There are four major patterns of HAV infections

worldwide divided into areas of high,

intermediate, low, or very low prevalence.

Endemic areas of high prevalence include parts

of Africa, Asia, and Latin America. Most

infections in these areas occur in early childhood.

Areas of low prevalence and very low prevalence

include North America and Western Europe with

few infections during childhood and majority of

the population are susceptible throughout

adulthood.

In the United States, HAV is one of the most

reported diseases among vaccine-preventable

diseases. Over 30,000 cases were reported in

1997. An estimated 270,000 HAV infections are

said to have occurred each year between 1980

and 1999. A total of 1390 cases of hepatitis A

were reported from 50 states to the Centers for

Disease Control and Prevention (CDC) in 2015.

There was a 12.2% increase from reported cases

of HAV in 2014. Of note, the overall incidence in

2015 was 0.4 cases per 100,000 population which

was the same as in 2014 (CDC, 2017). Since 1996,

the declining incidence in the United States is

attributed to the widespread use of HAV

vaccination for populations considered high-risk.

An incidence of 1 case per 10,000 was notably

the lowest recorded in 2007. States with routine

vaccination for children also noticeably made the

most noticeable difference (Epocrartes, 2017).

Overall, there has been a 95% decline in HAV in

the United States since the vaccine for HAV

became available in 1995.

Globally, the epidemiology of HAV is evolving, in

part attributed to improved sanitation standards

and living conditions mostly noticeable in

developing countries. This has undoubtedly

contributed to the global decline in the number

of infected children globally. However, the

incidence among adults has increased due to the

larger population of an adult who lacks

antibodies that are protective against HAV.

Issues of Concern

Recently, the Division of Disease Control and

Health Protection issued a Healthcare Provider

Advisory note on HAV in the State of Florida

indicating that 217 cases have been in reported in

the State of Florida alone since January 2017, a

significant increase when compared to the past 5-

year average of 94 cases. Of note was the fact

that most HAV cases did not have international

travel exposure. Southeast Florida (e.g., Broward

and Miami-Dade counties) had the most cases of

HAV with 69% among males (most had male

sexual contact). The median age of reported cases

was 38 years with highest rates of Hepatitis A

disease recorded among people ages 25 to 44

years. About 60% of the cases of HAV in Florida

required hospitalization.

Also of note is the fact that nearly 1200 outbreaks

of HAV were recorded among individuals who

are homeless, use intravenous (IV) drugs, men

who have sex with men, and their close or direct

contacts as investigated by the health

departments in Arizona, California, Colorado,

Michigan, New York and Utah (DOH, Florida

2017).

Clinical Significance

History and Physical Examination

Acute onset fever

Fatigue

Malaise

Nausea and vomiting

Jaundice
Hepatomegaly

Right upper quadrant pain

Joint pain

Clay-colored bowel movements

Other Clinical Factors

Headache

Fatigue

Dark urine

Pruritus

Rash

Arthralgias and myalgias

Cough

Bradycardia

Diarrhea

Constipation

Splenomegaly

Posterior cervical lymphadenopathy

Diagnostic Tests

Serum aminotransferases

Serum bilirubin

BUN

Serum Creatinine

Prothrombin time

IgM anti-hepatitis A virus (HAV)

IgG anti-hepatitis A virus (HAV)

Stool and body fluid electron microscopy

Hepatitis A virus RNA

Treatment Options

Presumptive: If unvaccinated with recent

exposure to HAV less than 2 weeks: HAV or

immune globulin

Acute presentation HAV infection

Confirmed HAV: Supportive and conservative

management

Worsening jaundice and encephalopathy: liver

transplant

Recommendations of the Advisory Committee on

Immunization Practices: DOH Florida, 2017.

All children at age 1 year

Persons who are at increased risk for infection

Persons who are at increased risk for

complications from HAV

Any person wishing to obtain immunity

Other Issues

Recommendation for two-dose HAV vaccine, 6 to 12

months apart for the following persons:

Men who have sex with men

Injection and non-injection drugs users

Persons with chronic liver disease

Persons traveling to or working in countries with

high or intermediate endemicity of hepatitis A

Persons with clotting-factor disorders

Household members and other close personal

contacts of adopted children newly arriving from

countries with high or intermediate hepatitis A

endemicity

Persons with direct contact with persons who

have hepatitis A