Hepatitis E

Overview

Hepatitis E is an infection of the liver caused by the hepatitis E virus. 'Hepatitis' simply means inflammation (swelling) of the liver. The virus mostly spreads when people swallow tiny amounts of contaminated poo in water or food, or when they eat undercooked meat from infected animals such as pigs and some wild animals. For most healthy people it causes a short illness that clears up on its own within a few weeks, and the liver usually recovers fully.

Hepatitis E is very common worldwide. It is one of the most frequent causes of short-term liver infection, especially in parts of Asia, Africa, the Middle East, and Central America where clean water and sanitation can be harder to access. In the UK and other high-income countries it is much less common, but cases do happen, often linked to travel or to eating undercooked pork products.

Anyone can get hepatitis E. Most cases in healthy adults and children are mild. Some groups are more likely to become seriously unwell: pregnant women (especially in the last three months of pregnancy), people with a weakened immune system (for example after an organ transplant or with HIV), people who already have liver disease, and older adults.

Symptoms

Common symptoms

• Feeling very tired and generally unwell
• Feeling sick (nausea) or being sick
• Pain or discomfort in the upper tummy area
• A high temperature or flu-like feeling
• Yellowing of the skin and the whites of the eyes (jaundice)
• Dark urine and pale, chalky-coloured poo
• Itchy skin
• Joint or muscle aches
• Loss of appetite

Symptoms in children

• Many children have no symptoms at all, or only very mild ones
• Some children get a short spell of feeling sick, tummy ache, or tiredness
• Jaundice in children is uncommon but can happen
• Because symptoms can be so mild, children can pass the virus on without anyone knowing they had it

Symptoms in older adults

• Older adults are more likely to feel genuinely unwell rather than having a mild illness
• Jaundice and marked tiredness are more common
• Recovery can take longer, and there is a higher chance of more serious liver problems
• Dehydration from vomiting or not eating and drinking enough is a particular risk

Causes

Main causes

• Drinking water that has been contaminated with the virus, often linked to poor sanitation or sewage getting into water supplies
• Eating food that has been washed or prepared with contaminated water, or handled by someone who is infected and has not washed their hands well
• Eating undercooked meat, particularly pork, pork products, and meat from wild animals such as boar or deer
• In rare cases, through blood transfusion or from a pregnant woman to her baby during pregnancy or birth

Risk factors

• Travelling to or living in an area where hepatitis E is common and sanitation is poor
• Drinking untreated or unboiled water, or using ice made from it, in those areas
• Eating raw or undercooked pork or game meat
• Working with animals, especially pigs
• Having a weakened immune system, which makes long-lasting infection more likely
• Already having another liver condition
• Being pregnant, especially in the third trimester, which raises the risk of a severe illness

When to see a doctor

See a doctor urgently if:

• You have jaundice (yellow skin or eyes)
• You cannot keep fluids down, or you feel dizzy and faint
• You feel very unwell and are getting worse quickly
• You are pregnant and have jaundice or feel seriously unwell
• You have a weakened immune system and develop jaundice or feel unwell

Book a routine appointment if:

• You have tiredness, nausea, or tummy discomfort that has lasted more than a few days
• You have recently travelled to an area where hepatitis E is common and you feel unwell afterwards
• Someone in your household has hepatitis E and you develop symptoms
• You are worried about your symptoms and would like advice

Diagnosis

A doctor will ask about your symptoms, where you have travelled recently, what you have eaten, and whether you could have been exposed to contaminated water. They may also examine you, gently pressing on your tummy and looking at your eyes and skin for signs of jaundice. If they think you might have hepatitis E, they will arrange a blood test to look at how your liver is working and to check for the virus itself. Hepatitis E is not diagnosed from symptoms alone, because many liver infections look alike.

Tests that may be done

• Blood tests called liver function tests, which show whether the liver is inflamed
• A specific blood test for hepatitis E antibodies (immune proteins your body makes against the virus), which shows whether you have been infected recently or in the past
• A test called PCR that looks for the virus's genetic material, useful for people with weakened immune systems or ongoing illness
• Tests to rule out other types of hepatitis and other causes of liver inflammation
• Occasionally an ultrasound scan of the liver

What to expect at your appointment

The tests are simple blood tests, usually done at your GP surgery, a clinic, or a hospital. Results for liver function usually come back within a few days, and hepatitis E specific tests can take a bit longer. While you wait, you will usually be advised to rest, drink plenty of fluids, avoid alcohol, and check with a pharmacist or doctor before taking any medicine, since some medicines are harder on the liver. If your results show hepatitis E, you will usually be contacted and told whether you need any follow-up.

Treatment

In most people, hepatitis E clears up on its own. Treatment is mainly about supporting your body while it fights the virus, easing symptoms, and watching for any signs that the illness is becoming more serious. There is no routine medicine that cures hepatitis E. People with a weakened immune system or a severe illness may need specialist care and follow-up.

