Overview

Liver health is an important aspect of our lives. It has numerous functions in the body and like any other organ, it is susceptible to disease. In this article, we will discuss a specific infection that occurs in the liver known as Hepatitis E, with a focus on its effect on people with weaker immune systems.

So let us briefly discuss hepatitis E – it is a significant and major cause of acute hepatitis worldwide.¹ It is a liver inflammation caused by hepatitis E virus (HEV).² HEV is an RNA virus that is part of the Hepeviridae family, and can be a significant concern for health especially in pregnant women (assigned at birth) where they experience 30% mortality rate.³ However, most patients that have hepatitis E are asymptomatic and get better on their own with a 3% mortality rate in young adults.³ It is important to note that even though hepatitis E can be self-limited, certain groups of people may experience a more severe form of the disease, such as immunocompromised and cancer patients.³

Around 3.3 million cases of symptomatic HEV are accounted for each year by the World Health Organization (WHO), with 44,000 deaths.³

HEV viruses vary as there are different genotypes: 1 to 8, but only 1, 2, 3, 4, and 7 infect humans.³ Types 1 and 2 only infect humans and leads to massive water contamination and as a result waterborne outbreaks in places like Southeast Asia, Africa, and Mexico.³ Meanwhile, types 3 and 4 can infect humans but also animals majorly through the consumption of infected animal products or close contact with an animal suffering from the infection.³ Type 7 is rarely encountered and hence not reported often.³

These different types can be contracted through multiple ways; for example, HEV 1 and 2 are transmitted through the faecal-oral route and from person to person; with HEV 1 being transmitted from mother to child and through blood transfusions as well.³ However, HEV 3 and 4 can infect humans through the consumption of contaminated shellfish and undercooked meat, contact with sick animals or environment contaminated by their faeces, or transfusion of contaminated blood.³

Since HEV is a self-limiting illness and not a major health concern, it has limited treatment options.³ However, hepatitis E can be a serious health risk to immunocompromised patients, pregnant women, or organ transplant patients.³ Hence, it is important to shed light on this topic and improve our knowledge of this illness to improve the quality of life of those affected.

Weakened immunity

Patients that deal with weakened immunity can have a magnitude of reasons – for example, people who have organ transplants become immunocompromised due to the treatment given to them to prevent their body from rejecting the organ.⁴ Another cause would be patients who are infected with HIV which can lead to damage to their immune system and lowered immunity with time.⁴ Furthermore, certain treatments can lead to a weakened immune system such as chemotherapy and immunosuppressive drugs (e.g. corticosteroids).⁵ Additionally, genetics, lifestyle and age can play a role in our immunity.⁶

Once our immunity is lowered, this leaves us vulnerable to diseases and infections, that in normal cases we can fight off without treatment.⁶ This is directly linked to HEV infections and their ability to become more severe and prolonged in such cases.

Hepatitis E

Pathology

When coming into contact with HEV, usually the symptoms can be mild or even non-existent.⁷ However, its pathology still occurs – hepatitis E is ingested, and it takes 28 to 40 days to incubate.⁷ Once the virus is ingested and absorbed from the intestines, it reaches the liver and starts causing morphological changes leading to acute hepatitis.⁷ This virus does not replicate in other organs, and it is often hard to distinguish it from other causes of acute hepatitis.⁷ 

Symptoms and complications

There are a number of symptoms associated with HEV infection:^2,8

• Jaundice which is the yellow tinge in the white of the eyes and skin
• Stomach-ache
• Fever
• Pain in joints
• Fatigue
• Loss of appetite
• Itching or rash
• Slightly enlarged and tender liver

In some rare cases, hepatitis E can lead to severe complications such as acute liver failure (fulminant hepatitis).² Patients who end up in such a stage have a risk of death.² This is a particular concern for pregnant individuals (mostly in 2^nd or 3^rd trimester) as they are at higher risk for fulminant hepatitis, loss of baby, and even death (up to 20-25%).²

Additionally, patients that are immunocompromised have a risk of developing chronic hepatitis E, particularly patients who undergo an organ transplant.⁹ Chronic hepatitis is defined as, according to Kamar et al. in 2013, an infection that persists for more than 3 months after the initial infection.⁹ Although a small portion of these patients can self-clear this chronic infection, in most cases where this is left untreated it can lead to liver changes such as the formation of nodules, fibrosis, and cirrhosis.⁹

Diagnosis

Diagnosis of HEV is difficult as it is not very easy to distinguish between hepatitis from HEV or other viral hepatitis causes.² However, some things that can be used to identify it is the epidemiological settings; for example, if there are numerous cases popping up in a known disease endemic area, possible risk of water contamination when facing a more severe form of the disease in a pregnant woman (assigned at birth), or if hepatitis A has been ruled out.²

Furthermore, lab tests can be done to confirm the results and clear suspicion. For example, running specific antibody testing (e.g. anti-HEV IgM) on a patient’s blood or using rapid tests are an option.² Also, RT-PCR can be used to detect hepatitis E in blood and stool samples.²

It is also important to detect this illness early to avoid complications from arising and helping individuals who are at higher risk of developing a serious form of the disease. Hence, early testing and monitoring in immunocompromised patients and pregnant individuals can be a helpful tool to maintain good health and provide timely treatment and interventions.

Treatment and therapy

There are multiple ways to approach treating HEV infections. Usually, people will not know they ever had hepatitis C infection as they are asymptomatic and the illness is self-limiting with the illness resolving within 4-6 weeks.¹⁰ However, people who have weakened immunity or are in a risk category have some options:¹⁰

• Using medication such as antiviral drugs (ribavirin) for acute cases, however it can have side effects such as depression, anaemia, fever, hair loss, and shortness of breath
• Chronic hepatitis C is rare but can be treated through reducing immunosuppression medication to allow the body to fight off the virus or using antiviral drugs in different patterns according to the GP’s prescription.
• Treating the symptoms that patients deal with and giving supportive care through rest, hydration, and lifestyle improvements
• Resorting to preventative measures as a treatment which will be discussed below

Prevention

The best treatment choice is the prevention of its occurrence. Hence, there are multiple steps that we can take to avoid and lower the risk of getting hepatitis C:¹¹

1. Making sure to cook the meat (especially pork or wild boar) and shellfish thoroughly to kill the virus
2. Washing fruits and vegetables before consumption, even more so if they are eaten raw
3. Washing hands and maintaining good hygiene, especially after handling animals, eating, or going to the bathroom
4. Taking precautionary steps when travelling such as identifying countries and areas that have hepatitis C infections
5. Drinking bottled water and avoiding ice in drinks when travelling
6. Avoiding the consumption of undercooked meats when travelling
7.  Considering hepatitis C vaccinations if they are available

Summary

Hepatitis C is a mild and unnoticeable illness that we might get and never even know we had. In healthy individuals, the infection is mild and resolves on its own. However, people with weakened immunity or pregnant women (assigned at birth), are at higher risk of developing a more serious infection. In these patients, hepatitis C can lead to a chronic infection, liver fibrosis, cirrhosis, and even liver failure and death. Therefore, it is important to spread awareness about this infection, its ways of transfer and methods of treatment and prevention. While treatment options for this are limited, the best therapy is prevention, and this includes having good hygiene practices and avoiding eating undercooked meals and drinking contaminated water. Our health is priceless and the better we understand these infections, the better we can approach them and deal with them in a timely manner and give ourselves a healthy and comfortable life.