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EASL releases clinical practice guideline for hepatitis E

The European Association for the Study of the Liver released a new clinical practice guideline for hepatitis E, specifically focused on genotype 3 and 4, which EASL recently published in Journal of Hepatology.

“Infection with hepatitis E virus (HEV) is a significant cause of morbidity and mortality, representing an important global health problem,” Harry R. Dalton, MD, from the University of Exeter, United Kingdom, and colleagues wrote. “Our understanding of HEV has changed completely over the past decade. Previously, HEV was thought to be limited to certain developing countries. We now know that HEV is endemic in most high-income countries and is largely a zoonotic infection.”

According to Dalton and colleagues, expert estimated that the global burden of HEV was at 20 million infections in 2005, but this estimate only included infections in a limited number of developing counties in which genotypes 1 and 2 are predominate and the seroprevalence data collected demonstrated poor sensitivity.

Recent studies have shown ‘hot-spots’ of HEV throughout Europe, including locations in France, the Netherlands, Scotland, Germany, Czech Republic, Poland and Italy.

“Our current estimate of global burden of HEV is of limited value, and requires updating urgently,” the researchers wrote.

Regarding HEV genotypes 1 and 2, the researchers recommend that travelers with hepatitis returning from endemic areas receive testing, and that pregnant women with HEV genotype 1 or 2 should receive care in a high-dependency setting and transferred to a liver transplant unit if liver failure occurs.

General recommendations from the guideline include testing for HEV in all patients with symptoms of acute hepatitis, patients with unexplained flares of chronic liver disease, and patients with immunosuppression with unexplained abnormal liver function tests.

The researchers recommend combination serology and nucleic acid amplification technique (NAT) testing to diagnose HEV and NAT testing for chronic HEV. The researchers also recommend antiviral treatment for patients with HEV and associated glomerular disease. Ribavirin may be considered in cases of severe acute HEV or acute-on-chronic liver failure; however, the researchers noted that very few case reports are available on ribavirin for severe acute HEV. Acute HEV, on the other hand, does not usually require antiviral therapy.

Patients who present with HEV should receive testing for proteinuria. Those who develop new onset proteinuria may require a renal biopsy.

Regarding prevention, the researchers advise that consumption of undercooked meat from pigs, wild boar and deer have been identified as risk factors for HEV infection in Europe. Patient-to-patient transmission is poorly defined and requires further study.

A vaccine licensed in China in 2011 showed an efficacy of 97% in preventing episodes of symptomatic acute hepatitis and proved long-term efficacy during follow-up. The vaccine is not currently licensed outside of China, but efforts are currently underway to obtain WHO prequalification for emergency settings.

“Our understanding of HEV infection has completely changed in the last decade,” the researchers wrote. “There are still many knowledge gaps, and it is likely that as answers to these questions become available, these [guidelines] will require amendment in a few years’ time.” – by Talitha Bennett

Disclosure: Dalton reports grant support from the British Medical Association; consultant or advisory roles with Roche, Gilead, Wantai, Merck; delivery of sponsored lectures for the Gates Foundation; and is the co-holder of patent Kernow CIPG with the National Institutes of Health and others. Please see the full study for the other authors’ relevant financial disclosures.