Putting hepatitis E on the radar

Irish Society of Gastroenterology, Winter Meeting, virtual, 2-3 December 2021

The Irish Society of Gastroenterology 2021 Winter Meeting heard a presentation by Prof Heiner Wedermeyer, Professor of Gastroenterology at University Hospital Essen and Hannover Medical School in Germany, who spoke on the topic ‘Hepatitis E and other viruses’. Prof Wedermeyer is a world-renowned authority on viral hepatitis and he provided an overview of hepatitis E virus (HEV), which he described as a challenging diagnosis and difficult to treat.

“HEV is very frequent and completely underestimated and it’s really something that we in the fields of gastroenterology and hepatology have to think about,” said Prof Wedermeyer. “For example, if you have a patient with acute hepatitis, in Germany we do lab screenings for A, B, and C, and then they stop. The most frequent cause of acute hepatitis in Germany is hepatitis E, and this is something we should keep in mind.”

HEV can infect not only humans, but also pigs and cows and this inter-species transmission is most predominant when pigs and cows are co-housed, explained Prof Wedermeyer. Recent research has shown that it can also be found in sheep, rabbits, cats, goats, camels, and even dogs. HEV genotype 3 infects humans and is found mainly in pigs; however, a hepatitis E-like virus is also found in rats and can also infect humans, said Prof Wedermeyer, and some such cases have been identified in China.

“HEV may cause permanent hepatitis in pregnant women, but it’s very important to note that it only infects HEV genotype 1, which is found in India. So if pregnant women in Europe eat meat [infected with HEV], for example, they are not at risk of developing permanent hepatitis,” he told the conference. He briefly discussed liver-related complications and said on ward rounds, his main concerns are acute and chronic liver failure, particularly in chronic disease courses in the immunocompromised.

“The huge field of extrahepatic complications is largely underestimated,” he said, commenting that in diagnostics, one should consult with a virologist and the laboratory to establish which assay and algorithm they are using.

Prof Wedermeyer summarised: “For the future of hepatitis E research, I think we need to better define the animal and environment reservoir,” he said. “This holds true for many European countries, [to define] how big the threat is. In Germany, HEV has even been detected in drinking water…. I think it is probably impossible to ‘escape’ from hepatitis E. Most of us have been somehow exposed, even if not infected, to HEV, along with probably almost every other person in Europe, and the disease burden needs to be determined.

“A practical question is, should we really treat all blood products for HEV RNA and we should ask is this pooling sufficient, or is there a remaining risk for HEV infections,” he continued. “We need more research to explain why some patients have severe acute [disease] courses, or mild acute courses, and why others have progressive chronic liver disease. Also, the role of immunosuppressants in pregnancy requires further investigation, as do extrahepatic manifestations, because these are very frequent and we don’t have very good treatment algorithms for these situations.

“This leads me to think that we need more basic research in virology and immunology in the field of hepatitis E. Probably most importantly, ribavirin is a step forward, but we need alternative antiviral drugs. I think that’s very clear and for all hepatitis E patients, the message holds true that coffee is good for the liver; coffee reduces the risk of developing liver cirrhosis and hepatocellular carcinoma.”

See www.medicalindependent.ie for more ISG Winter Meeting coverage.