viral Hepat 2007: 14(5): 304309. Mizuo H, Yazaki Y, Sugawara K et al. Possible risk factors for the transmission of hepatitis E virus and for the severe form of hepatitis E acquired locally in Hokkaido, Japan. J Med Virol 2005: 76(3): 341349. Dalton HR, Fellows HJ, Gane EJ et al. Hepatitis E in New Zealand. J Gastroenterol Hepatol 2007: 22(8): 12361240.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

Colson P, Romanet P, Moal V et al. Autochthonous infections with hepatitis e virus genotype 4, France. Emerg Infect Dis 2012: 18(8): 1361 1364. Dalton HR, Stableforth W, Thurairajah P et al. Autochthonous hepatitis E in Southwest England: natural history, complications and seasonal variation, and hepatitis E virus IgG seroprevalence in blood donors, the elderly and patients with chronic liver disease. Eur J Gastroenterol Hepatol 2008: 20(8): 784790. Said B, Ijaz S, Kafatos G et al. Hepatitis E outbreak on cruise ship. Emerg Infect Dis 2009: 15(11): 17381744. Dalton HR, Bendall RP, Rashid M et al. Host risk factors and autochthonous hepatitis E infection. Eur J Gastroenterol Hepatol 2011: 23(12): 12001205. Kamar N, Bendall RP, Peron JM et al. Hepatitis E virus and neurologic disorders. Emerg Infect Dis 2011: 17(2): 173179. Dalton HR, Fellows HJ, Stableforth W et al. The role of hepatitis E virus testing in drug-induced liver injury. Aliment Pharmacol Ther 2007: 26 (10): 14291435. Davern TJ, Chalasani N, Fontana RJ et al. Acute hepatitis E infection accounts for some cases of suspected drug-induced liver injury. Gastroenterology 2011; 141(5):1665 1672. e1e9. Dalton HR, Hazeldine S, Banks M, Ijaz S, Bendall R. Locally acquired hepatitis E in chronic liver disease. Lancet 2007: 369(9569): 1260. Peron JM, Bureau C, Poirson H et al. Fulminant liver failure from acute autochthonous hepatitis E in France: description of seven patients with acute hepatitis E and encephalopathy. J Viral Hepat 2007: 14(5): 298303. Dalton HR, Bendall RP, Pritchard C, Henley W, Melzer D. National mortality rates from chronic liver disease and consumption of alcohol and pig meat. Epidemiol Infect 2010; 138(2): 174182. Dalton HR, Stableforth W, Hazeldine S et al. Autochthonous hepatitis E in Southwest England: a comparison with hepatitis A. Eur J Clin Microbiol Infect Dis 2008: 27(7): 579585. Mitsui T, Tsukamoto Y, Hirose A et al. Distinct changing profiles of hepatitis A and E virus infection among patients with acute hepatitis, patients on maintenance hemodialysis and healthy individuals in Japan. J Med Virol 2006: 78 (8): 10151024.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

Beale MA, Tettmar K, Szypulska R, Tedder RS, Ijaz S. Is there evidence of recent hepatitis E virus infection in English and North Welsh blood donors? Vox Sang 2011: 100(3): 340342. Faramawi MF, Johnson E, Chen S, Pannala PR. The incidence of hepatitis E virus infection in the general population of the USA. Epidemiol Infect 2011; 139(8): 11451150. Kamar N, Selves J, Mansuy JM et al. Hepatitis E virus and chronic hepatitis in organ-transplant recipients. N Engl J Med 2008: 358(8): 811817. Haagsma EB, van den Berg AP, Porte RJ et al. Chronic hepatitis E virus infection in liver transplant recipients. Liver Transpl 2008: 14 (4): 547553. Gerolami R, Moal V, Colson P. Chronic hepatitis E with cirrhosis in a kidneytransplant recipient. N Engl J Med 2008: 358(8): 859860. Gerolami R, Moal V, Picard C, Colson P. Hepatitis E virus as an emerging cause of chronic liver disease in organ transplant recipients. J Hepatol 2009: 50(3): 622624. Dalton HR, Bendall RP, Keane FE, Tedder RS, Ijaz S. Persistent carriage of hepatitis E virus in patients with HIV infection. N Engl J Med 2009: 361(10): 10251027. Peron JM, Mansuy JM, Recher C et al. Prolonged hepatitis E in an immunocompromised patient. J Gastroenterol Hepatol 2006: 21(7): 12231224. Kamar N, Garrouste C, Haagsma EB et al. Factors associated with chronic hepatitis in patients with hepatitis E virus infection who have received solid organ transplants. Gastroenterology 2011: 140(5): 14811489. Kamar N, Abravanel F, Selves J et al. Influence of immunosuppressive therapy on the natural history of genotype 3 hepatitis-E virus infection after organ transplantation. Transplantation 2010: 89(3): 353360. Pas SD, de Man RA, Mulders C et al. Hepatitis E virus infection among solid organ transplant recipients, the Netherlands. Emerg Infect Dis 2012: 18(5): 869 872. Pischke S, Stiefel P, Franz B et al. Chronic hepatitis E in heart transplant recipients. Am J Transplant 2012; doi: 10.1111/j.1600-6143. 2012.04200.x.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

