HEV and HBV Dual Infection: A Review

Abstract

Hepatitis E virus (HEV) is a global health problem, affecting about 20 million people worldwide. There is significant overlap of hepatitis B virus (HBV) and HEV endemicity in many Asian countries where dual infections with HEV and HBV can occur. Though the clinical course of HEV is largely self-limited, HEV superinfection in patients with chronic hepatitis B (CHB) can result in acute exacerbation of underlying CHB. HEV superinfection in patients with CHB-related cirrhosis has been identified as a risk factor for decompensated cirrhosis and an independent predictor of mortality. Whereas acute HEV infection in pregnancy can cause fulminant liver failure, the few studies on pregnant patients with dual HBV and HEV infection have shown a subclinical course. Immunosuppression is a risk factor for the development of chronic HEV infection, which can be managed by decreasing the dose of immune-suppressants and administering ribavirin. Vaccination for HEV has been developed and is in use in China but its efficacy in patients with CHB has yet to be established in the USA. In this review, we appraise studies on dual infection with HEV and HBV, including the effect of HEV superinfection and coinfection in CHB, management strategies used and the role of active vaccination in the prevention of HEV.

Current Paradigm of Hepatitis E Virus Among Pediatric and Adult Patients

“…Several studies show that HEV can be transmitted vertically to the newborn from positive mothers with high maternal and fetal mortality ( 72 , 78 ). Studies from literature show that especially in India, in certain geographical areas, in pregnant women, acute infection is associated with an increased risk of liver failure, and the mortality rate was up to 25% ( 72 ).…”

“…There are no clear data on the vertical transmission of HEV in non-endemic regions. The results of studies performed on a small number of patients in Southwest Europe suggest that this risk is low ( 72 ). Studies have been performed on the milk of infected mothers (colostrum) for HEV RNA and antibodies and lower levels have been found than in the corresponding serum samples.…”

“…In children, HEV clinical picture include fever, abdominal pain, vomiting, hepatomegaly. One study including 44 symptomatic children with HEV reveals that ALF appears in 15.9% ( 72 , 122 ). Study analysis reveals that patients develop immunity against HEV once the infection is cleared but the re-infection is still possible.…”

“…Data suggest that in patients with SOT, children or adults, with HEV infection, which persists for over 3 months, chronic HEV infection must be considered. Studies showed that in patients with SOT, chronic HEV infection varies from 0.9 to 3.5% ( 70 , 72 , 124 ). Other studies revealed that HEV infection was detected among 4.3–6.5% transplant patients with high liver enzymes ( 18 , 39 , 76 ).…”

“…The liver fibrosis progression seems to be fast and it may lead to cirrhosis in 2–3 years after the infection. Only a few studies reveal incidents of infection in pediatric SOT, data suggest that HEV seroprevalence is 3.2%, and one in three children developed chronic HEV-3 infection ( 71 , 72 ).…”