Hepatitis A

Hepatitis A is a highly contagious liver infection caused by the hepatitis A virus. Although not usually as serious as other types of viral hepatitis, hepatitis A causes inflammation that affects your liver's ability to function.

You're most likely to contract hepatitis A from contaminated food or water or from close contact with someone who's already infected — even if that person doesn't appear sick. Some people who are infected never develop signs and symptoms, but others may feel as if they have a severe case of the flu.

Mild cases of hepatitis A don't require treatment, and most people who are infected recover completely with no permanent liver damage. Unlike hepatitis B and C, hepatitis A doesn't develop into chronic hepatitis or cirrhosis — both potentially fatal conditions.

Practicing good hygiene — including washing your hands often — is one of the best ways to protect against hepatitis A. Effective vaccines are available for people who are
most at risk.                                                       

Hepatitis A Causes

  • The hepatitis A virus is found in the stools (feces) of people with hepatitis A. It is transmitted when a person puts something in his or her mouth that has been contaminated with the feces of an affected person. This is referred to as fecal-oral transmission.
     

    • If food or drinking water becomes contaminated with stool from an infected person (usually because of inadequate hand washing or poor sanitary conditions), the virus can quickly spread to anyone who drinks or swallows the contaminated food or water.

    • The virus can also be spread by eating raw or undercooked shellfish collected from water that has been contaminated by sewage.

    • The hepatitis A virus can be transmitted through blood transfusions, although this is extremely rare.

  • People who are infected can start spreading the infection about 1 week after their own exposure. People who do not have symptoms can still spread the virus. Infection with HAV is known to occur throughout the world.
     
    • The risk of infection is greatest in developing countries with poor sanitation or poor personal hygiene standards.
    • Infection rates are also higher in areas where direct fecal-oral transmission is likely to occur, such as daycare centers, prisons, and mental institutions.
  • People at increased risk for hepatitis A infection
     
    • Household contacts of people infected with HAV

    • Sexual partners of people infected with HAV

    • International travelers, especially to developing countries

    • Military personnel stationed abroad, especially in developing countries 

    • Men who have sex with other men

    • Users of illegal drugs (injected or non-injected)

    • People who may come into contact with HAV at work

  • Workers in professions such as health care, food preparation, and sewage and waste water management are not at greater risk of infection than the general public.

People who live or work in close quarters, such as dormitories, prisons, and residential facilities, or work in or attend daycare facilities are at increased risk only if strict personal hygiene measures are not observed.

Signs And Symptoms

  • Some people may have hepatitis A and never develop signs or symptoms. Young children, especially, tend to have mild cases, but signs and symptoms in older children and adults are likely to be more severe. In general, you'll have the virus for up to one month — its average incubation period — before developing any problems. When signs and symptoms appear, they often come on suddenly, and you may mistake them for intestinal flu (gastroenteritis). They include:

  • Fatigue

  • Nausea and vomiting

  • Abdominal pain or discomfort, especially in the area of your liver on your right side beneath your lower ribs

  • Loss of appetite

  • Low-grade fever

  • Dark urine

  • Muscle pain

  • Itching

You also may experience yellowing of your skin and the whites of your eyes (jaundice). Not all people with hepatitis A develop jaundice.

You'll likely regain more energy after signs and symptoms disappear, and your liver may heal completely within one or two months. Some people with hepatitis A have relapses over a six- to nine-month period.

Prevention Of Hepatitis A

To prevent hepatitis A, remember to:

  • Wash hands well after using any washroom.

  • Eat only freshly cooked foods.

  • Drink only commercially bottled water or boiled water in places where sanitation and the water supply are questionable.

  • Do not drink drinks with ice in them.

  • Do not eat non-peelable raw fruits or vegetables unless cleaned thoroughly.

  • Maintain a reasonably high index of suspicion while traveling anywhere and be appropriately cautious about ingesting food or water where one might suspect hepatitis A is more common.

Get a hepatitis A vaccination before traveling to areas such as Mexico, eastern Europe and developing countries. Short term protection for hepatitis A can also be provided by immune globulin, including its administration up to two weeks following exposure. 

Diagnosis Of Hepatitis A

The doctor will take a thorough medical history and may palpate the area over the liver to check for tenderness or enlargement.

If the skin becomes jaundiced and the person is exhibiting other symptoms of hepatitis, the doctor will do various lab tests, such as blood tests and liver panel tests. Additional lab tests include the hepatitis A antibody tests ELISA II and RIBA II.

Rarely, the doctor may also perform a liver biopsy where a small portion of the liver would be taken for further examination under a microscope.

Test Overview

Hepatitis A virus tests detect substances in the blood that indicate a hepatitis infection is active or has occurred in the past. The test detects proteins (antibodies) made by the body in response to the virus that causes hepatitis. It is important to identify the type of hepatitis virus causing infection so that its spread can be prevented and the proper treatment can be started immediately.        

