Since its discovery in the early 1980s, hepatitis E has been a potent threat to military forces around the world.
At one point, the U.S. military was concerned enough to fund intensive research on a vaccine to protect against Hepevirus, most often transmitted by fecal contamination of drinking water.
Col. Kent E. Kester
The threat has never really materialized for U.S. troops, however, because it is effectively controlled by strict guidelines for food and drinking water, even in areas such as Iraq and Afghanistan where the disease is a problem, according to Col. Kent E. Kester, consultant to the Army Surgeon General in Infectious Diseases. In fact, Kester notes, since 2010 there have been only nine cases of hepatitis E reported among all the military services, adding, “In general, the rates of this disease are fairly stable and have not appreciably changed over the past five to 10 years.”
Concern about possible infection and even the largely successful vaccine effort was well-warranted, however. Hepevirus epidemics have been reported in Central and Southeast Asia, North and West Africa, and even Mexico; Hepatitis E is the principal cause of acute hepatitis in these areas, as well as on the Indian subcontinent. Symptoms, which include jaundice, fatigue, abdominal pain, nausea or vomiting, diarrhea, fever, loss of appetite and dark urine, can be devastating to military forces.
Because fecal contamination of drinking water is the most common source of exposure for hepatitis E, cases usually are found in areas of poor sanitation, and large outbreaks usually are associated with particularly severe breakdowns in baseline sanitation, as often occurs during heavy rainfall and floods. Outbreaks also have been reported in refugees and internally displaced persons camps, where extensive fecal contamination of drinking water often occurs.
Hepatitis E is clinically indistinguishable from hepatitis A, and, while both diseases are generally self-limited illnesses with very low fatality rates, they can cause significant lost duty time, according to Kester, who is also currently working as Associate Dean for Clinical Research, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD.
Aside from bed rest and general supportive care, Kester said no specific treatment exists. “The debilitating symptoms of hepatitis E usually persist for approximately three to four weeks or longer, followed by complete recovery. Hospital care is generally not required, but admission to provide monitored bed rest may be needed in deployed or operational military settings.”
Guidelines Must Be Observed
Because a vaccine is not yet available, environmental prevention measures are paramount in deployment areas such as Iraq and Afghanistan. “U.S. commanders operating in high- or intermediate-risk countries must continue to impose strict requirements on approval of food and water sources, sanitation and food hygiene to decrease the risk of hepatitis E,” said Kester, who notes that these measures also prevent other major food- and waterborne diseases, including bacterial and protozoal diarrhea, typhoid fever and hepatitis A.
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