Epidemiology and Infection

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Epidemiology and Infection (2010), 138:145-166 Cambridge University Press
Copyright © Cambridge University Press 2009

Review Article

Transmission routes and risk factors for autochthonous hepatitis E virus infection in Europe: a systematic review

H. C. LEWISa1a2 c1, O. WICHMANNa3 and E. DUIZERa4

a1 Department of Epidemiology, Statens Serum Institut, Copenhagen, Denmark
a2 European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Control, Stockholm, Sweden
a3 Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
a4 National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
Article author query
lewis hc [PubMed]  [Google Scholar]
wichmann o [PubMed]  [Google Scholar]
duizer e [PubMed]  [Google Scholar]


Increasing numbers of non-travel-associated hepatitis E virus (HEV) infections have been reported in Europe in recent years. Our objective was to review the evidence on risk factors and transmission routes of autochthonous HEV infection and hepatitis E in Europe in order to develop recommendations for future research, prevention and control. A systematic literature review was performed to identify all primary reports and studies published during 1998–2008 on hepatitis E in humans and animals in Europe by searching Pubmed, reference lists of major articles and international conference proceedings. Each of the 106 included studies was categorized into one of three evidence levels (EL) based on study design and diagnostic methodology. The evidence was generally weak (73 were assigned to EL1, two to both EL1 and EL2, and 30 to EL2), further compounded by the use of poorly validated serological assays in some studies. Only one case-control study was assigned to EL3. Persons with autochthonous hepatitis E infection were on average older than the general population and predominantly male. There was no evidence for one main transmission route of HEV infection or risk factor for hepatitis E. However, zoonotic transmission seemed likely and person-to-person transmission too inefficient to cause clinical disease. Multiple routes of transmission probably exist and should be further investigated through analytical studies and reliable diagnostic kits. Based on current evidence that points to zoonotic transmission from pigs, thorough cooking of all porcine products, prevention of cross-contamination in the kitchen and improved education for occupationally exposed people (e.g. pig farmers, veterinarians and sewage workers) may help prevent HEV infection. Although evidence for parenteral transmission is limited, it is recommended that a risk assessment is undertaken.

(Accepted August 19 2009)

(Online publication October 06 2009)

Key Words:Autochthonous; Europe; hepatitis E; risk factors; systematic review


c1 Author for correspondence: Miss H. C. Lewis, Epidemiologist, World Health Organization Lao PDR Country Office, P.O. Box 343, Vientiane, Lao PDR. (Email: lewish@wpro.who.int)