Hepatitis E Symptoms, Transmission, Causes, and Treatment (During Pregnancy)

The medical definition of hepatitis E is a kind of inflammation and swelling of the liver that is caused by the hepatitis E virus (hep E). There are about 20 million cases of hep E infections per year in the world. About 3 million of them have symptoms or signs. HEV can be dangerous to some groups of people. About 3.3% of people with hep E infection die. Death rate is much higher in women who are pregnant. Up to one-quarter of pregnant women who get hep E may die. Most hep E infections happen in parts of the world that have poor sanitation or unsafe water supplies.

The hepatitis E virus exists throughout the world. It is most common in Mexico, Central America, North and East Africa, the Middle East, Asia and Southeast Asia. Cases of hepatitis E are very uncommon in developed countries like the United States, Canada, Northern Europe, and Australia. Most hepatitis E outbreaks occur in Southeast and East Asia. Even though hepatitis E virus is uncommon in the U.S., surveys have shown that up to 20% of Americans have antibodies to it and have probably been exposed.

HEV can be acute or chronic. Acute hepatitis E is more common than chronic hepatitis E. Acute hepatitis E lasts for a limited time and then goes away. It does not cause lasting or ongoing liver damage after it has run its course. Chronic hepatitis does not go away and is a long-lasting infection of the liver. Chronic viral hepatitis E can cause cirrhosis (liver scarring) over time that leads to liver failure. Chronic hepatitis E is more common in most people with hepatitis C. However, hep E occurs less often than hep B, and very rarely, with hep E can become chronic in people whose immunity is suppressed by drugs given to prevent rejection of a transplanted organ.

Symptoms and signs of HEV infection include fever, poor appetite (not hungry), tiredness, nausea (feeling sick to your stomach) and vomiting (throwing up), yellow eyes or skin (jaundice), ache in right side of the belly (pain in the liver), soreness in the right side of the belly when pressed (swollen liver), dark or brown urine, light-colored or clay-colored stool, itchy skin, with or without a rash, and painful joints. Symptoms and signs may last for up to six weeks.

Between one in two to one in 13 people with hep E will develop symptoms and signs of acute hepatitis. Often, hepatitis E often causes symptoms and signs in people aged 15 to 40 years. Children generally have no or very mild symptoms and signs.

The fatality rate for most HEV outbreaks is only 1% but may be much higher in women who are pregnant.

Hepatitis C is like hepatitis A. You get both infections by the "fecal-oral route." This means that it passes on in endemic areas by eating or drinking food or water contaminated by feces. In poor areas of the world, there may be few options for disposing of human feces or public sanitation. Feces may contaminate water that people use for drinking and cooking. Sometimes sanitation, water, and public health systems break down during wars or natural disasters. In these situations, infection often happens from drinking dirty water. Hepatitis E infection can happen if someone is using dirty water to prepare food. A person who has HEV or is caring for a child with hep E can cause an outbreak if he or she does not wash hands before cooking for others.

Less often, people can get HEV food-borne infection from eating undercooked pork or deer meat or organs (especially liver). Hep E genotype 3 or 4 are most likely to be transmitted by meat. Rarely, raw or undercooked shellfish may pose a risk. It is less likely, but possible, to get transfusion-transmitted hepatitis E. Rarely, a woman who is pregnant can pass HEV infection to her baby.

Hepatitis E has not been reported to be a sexually transmitted disease (STDs). However, it may be possible that we aren't aware of it yet because it is so uncommon in areas with clean water and sanitation. Hepatitis A spreads the same way as hepatitis E, except it has been transmitted by mouth-to-anus (oral-anal) sex. Theoretically, it is possible for hepatitis E infection to spread like an STD.

HEV appears in the feces about one week before symptoms and signs begin and may last for up to four weeks. People who are shedding the virus are contagious if they do not wash their hands after using the bathroom. Babies and young children in diapers may be contagious to anyone who handles their diapers without washing their hands afterward. Some people may not be aware they are sick or shedding a virus.

To prevent the spread of hepatitis E virus (and other infections), people who prepare food or drinks for others should wash their hands with soap and water, whether they feel sick or not. Anyone can start a hepatitis E outbreak without realizing it.

Blood or stool (feces) tests diagnose hepatitis E infection. Blood tests can be used for testing for antibodies against the hepatitis E virus or HEV RNA. Hep C IgM is found during current infection. Hepatitis E IgG detects past infection. Blood and feces can be tested for the presence of hepatitis E virus (hep E) "viral load" or "PCR". There is no antigen test for the hep E.

Because hepatitis E infections are rare in the U.S., it can cause outbreaks of the infection. Doctors and other health professionals should call the Centers for Disease Control and Prevention (CDC) if they suspect that they have hepatitis E. CDC has a Viral Hepatitis Reference Lab. They offer testing at no cost. Specimens must be ordered by a health professional and shipped by a medical laboratory according to instructions provided by the CDC. Not all commercial laboratories offer these tests, and they are not free of charge.