Jagjit Singh GK, Ijaz S, Rockwood N et al. Chronic Hepatitis E as a cause for cryptogenic cirrhosis in HIV. J Infect 2011; doi: 10.1016/j.jinf. 2011.11.027. Keane F, Gompels M, Bendall R et al. Hepatitis E virus coinfection in patients with HIV infection. HIV Med 2011: 13(1): 8388. Dalton HR, Keane FE, Bendall R, Mathew J, Ijaz S. Treatment of chronic hepatitis E in a patient with HIV infection. Ann Intern Med 2011; 155(7): 479480. Kamar N, Izopet J, Cintas P et al. Hepatitis E virus-induced neurological symptoms in a kidney-transplant patient with chronic hepatitis. Am J Transplant 2010; 10(5): 1321 1324. Drobeniuc J, Meng J, Reuter G et al. Serologic assays specific to immunoglobulin M antibodies against hepatitis E virus: pangenotypic evaluation of performances. Clin Infect Dis 2010: 51(3): e24e27. Bendall R, Ellis V, Ijaz S, Ali R, Dalton H. A comparison of two commercially available anti-HEV IgG kits and a re-evaluation of anti- HEV IgG seroprevalence data in developed countries. J Med Virol 2010: 82(5): 799805. Goyal R, Kumar A, Panda SK, Paul SB, Acharya SK. Ribavirin therapy for hepatitis E virus-induced acute on chronic liver failure: a preliminary report. Antivir Ther 2012: 17 (6): 10911096. Peron JM, Dalton H, Izopet J, Kamar N. Acute autochthonous hepatitis E in western patients with underlying chronic liver disease: a role for ribavirin? J Hepatol 2011; 54(6):1323 1324; author reply 4-5. Kamar N, Rostaing L, Abravanel F et al. Pegylated Interferon for Treating Chronic Hepatitis E Virus Infection after Liver Transplantation. Clin Infect Dis 2010: 50(5): e30e33. Haagsma EB, Riezebos-Brilman A, van den Berg AP, Porte RJ, Niesters HG. Treatment of chronic hepatitis E in liver transplant recipients with pegylated interferon alpha-2b. Liver Transpl 2010: 16(4): 474 477. Mallet V, Nicand E, Sultanik P et al. Brief communication: case reports of ribavirin treatment for chronic hepatitis E. Ann Intern Med 2010: 153(2): 8589. Dalton HR, Bendall R, Ijaz S, Banks M. Hepatitis E: an emerging infection in developed countries. Lancet Infect Dis 2008; 8(11): 698709.

57.

58.

59.

60.

61.

62.

63.

64.

65.

66.

67.

68.

