Hepatitis A

By: Mohamad El-Shar

  Hepatitis A infection is caused by the hepatitis A virus (HAV).
 HAV infection is usually a self-limited illness that does not become
chronic.
Introduction:  Fulminant hepatic failure occurs in < 1 percent of cases.
 Infection confers lifelong immunity and is preventable via
vaccination.
 Clinical Criteria:
What is the An acute illness with a discrete onset of , any sign or symptom
consistent with acute viral hepatitis (e.g., fever, headache,
case definition malaiseanorexia, nausea, vomiting, diarrhea, abdominal pain, or dark
for acute urine)
AND
hepatitis A? a) jaundice or elevated total bilirubin levels ≥ 3.0 mg/dL, OR
b) elevated serum alanine aminotransferase (ALT) levels >200 IU/L
AND
c) the absence of a more likely diagnosis
Laboratory Criteria for Diagnosis: Confirmatory laboratory
evidence:
Immunoglobulin M (IgM) antibody to hepatitis A virus (anti-HAV)
positive,
OR
  A case that meets the clinical criteria and is IgM anti-HAV
positive† OR
What is a  A case that has hepatitis A virus RNA detected by NAAT (such as
PCR or genotyping) OR
confirmed  A case that meets the clinical criteria and occurs in a person who
case? had contact (e.g., household or sexual) with a laboratory-
confirmed hepatitis A case 15–50 days prior to onset of symptoms
How is the   Hepatitis A virus is usually transmitted via the fecal-oral route,
either via person-to-person contact or consumption of
hepatitis A contaminated food or water.

virus  Current data indicate that bloodborne transmission of hepatitis A

virus is uncommon.
transmitted?
How is the
hepatitis A
virus
transmitted?
Who is at  People at increased risk for HAV infection
increased risk International travelers

for acquiring Men who have sex with men

People who use injection or noninjection drugs (all those who use
hepatitis A illegal drugs)
virus (HAV) People with occupational risk for exposure
infection? People experiencing homelessness
People at
increased risk People with chronic liver disease ( hepatitis B or C)
for severe People with human immunodeficiency virus infection
disease from  Individuals >50 years of age

HAV infection
  The incubation period of hepatitis A infection averages 28 days (range
15 to 50 days)
 Symptoms are uncommon in children <6 years of age.

What are the Nausea

signs and Vomiting

Anorexia
symptoms of  Fever
hepatitis A Malaise
virus infection? Abdominal pain.
  Within a few days to a week:
Dark urine (bilirubinuria) appears
Pale stools (lacking bilirubin pigment) may also be observed.
These are followed by jaundice and pruritus (40 to 70 percent of cases).
What are the  Physical findings include:
signs and  Jaundice,
symptoms of  Scleral icterus,

hepatitis A Hepatomegaly (80 percent of cases), and right upper quadrant tenderness to
palpation .

virus infection?
 Less common findings include:
Splenomegaly
Extrahepatic manifestations such as skin rash and arthralgias.
• In pregnant women, acute hepatitis A infection has been associated with
increased risk of preterm labor and gestational complications
 Infected individuals are contagious during the incubation period
and remain so for about a week after jaundice appears.
 HAV replicates in the liver and is shed in the stool in high
concentrations from two to three weeks before to one week after
onset of clinical illness
When
symptoms
occur, how  Symptoms of hepatitis A usually last < 2 months.
long do they
last?
How is the
hepatitis A   killed when exposed to temperatures of >85 degrees C for 1
minute .
virus (HAV)  Adequate chlorination of water.
killed?
Can hepatitis A
become  No. Hepatitis A does not become a chronic.
chronic?
Can someone
become re-  No. Immunoglobulin G antibodies to the hepatitis A virus, which
infected with appear early in the course of infection, provide lifelong protection
against the disease
the hepatitis A
virus?
  HAV infection is usually self-limited, and treatment consists of
supportive care. 
  Most important is the avoidance of unnecessary medications.
Acetaminophen / Paracetamol and medication against vomiting
Treatment: should not be given.
 Therapy is aimed at maintaining comfort and adequate nutritional
balance, including replacement of fluids that are lost from
vomiting and diarrhea.
 Low fat diet.
  Tools for prevention of HAV infection include:
Vaccination.
Prevention: Immune globulin
Aattention to hygienic practices.
  Children
All children aged 12–23 months
Unvaccinated children and adolescents aged 2–18 years