Pregnant women are at very high risk of problems from hep E infections, especially severe hep E, and acute liver failure. The body shuts down parts of the immune system in order to keep from "rejecting" the baby. This makes the second half of pregnancy a time of weakened immunity. Women who get hep C after 12 weeks of pregnancy are more likely to experience severe hepatitis, acute liver failure, loss of the fetus, or even death from liver failure. Death rate (case-fatality or mortality) may be as high as 25% for women infected after 29 weeks.

Breastfeeding is not known to increase the risk of passing hep E infections to infants and toddlers. Collecting and preparing breast milk for bottle feeding requires careful sanitation of equipment, safe storage, and clean hands.

There is no antiviral drug recommended for most cases of acute hepatitis E at this time. The disease must run its course. For people with weak immune systems from drugs taken to prevent transplant rejection, the doses may be lowered if it is safe to do so.

There is a small amount of experimental evidence for using ribavirin or pegylated interferon-alpha drugs for cases in which hep E becomes a chronic infection. This only happens to people who have weak immunity after organ transplant. These drugs have a lot of side effects and are not used for most people who get acute hep E. If you are pregnant and have hep E talk, talk to your OB/GYN to discuss options for hep E treatment because they can cause birth defects and other serious side effects.

There are no special foods that should be eaten or avoided if a person has hepatitis E, but alcohol should be completely avoided. Usually, a person with hep E has a poor appetite, and then he or she may lose weight. The best diet for hep E is eating a well-balanced diet with foods that are appealing to the person infected.

Alcohol (like beer, wine, or hard liquor) is inflammatory to the liver, especially a liver that is already sick. Alcohol worsens liver inflammation from hep E. It can increase the risk of severe hepatitis and liver failure from acute viral hepatitis. Alcohol should be completely avoided when a person has any type of hepatitis or liver disease.

A person with hepatitis E should listen to their body's signals of fatigue and get plenty of rest. The infected person should be encouraged to at least drink plenty of liquids every day. This is especially important if they have been vomiting, have fevers, or do not feel like taking much by mouth. Alcohol must be eliminated completely with all types of hepatitis (A, B, C, E, D, F, G) until the liver has fully healed.

If you are pregnant with hepatitis E, eat and keep hydrated, and keep in close contact with your OB/GYN or midwife. He or she may want to monitor you frequently. You may need to be hospitalization to ensure the well-being of you and your baby if you cannot keep up fluids, or if you lose weight at home.

The liver's most important job is to process chemicals (like drug), toxins, and waste products. This job is weakened during acute hepatitis. Consult your doctor before taking any over-the-counter (OTC) medications. For example, usually acetaminophen (Tylenol) and NSAIDs (nonsteroidal anti-inflammatories) like ibuprofen (Motrin and others) are safe when used for fevers and body aches, but it may need to be limited while the liver is inflamed. The normal dose might create too much damage to the liver to handle and may even cause overdose or more liver damage.

In most people with acute hepatitis E infection, it will resolve on its own without specific treatment in one to six weeks. Unlike hepatitis B or C virus, hep E is usually self-limiting and rarely causes chronic infection. This can happen to people with weakened immunity after organ transplantation.

There is no antiviral drug for acute hepatitis E. There is no complication related to lack of treatment. However, dehydration can cause weakness and further reduce the person's ability to take in fluids. It can cause dangerously low blood pressure (hypotension). A person who is not eating may lose fat and muscle mass. This harms the immune functions needed to fight the infection. These complications are especially threatening to a woman who is pregnant. They can cause premature labor, poor fetal growth, or loss of the baby. Her health care professional may decide to monitor her in the hospital when the infection is at its worst. Severe hepatitis may cause acute liver failure that may affect other organ systems. People with weakened immunity who get chronic HEV infection may develop scarring of the liver (cirrhosis).

Rarely, complications in organs other than the liver may be related to hepatitis E. Hepatitis E has been associated with Guillain-Barré syndrome, glomerulonephritis (a type of kidney inflammation), acute pancreatitis, hemolytic anemia in people who have glucose phosphate dehydrogenase deficiency (G6PD), and thrombocytopenia (very low platelets).

Prognosis (outcome) is excellent for most people with hepatitis E infection, and a full recovery is common. Hepatitis E itself does not cause lasting complications or liver damage once the disease runs its course, even in pregnant women or their babies.

Unfortunately, people who have liver disease from other causes, like chronic hepatitis C or cirrhosis (scarring) of the liver, can worsen if they get another type of hepatitis viral infection. If the person does contract hepatitis A, B, or E infections on top of their hepatitis C, it may worsen their liver scarring and even shorten their lifespan from liver failure. People who develop chronic hep E because of weakened immunity can develop cirrhosis and liver failure over time, leading death.

There is no vaccine to prevent hepatitis E except in China at this time. The only way to prevent hepatitis E is to ensure that you use proper sanitation, dispose of human waste, and proper treatment of water supplies.

If you are pregnant, have received an organ transplant, or have liver problems like cirrhosis, you should protect yourself from hepatitis E by not eating undercooked or raw pork, deer, or seafood.

While traveling to poorer parts of the world, you can protect yourself against hepatitis E by drinking only purified or chlorinated water and eating only fully cooked foods. Always wash your hands with purified or chlorinated water before handling or eating food or drink to help prevent other diseases that are transmitted the same way, such as traveler' diarrhea, hepatitis A, and typhoid fever (Salmonella).