The silent spread of Hepatitis E in India - from epidemiological insight to public health action: a comprehensive review

Hepatitis E represents an increasingly significant yet often overlooked public health issue in India, contributing substantially to both sporadic hepatitis cases and widespread waterborne outbreaks. Hepatitis E virus (HEV) is the foremost cause of acute viral hepatitis (AVH) in India and spreads primarily through contaminated water. Genotype-specific differences in transmission routes, ranging from enteric routes in developing regions to zoonotic routes in industrialized settings, underscore the complexity of its epidemiology. Vulnerable populations such as pregnant women, animal handlers, and immunocompromised individuals face a markedly increased risk of severe disease outcomes, including fulminant hepatic failure and chronic infection, in cases of coinfection with hepatitis B virus. This comprehensive review delves into Indian epidemiological trends, clinical features, diagnostic approaches, and current management options for HEV. While most infections are self-limiting, ribavirin has shown efficacy in select high-risk populations. However, the absence of an approved vaccine in India remains a critical gap in preventive strategies. Emerging therapeutics and vaccine candidates are currently in various stages of development. However, challenges such as the genetic diversity of HEVs, lack of long-term efficacy data, and limited public awareness hinder progress. This review emphasizes the urgent need for strengthened national surveillance systems, improved water and sanitation infrastructure, and integrated public health policies tailored for high-risk groups. A multipronged approach that combines epidemiological vigilance, clinical preparedness, and policy-driven interventions is imperative to halt the silent transmission of hepatitis E in India.