Self-care at home

• Rest as much as your body tells you to, and return to activity gradually
• Drink plenty of fluids, especially water, to avoid dehydration, particularly if you are being sick
• Eat small, simple meals more often if large meals feel too much
• Avoid alcohol completely until you have fully recovered and your liver tests are back to normal
• Check with a pharmacist or doctor before taking any medicine, including everyday painkillers and herbal remedies, as some can strain the liver
• Wash your hands well with soap and water after going to the toilet and before preparing food, to avoid passing the virus on
• Stay off work or school while you are unwell and until your doctor advises it is safe to return
• Keep follow-up appointments so your liver can be checked until it recovers

Medical treatments

There is no standard medicine that cures hepatitis E in otherwise healthy people. Care focuses on resting, staying hydrated, and treating symptoms such as feeling sick or itching if these are troublesome. For people who are very unwell, pregnant, or have a weakened immune system, doctors may recommend hospital monitoring, fluids, and specialist assessment. In the small number of people who develop a long-lasting infection, specialists may adjust immune-suppressing medicines and consider specific antiviral treatment chosen by a liver or infections specialist. Your doctor will discuss options with you and any medicine will be prescribed and monitored by a specialist.

When is surgery considered?

Surgery is not used to treat hepatitis E itself. Very rarely, a person whose liver is severely damaged may be assessed by a specialist liver team, and a liver transplant could be considered in those exceptional cases.

Living with this condition

Most people spend a few weeks feeling tired and off their food, then gradually get back to normal. Plan for a slower pace than usual, and do not push yourself too hard too soon. Keep up hand washing and use your own towel while you are infectious, and ask your doctor when it is safe to go back to work, school, or childcare. Avoid donating blood until a doctor confirms you have fully recovered.

Lifestyle tips

• Avoid alcohol until your liver has fully recovered, and consider cutting back afterwards
• Keep up good hand hygiene, especially after the toilet and before preparing food
• Wash fruit and vegetables carefully and cook meat, particularly pork and game, all the way through
• When travelling, drink bottled or boiled water and avoid ice made from tap water in areas where hepatitis E is common
• Get plenty of sleep and build rest into your day while you recover
• Tell your doctor about all medicines, supplements, and herbal products you take

Diet and exercise

There is no special diet for hepatitis E, but eating regularly and keeping meals light and simple can help if you feel sick. Try small portions of foods you fancy, and sip fluids through the day rather than drinking a lot at once. Once you start to feel better, gentle activity such as short walks is fine, and you can build up gradually. Hard exercise and heavy lifting are best left until your energy is back and your doctor is happy with your recovery.

Mental health and emotional wellbeing

Being unwell with a liver infection can be worrying, especially if you are pregnant, have another health condition, or are far from home. Feeling low, anxious, or frustrated during a slow recovery is common, and it usually improves as your energy returns. If these feelings are weighing on you, or you have thoughts of harming yourself, tell your doctor straight away and contact your local crisis line or emergency services if you feel unsafe.

Prevention

Hepatitis E can often be prevented with simple hygiene and food safety steps. Wash your hands well with soap and water after using the toilet, after changing nappies, and before preparing or eating food. When travelling in areas where hepatitis E is common, drink bottled or boiled water, avoid ice made from tap water, and be careful with salad and fruit you cannot peel or wash in safe water. Cook pork, pork products, and game meat thoroughly, and avoid raw or undercooked meat. If you have hepatitis E, good hand washing helps protect the people around you.

Vaccines

A vaccine against hepatitis E has been licensed in some countries, mainly China, and is used in some specific situations. It is not routinely available in most other countries, including the UK. Ask your doctor or a travel health clinic if you are travelling to an area where hepatitis E is common and you think a vaccine may be relevant for you.

Screening programmes

There is no general screening programme for hepatitis E. Blood donors in many countries are screened, and people with a weakened immune system or abnormal liver tests may be tested if a doctor thinks it is needed. If you are pregnant and have been exposed to hepatitis E, or have symptoms, your doctor can arrange testing.

Complications

If left untreated

• Dehydration from vomiting or not drinking enough, which can make you feel much worse
• A small number of people develop sudden, severe liver failure, which is a medical emergency
• Pregnant women, especially in the last three months, have a higher risk of a severe illness
• People with weakened immune systems can develop a long-lasting (chronic) infection that slowly damages the liver
• Rarely, the virus can affect other parts of the body, such as the nerves, kidneys, pancreas, or blood
• Ongoing tiredness for several weeks after the infection clears

Long-term outlook

The outlook for most people with hepatitis E is very good. The illness usually settles within a few weeks and the liver heals fully, with no lasting damage. A small number of people need closer medical care, particularly pregnant women, people with weakened immune systems, and people who already have liver disease, and they may be looked after by a specialist team. Even in these situations, most people recover well with the right support and follow-up, so it is worth keeping in touch with your doctor and asking questions.

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