Teo CG. Fatal outbreaks of jaundice in pregnancy and the epidemic history of hepatitis E. Epidemiol Infect 2012: 140(5): 767787. Purdy MA, Khudyakov YE. Evolutionary history and population dynamics of hepatitis E virus. PLoS ONE 2010: 5(12): e14376. Izopet J, Dubois M, Bertagnoli S et al. Hepatitis E virus strains in rabbits and evidence of a closely related strain in humans, France. Emerg Infect Dis 2012: 18(8): 1274 1281. Lack JB, Volk K, Van Den Bussche RA. Hepatitis e virus genotype 3 in wild rats, United States. Emerg Infect Dis 2012: 18(8): 12681273. Crossan C, Baker PJ, Takeuchi Y, Dalton HR, Scobie L. Identification of Hepatitis E virus Genotype-3 in shellfish in the United Kingdom. Emerg Infect Dis. In press. Li TC, Miyamura T, Takeda N. Detection of hepatitis E virus RNA from the bivalve Yamato-Shijimi (Corbicula japonica) in Japan. Am J Trop Med Hyg 2007; 76(1): 170 172. Donia D, Dell'amico MC, Petrinca AR et al. Presence of hepatitis E RNA in mussels used as bio-monitors of viral marine pollution. J Virol Methods 2012; http://dx.doi.org/10.1016/j.jviromet.2012.06.007. Ijaz S, Arnold E, Banks M et al. Non-travel-associated hepatitis E in England and Wales: demographic, clinical, and molecular epidemiological characteristics. J Infect Dis 2005: 192(7): 11661172. Madden RG, Hunter JG, Stone AM et al. Locally acquired hepatitis E. Geographical clustering and environmental factors: a nested case control study. J Hepatol 2012; 56 (Suppl. 2): s64. Brassard J, Gagne MJ, Genereux M, Cote C. Detection of human foodborne and zoonotic viruses on irrigated, field-grown strawberries. Appl Environ Microbiol 2012: 78(10): 37633766. Boxall E, Herborn A, Kochethu G et al. Transfusion-transmitted hepatitis E in a 'nonhyperendemic' country. Transfus Med 2006: 16(2): 7983. Baylis SA, Gartner T, Nick S, Ovemyr J, Blumel J. Occurrence of hepatitis E virus RNA in plasma donations from Sweden, Germany and the United States. Vox Sang 2012: 103(1): 8990.

69.

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

80.

Ijaz S, Szypulska R, Tettmar K, Kitchen K, Tedder R. Detection of Hepatitis E Virus RNA in Plasma Mini-Pools from Blood Donors in England. Vox Sang 2011: 102(3): 272. Zaaijer HL, Kok M, Lelie PN, Timmerman RJ, Chau K, van der Pal HJ. Hepatitis E in The Netherlands: imported and endemic. Lancet 1993: 341(8848): 826. Zanetti AR, Dawson GJ. Hepatitis type E in Italy: a seroepidemiological survey. Study Group of Hepatitis E. J Med Virol 1994: 42(3): 318 320. Christensen PB, Engle RE, Hjort C et al. Time trend of the prevalence of hepatitis E antibodies among farmers and blood donors: a potential zoonosis in Denmark. Clin Infect Dis 2008: 47(8): 10261031. Kuniholm MH, Purcell RH, McQuillan GM, Engle RE, Wasley A, Nelson KE. Epidemiology of hepatitis E virus in the United States: results from the Third National Health and Nutrition Examination Survey, 19881994. J Infect Dis 2009: 200 (1): 4856. Ijaz S, Vyse AJ, Morgan D, Pebody RG, Tedder RS, Brown D. Indigenous hepatitis E virus infection in England: more common than it seems. J Clin Virol 2009: 44(4): 272276. Mansuy JM, Bendall R, Legrand- Abravanel F et al. Hepatitis E virus antibodies in blood donors, France. Emerg Infect Dis 2011: 17(12): 23092312. Zhu FC, Zhang J, Zhang XF et al. Efficacy and safety of a recombinant hepatitis E vaccine in healthy adults: a large-scale, randomised, doubleblind placebocontrolled, phase 3 trial. Lancet 2010: 376(9744): 895 902. Vine LJ, Shepherd K, Hunter JG et al. Characteristics of Epstein-Barr virus hepatitis among patients with jaundice or acute hepatitis. Aliment Pharmacol Ther 2012; 36 (1): 1621. Acknowledgements The authors' current research on HEV is being supported by Chief Scientist Office Scotland ETM/32. HRD acknowledges the support of the Royal College of Physicians, London, who awarded him the Sheila Sherlock Travelling Bursary, 2011.Abbreviations ALT: alanine aminotransferase; CMV: Cytomegalovirus; CSF: cerebrospinal fluid; DILI: drug-induced liver injury; EBV: EpsteinBarr Virus; HAV: hepatitis A virus; HBV: hepatitis B virus; HCV: hepatitis C virus; HEV: hepatitis E virus; UTR: untranslated region. J Viral Hepat. 2013;20(1):1-11. 2013 Blackwell Publishing

81.

82.

83.

84.

85.

86.

87.

88.