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Chapter 3Infectious Diseases Related To Travel
Hepatitis E
Chong-Gee Teo
INFECTIOUS AGENT
Infection is caused by hepatitis E virus (HEV), a single-stranded, RNA virus belonging to the Hepeviridae family.
MODE OF TRANSMISSION
HEV is transmitted primarily by the fecal-oral route. Epidemics of hepatitis E are principally due to drinking fecally contaminated water. Sporadic disease in Japan and Europe is zoonotic and foodborne and is associated with eating meat and offal of deer, boars, and pigs. Sporadic disease is also observed in other temperate countries, including the United States, but its cause is unknown in most cases. Disease from blood transfusion has been reported, although rare. Perinatal HEV transmission from women infected during pregnancy is common.
EPIDEMIOLOGY
Waterborne outbreaks (often large, involving hundreds to thousands of people) have occurred in South and Central Asia, tropical East Asia, Africa, and Central America (Map 3-06). Clinical attack rates are highest in young adults aged 15–49 years. In outbreak-prone areas, interepidemic disease is sporadically encountered. In these areas, pregnant women—whether infected sporadically or during an epidemic—are at significant risk of progressing to liver failure and death.
Sporadic disease also occurs in non-outbreak-prone regions such as the Middle East, temperate East Asia (including China), North and South America, and Europe. In Europe, symptomatic disease is observed most frequently in adults aged >60 years, especially men. Primary infection acquired by people who are immunosuppressed, such as after organ transplantation, may progress to chronic infection.
People living in the United States are at risk of HEV infection when they travel to areas where epidemics have occurred. When traveling in Japan and Europe, eating raw or inadequately cooked venison, boar meat, pig liver, or food products derived from these, is a significant risk factor for infection.
CLINICAL PRESENTATION
The incubation period is 2–9 weeks (mean 6 weeks). Signs and symptoms of disease during primary infection include jaundice, fever, loss of appetite, abdominal pain, and lethargy. Acute hepatitis E is frequently self-limited. Pregnant women (particularly those infected during the second or third trimester) may present with or progress to liver failure, and their infants are at risk for spontaneous abortion and premature delivery. People with preexisting chronic liver disease may undergo further hepatic decompensation.
DIAGNOSIS
The diagnosis of acute hepatitis E is established by detecting anti-HEV IgM and IgG in serum. Detecting HEV RNA in serum or stools further confirms the serologic diagnosis but is seldom required. Longer-term, serial detection of HEV RNA in serum or stools, regardless of the HEV antibody serostatus, suggests chronic HEV infection. No diagnostic test has been approved by the Food and Drug Administration.
TREATMENT
Treatment is supportive.
PREVENTIVE MEASURES FOR TRAVELERS
No vaccine is available, nor are drugs for preventing infection. Travelers should avoid drinking unboiled or unchlorinated water and beverages that contain unboiled water or ice. Travelers should eat only thoroughly cooked food, including seafood, meat, offal, and products derived from these (see Chapter 2, Food and Water Precautions).
BIBLIOGRAPHY
- Colson P, Borentain P, Queyriaux B, Kaba M, Moal V, Gallian P, et al. Pig liver sausage as a source of hepatitis E virus transmission to humans. J Infect Dis. 2010 Sep 15;202(6):825–34.
- Labrique A, Kuniholm MH, Nelson KE. The global impact of hepatitis E—new horizons for an emerging virus. In: Grayson L, editor. Emerging Infections 9. Washington, DC: American Society for Microbiology; 2010.
- Teo CG. Much meat, much malady: changing perceptions of the epidemiology of hepatitis E. Clin Microbiol Infect. 2010 Jan;16(1):24–32.
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