Food and Environmental Virology

, Volume 10, Issue 3, pp 225–252 | Cite as

Hiding in Plain Sight? It’s Time to Investigate Other Possible Transmission Routes for Hepatitis E Virus (HEV) in Developed Countries

  • Nicola J. King
  • Joanne HewittEmail author
  • Anne-Marie Perchec-Merien
Review Paper


Historically in developed countries, reported hepatitis E cases were typically travellers returning from countries where hepatitis E virus (HEV) is endemic, but now there are increasing numbers of non-travel-related (“autochthonous”) cases being reported. Data for HEV in New Zealand remain limited and the transmission routes unproven. We critically reviewed the scientific evidence supporting HEV transmission routes in other developed countries to inform how people in New Zealand may be exposed to this virus. A substantial body of indirect evidence shows domesticated pigs are a source of zoonotic human HEV infection, but there is an information bias towards this established reservoir. The increasing range of animals in which HEV has been detected makes it important to consider other possible animal reservoirs of HEV genotypes that can or could infect humans. Foodborne transmission of HEV from swine and deer products has been proven, and a large body of indirect evidence (e.g. food surveys, epidemiological studies and phylogenetic analyses) support pig products as vehicles of HEV infection. Scarce data from other foods suggest we are neglecting other potential sources of foodborne HEV infection. Moreover, other transmission routes are scarcely investigated in developed countries; the role of infected food handlers, person-to-person transmission via the faecal–oral route, and waterborne transmission from recreational contact or drinking untreated or inadequately treated water. People have become symptomatic after receiving transfusions of HEV-contaminated blood, but it is unclear how important this is in the overall hepatitis E disease burden. There is need for broader research efforts to support establishing risk-based controls.


Hepatitis E virus New Zealand Transmission routes Autochthonous 



The authors thank the New Zealand Ministry for Primary Industries for funding the literature review and the Institute of Environmental Science and Research for funding manuscript preparation. The authors also wish to thank Dr Jill Sherwood for assisting with the New Zealand public health data and Dr Jan Gregor for providing peer review.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Institute of Environmental Science and ResearchPoriruaNew Zealand
  2. 2.New Zealand Ministry for Primary Industries, Pastoral HouseWellingtonNew Zealand

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