Merck Manual

Please confirm that you are a health care professional

honeypot link

Hepatitis E


Sonal Kumar

, MD, MPH, Weill Cornell Medical College

Reviewed/Revised Aug 2022 | Modified Sep 2022

Hepatitis E is caused by an enterically transmitted RNA virus and causes typical symptoms of viral hepatitis, including anorexia, malaise, and jaundice. Fulminant hepatitis and death are rare, except during pregnancy. Diagnosis is by antibody testing. Treatment is supportive unless chronic infection develops.

There are 4 genotypes of hepatitis E virus (HEV). All can cause acute viral hepatitis.

Genotypes 1 and 2 usually cause waterborne outbreaks that are linked to fecal contamination of the water supply and fecal-oral person-to-person transmission. Outbreaks have occurred in China, India, Mexico, Pakistan, Peru, Russia, and central and northern Africa. These outbreaks have epidemiologic characteristics similar to those associated with hepatitis A virus Hepatitis A Hepatitis A is caused by an enterically transmitted RNA virus that, in older children and adults, causes typical symptoms of viral hepatitis, including anorexia, malaise, and jaundice. Young... read more epidemics. Sporadic cases also occur. No outbreaks have occurred in the US or in Western Europe. Most cases in the areas with adequate and effective sanitation facilities occur in travelers returning from an area without such sanitation facilities, but sporadic cases not associated with travel have been reported.

Genotypes 3 and 4 typically cause sporadic cases rather than outbreaks. Transmission is food-borne and can involve eating uncooked or undercooked meat; cases have been associated with consumption of pork, deer, and shellfish.

HEV was not originally thought to cause chronic hepatitis Overview of Chronic Hepatitis Chronic hepatitis is hepatitis that lasts > 6 months. Common causes include hepatitis B and C viruses, nonalcoholic steatohepatitis (NASH), alcohol-related liver disease, and autoimmune liver... read more , cirrhosis, or chronic carrier state; however, reports document chronic genotype 3 hepatitis E exclusively in immunocompromised patients (including organ-transplant recipients, patients receiving cancer chemotherapy, and HIV-infected patients).

Symptoms and Signs of Hepatitis E

Diagnosis of Hepatitis E

  • IgM antibody test (when available)

  • IgM antibody to hepatitis A virus (IgM anti-HAV)

  • Hepatitis B surface antigen (HBsAg)

  • IgM antibody to hepatitis B core (IgM anti-HBc)

  • Antibody to hepatitis C virus (anti-HCV) and hepatitis C RNA (HCV RNA) polymerase chain reaction

If tests for hepatitis A, B, and C are negative but the patient has typical manifestations of viral hepatitis and has recently traveled to an endemic area, IgM antibody to HEV (IgM anti-HEV) should be measured if the test is available.

Treatment of Hepatitis E

  • Supportive care

  • For chronic hepatitis E, possibly ribavirin

No treatments attenuate acute viral hepatitis, including hepatitis E.

Preliminary studies suggest ribavirin, given for 12 weeks, has antiviral efficacy in the treatment of chronic hepatitis E.

Alcohol should be avoided because it can increase liver damage. Restrictions on diet or activity, including commonly prescribed bed rest, have no scientific basis.

Viral hepatitis should be reported to the local or state health department.

Prevention of Hepatitis E

Good personal hygiene and standard universal precautions help prevent fecal-oral transmission of hepatitis E. Boiling water appears to reduce risk of infection. Because person-to-person transmission is rare, isolation of infected patients is not indicated.

A vaccine for hepatitis E is now available in China; it is not available in the US. The vaccine appears to have about 95% efficacy in preventing symptomatic infection in males and is safe. Efficacy in other groups, duration of protection, and efficacy in preventing asymptomatic infection are unknown.

Key Points

  • Transmission of hepatitis E is usually by the fecal-oral route.

  • Most patients recover spontaneously, but pregnant women have an increased risk of fulminant hepatitis and death.

  • Genotype 3 may cause chronic hepatitis in immunocompromised patients.

  • Suspect hepatitis E in travelers to endemic regions; do IgM anti-HEV testing if available.

  • Treat patients supportively; consider using ribavirin for chronic hepatitis E.

  • A vaccine is available in China.

Drugs Mentioned In This Article

Drug Name Select Trade
Copegus, Moderiba, Rebetol, RibaPak, Ribasphere, Ribasphere RibaPak, RibaTab, Virazole
NOTE: This is the Professional Version. CONSUMERS: View Consumer Version
quiz link

Test your knowledge

Take a Quiz!