Pegylated interferon alpha-2a/alpha-2b64 or ribavirin65 for 3-12 months have been tried in persons with chronic HEV infection, with moderate success in achieving an absence of detectable serum HEV RNA for 3-6 months after stopping drugs. Only short case series are available, and controlled trials with longer follow-up are needed. Withdrawal or reduction in dose of immunosuppressive drugs has also led to the disappearance of HEV viremia and should be tried before considering antiviral treatment. No data are available on the role of antiviral drugs in acute HEV infection associated

with acute or acute-on-chronic liver failure. Hepatitis E can be prevented by the provision of Luminespib nmr safe drinking water, proper disposal of human feces, and education about personal hygiene. During outbreaks, boiling and chlorination of water would be useful. Sanitary handling and proper cooking of pig and deer meat is recommended in areas with zoonotic transmission. Two candidate vaccines against hepatitis E have undergone clinical testing. The first contained a 56-kDa truncated ORF2 protein of HEV (amino acids 112-607), expressed Opaganib solubility dmso using a baculovirus expression

system, which assembles into highly immunogenic VLPs. In a trial among 2,000 volunteer Nepalese soldiers, 3 doses of an alum-adjuvanted preparation of this protein (20 μg each at 0, 1, and 6 months) achieved 100% seroconversion and protective efficacy of up to 95.5% during a 2-year follow-up.11 The second vaccine consisted of a truncated ORF2 protein, p239 (amino acids 368-606), which is expressed in Escherichia coli and forms 23-nm VLPs. In a large clinical trial in southern China, administration of 3 doses (30 μg each) showed a protective

efficacy of 100% during a 13-month follow-up.12 Though several questions remain, the successful clinical testing of these vaccines is a major step forward in the future control of hepatitis E. Unfortunately, neither vaccine has yet been licensed for marketing, possibly because the industry is 上海皓元 not assured of a sufficient market. Hepatitis E, though mainly a disease of the resource-poor regions of the world, has also been identified as occasional autochthonous cases in developed countries. The global presence of HEV, its ability to cause sporadic infections as well as large outbreaks, and its ability to cause chronic hepatitis in immunocompromised persons are all causes for concern. The disease has a complex epidemiology with both waterborne human-to-human and zoonotic transmission, and limited treatment options, and its pathogenetic mechanisms are poorly understood. Thus, hepatitis E deserves serious attention from physicians and researchers alike. Recent successful clinical testing of two recombinant vaccines augurs well for the future. The authors thank Prasida Holla and Imran Ahmad for composing the figures.