Hepatitis A

Contents

Hepatitis A is most common hepatitis virus. It is often seen in epidemics (usually in children), and most commonly occurs in the autumn
Often found in communities with overcrowding
Commonly found in water – particularly beware salads washed in contaminated water – often patients may have had recent travel abroad
- Can also be sexually transmitted
Very common, particularly in the developing world. In some countries, 100% of the population has been infected by the age 10 – but the disease is often asymptomatic in children and so may go unnoticed
In the developed world, 5-40% of the population have had the infection
There are sometimes ‘mini-epidemics’ in children in nursery / day-care centres
Often found after flooding
Shellfish have also been implicated in transmission – possibly due to human sewage reaching their habitat
There isn’t a carrier state
The virus can be killed by boiling water for 10 minutes.
Vaccination provides immunity for 10 years (often considered life-long)

Incubation 2-6 weeks
Oro-faecal transmission. Viral shedding occurs in the faeces at about the time of the onset of symptoms
RNA virus

Many patients are asymptomatic. They may never know they have had the disease
Very rarely it can be life-threatening (mortality 0.3-2%)
Symptoms depend on age:
- < 4 years – 90% anicteric
- 15 years – 40 – 70% icteric
May be a prodromal phase
Jaundice, malaise, abdominal pain, nausea & fever – usually lasting around 2 weeks
- Jaundice may occur 1-2 weeks after other symptoms. As the jaundice worsens, other symptoms may subside, but the urine may become dark and the stools pale, due to intrahepatic cholestasis (i.e. the intrahepatic bile ducts get blocked)
- 10% of patients get splenomegaly resulting in a palpable spleen
Other non-specific symptoms – including distaste for cigarettes!

Only one antigen has been found – HAV. However, it is not tested for as levels vary during the course of an infection. Instead we test for anit-HAV – the levels of which are more predictable.
- You can see IgM in the blood for the first 6 weeks, then IgG after that.
Diagnosis – abnormal LFTs / +ve IgM anti-HAV
- ALT > AST
- AST may be > 1000
IgM HAV antibody may be positive for up to 6 months after clinical feautres subside
IgG antibody positive indicates past exposure
Prognosis – can be determined by INR

Usually self limiting. Does not usually require hospital admission in uncomplicated cases.
Advise no unprotected sexual contact for 7 days after the onset of jaundice
Rest and dietary modification seem to have little effect – basically, you just have to sit it out!
In most people, the severity of the virus peaks 4 weeks after infection, and symptoms will be virtually gone 2 weeks later.

Acute fulminant liver failure is rare – 0.1 to 0.4%
Not associated with chronic liver disease
The mortality rate is low – around 0.3%, increasing to 2% with age and other co-morbities.
Extra-hepatic complications are very rare, but include arthritis, myocarditis and renal failure.
10% of patient’s will have a relapse before recovery.
Some patients may ‘feel ill’ for months after the disease – this is known as post hepatitis syndrome and it is a functional disease that is treated by reassurance

Hepatitis A vaccine is recommended for travellers before they visit:

Hepatitis A vaccine schedule:

Initial dose 4-6 weeks before travel
- Provides protection for 12 months
Booster 6-12 months later
- Provides immunity for 10 years (often considered life-long)