• People at increased risk for HAV infection:

Who should be International travelers

Men who have sex with men
vaccinated People who use injection or noninjection drugs (all those who use illegal drugs)

against People with occupational risk for exposure

hepatitis A? People experiencing homelessness

 Individuals at increased risk for severe disease from HAV infection:

Individuals ≥1 year with HIV infection
Individuals with chronic liver disease

 Other individuals recommended for vaccination:

Pregnant women at risk for HAV infection
Any person who requests vaccination
Who should be
vaccinated  In addition, a person who has not previously received hepatitis A vaccine
against and who has direct contact with someone with hepatitis A should get
hepatitis A vaccine within 2 weeks after exposure.
hepatitis A?
  Single-antigen inactivated hepatitis A vaccines:
HAVRIX 
Available VAQTA
Vaccines:
 Live attenuated hepatitis A vaccine.
Hepatitis A
vaccination:
Dosing and
schedule
How long does
protection
 Anti-HAV has been shown to persist for at least 20 years in most
from hepatitis people receiving the 2-dose series.
A vaccine last?
Can hepatitis A
vaccine be
administered
concurrently  Yes. 

with other
vaccines?
What should
be done if the
second (last)
dose of  The second dose should be given as soon as possible. Even if the
second dose is delayed, the first dose does not need to be
hepatitis A repeated.
vaccine is
delayed?
Can hepatitis A
vaccine be
given during  Yes. 

pregnancy?
Can hepatitis A
vaccine be given
to people who
are
immunocompro  Yes. Because hepatitis A vaccine is inactivated.
mised (e.g.,
people on
hemodialysis or
people with HIV)?
Is it harmful to
administer an
extra dose(s) of
hepatitis A vaccine
or to repeat the
 No. If necessary, administering extra doses of hepatitis A vaccine
entire vaccine is not harmful.
series if
documentation of
vaccination history
is unavailable?
What adverse
events have Redness where the shot is given.
been Fever.
associated Headache.

with hepatitis Tiredness

A vaccination? Loss of appetite 

Immune   Immune globulin can decrease the incidence of HAV infection by
Globulin: more than 90 percent.
  Groups warranting immune globulin in addition to HAV
vaccination (administered at a separate anatomic site) include:

Pre-exposure Adult travelers >40 years, at risk for relatively severe

manifestations of hepatitis A infection.
protection Individuals with chronic liver disease.
against HAV: Immunocompromised individuals incapable of mounting an
adequate immune response to HAV vaccine.
  Groups warranting immune globulin (in the absence of HAV
Pre-exposure vaccination) include:
protection Infant travelers <6 months of age.

against HAV: Travelers for whom vaccine is contraindicated (eg, who are allergic
to the hepatitis A vaccine).
The approach
to HAV post-
exposure
prophylaxis is
as follows:
Dosing:
  Hygienic practices for prevention of HAV infection include:
Handwashing (including after using the bathroom, changing
diapers, and before preparing or eating foods).
HYGIENIC Avoiding tap water and raw foods in areas with poor sanitation.
PRACTICES: Heating foods appropriately (the virus can be inactivated by
heating to [>85°C] for 1 min
Chlorine, iodine, and disinfecting solutions (household bleach
1:100 dilution) are effective for inactivation of HAV.
  The spread of hepatitis A can be reduced by:

HYGIENIC adequate supplies of safe drinking water;

proper disposal of sewage within communities; and
PRACTICES: personal hygiene practices such as regular hand-washing before
meals and after going to the bathroom.
  Uptodate.com

References:  CDC.gov
 Who.int