Until recently, HEV was thought not to occur in developed countries. It is now clear that locally acquired HEV is common in many developed countries. HEV infection acquired in these areas differs from that in developing countries in a number of important aspects: it is caused by genotype 3 (and 4 in China and Japan); it mainly affects middle-aged/elderly males; it is zoonotic with a porcine primary host. Pig herds worldwide are infected with HEV genotype 3 and HEV has been found in the human food chain in a number of developed countries. However, the route of transmission is not fully understood, since most cases are not obviously associated with pigs/pig products. HEV can be transmitted by blood transfusion and surprisingly high numbers of asymptomatic blood donors are viraemic at the time of donation.Our understanding of the clinical phenotype of HEV infection in humans has undergone a sea-change in recent years. Previously, HEV was thought to cause only acute self-limiting hepatitis. However, HEV may cause persistent disease in the immunocompromised. Patients with chronic HEV infection have no symptoms, but some develop rapidly progressive liver cirrhosis. The full clinical spectrum of HEV is still emerging. HEV has important extra-hepatic manifestations, which deserve further investigation. For example, HEV can cause a wide range of neurological illness. In particular, very recent data suggests that Guillain-Barré syndrome and neuralgic amyotrophy are associated with locally acquired HEV in approximately 5% and 10% of cases respectively.
Overview of Virology of HEVHEV is a small non-enveloped virus with an icosahedral capsid and a size of 27-34 nm. The virus has a positive-sense, single-stranded RNA 7.2-kilobases-long genome which is capped and polyadenylated at the 5' and 3'-termini, respectively (Reyes et al. 1990;Tam et al. 1991). The HEV genome contains three open reading frames (ORF). ORF1 encodes a protein of 1693 amino acids containing functional domains present in the non-structural proteins of other positive-stranded RNA viruses (Koonin et al. 1992). These functional domains include methyltransferase, cysteine protease, RNA helicase and RNA-dependent RNA polymerase. ORF2 encodes the viral capsid protein of 660 amino acids that is responsible for virion assembly (Li et al. 1997), interaction with target cells (He et al. 2008;Kalia et al. 2009), and immunogenicity (Xing et al. 2011). The ORF2 protein consists of three linear domains, the shell domain (S) (amino acids 129-319), the middle domain (M) (amino acids 320-455), and protruding domain (P) (amino acids 456-606) harbouring the neutralizing epitope(s) (Guu et al. 2009;Tang et al. 2011;Xing et al. 2010;Yamashita et al. 2009). ORF3, which overlaps ORF2, encodes a small protein of 113 or 114 amino acids involved in virion morphogenesis and release (Emerson et al. 2010;Yamada et al. 2009). HEV replicates in the cytoplasm, with a subgenomic RNA producing OFR2 and OFR3 proteins and the full genomic RNA encoding non-structural proteins and ser...