1. Detection of the virus or antigen ;- The virus can be detected in the faeces up to 2 weeks before the appearance of the jaundice and up to 2 weeks afterwards. However by the time that jaundice appears, viral titres in the faeces are already at a low titre and so in practice EM if the stools is rarely of diagnostic value. Hepatitis A virus can also be detected in the serum, saliva, urine and semen although transmission is unlikely to take place via these routes. There had been anecdotal reports of hepatitis A transmitted through blood transfusions.

2. Serology ;- This is the method of choice for the diagnosis of acute hepatitis A. A variety of ELISAs and RIAs are available. The detection of specific IgM is diagnostic of recent infection. (IgM may be found 45 - 60 days after the onset of symptoms). Serum IgG is used in determining the immune status of the individual before the prescription of immunoglobulin for foreign travel.

Hepatitis A virus (HAV) Testing

HAV infection is spread through food or water that has been contaminated by the feces (stool) of an infected person.

IgM anti-HAV antibodies indicate a recent infection with hepatitis A virus. IgM anti-HAV antibodies generally can be detected in the blood as early as 2 weeks after the initial HAV infection. These antibodies disappear from the blood 3 to 12 months after the infection.

IgG anti-HAV antibodies mean that you have had a hepatitis A viral infection. About 8 to 12 weeks after the initial infection with hepatitis A virus, IgG anti-HAV antibodies appear and remain in the blood for lifelong protection against HAV.      

Hepatitis A test               


Normal (negative):
 
No hepatitis A virus (HAV) antibodies are found.

Abnormal (positive):







 

Hepatitis A virus (HAV) antibodies are found. You may need more tests to find out if you have a present, active infection or a past, resolved infection.

  • IgM anti-HAV antibodies are found if you have an active infection. IgM antibodies usually show up in the blood as early as 2 weeks after you become infected with HAV, when symptoms of hepatitis A are present, and for a few months after symptoms have gone away.

  • Only IgM anti-HAV antibodies are found if you have had an infection in the past or when you have had the hepatitis A vaccine. This means that you are protected against the infection for life.

Who Is At Risk For Hepatitis A?

Anyone who has not already been infected with hepatitis A virus can become infected, but some people are at increased risk:

  • Persons who share a household or have sexual contact with someone who is infected with hepatitis A virus

  • Children and staff in child-care centers (especially centers where children are in diapers) where someone has hepatitis A virus infection

  • Travelers to countries where hepatitis A is common and where proper sewage disposal and clean water, food, and sanitation are not available

  • Residents and staff of institutions for developmentally disabled persons where someone has hepatitis A

  • Men who have sex with men

  • Persons who use street drugs

  • Workers who handle animals infected with hepatitis A virus or who work with hepatitis A virus in a research laboratory

  • Persons with clotting factor disorders who receive injections of factor concentrates.

Epidemiology

Hepatitis A occurs endemically in all parts of the world, the exact incidence is hard to estimate because of the high proportion of sub clinical infections. At least 1.5 million new cases are reported each year. While the actual incidence in developed countries is decreasing, the infection is almost universal in developing countries. Hepatitis A virus (HAV) is a faecal-oral pathogen and transmission is particularly associated with faecally contaminated food and water. Shellfish is particularly notorious as a vehicle for the spread of HAV. In a recent epidemic in Shanghai following a clam festival, there were over 500,000 cases. Infection is particularly common in conditions of poor sanitation and overcrowding, institutions for the mentally handicapped are particularly vulnerable. Many food borne outbreaks can be traced to poor hygiene in infected food handlers who were shedding large amounts of virus during the incubation period. The source of the outbreak can often be traced to uncooked food or food that has been handled after cooking. Until recently, about 50% of young adults in the UK had evidence of past infection, but as in the case of other industrialized countries, the incidence is rapidly decreasing so that hepatitis A is rapidly becoming a disease of young adults rather than children in these countries. HAV is frequently acquired from travelers from areas where HAV infection is of a low prevalence to an area where it is hyper endemic.

The incubation period is 3 - 5 weeks (15 - 40 days), with a mean of 28 days. Spread is faecal-oral although blood borne infection is possible in theory (this was achieved experimentally in volunteers). All age groups are susceptible to HAV. In areas where HAV is hyper endemic, hepatitis A is an childhood infection where the infection is usually sub clinical or mild. In developed countries where the overall incidence is decreasing rapidly, the infection is now more commonly seen in adults where the disease is usually more serious.

Pathogenesis

The pathological changes are common to all types of viral hepatitis, with parenchymal cell necrosis and histiocytic periportal inflammation. Rarely in cases of fulminant hepatitis there is massive necrosis. Liver enzymes such as AST and ALT are elevated as a result of release by damaged liver cells. Elevation of these enzymes may often be the only abnormality found in individuals with asymptomatic and anicteric infections who are tested because of known exposure. Serum bilirubin may be elevated, especially in most cases of symptomatic infections and bilirubin may be found in the urine. The leucocyte count is usually normal but sometimes atypical lymphocytes are seen.

Clinical Features

Following an incubation period of around 4 weeks, at the end of which virus particles are excreted in the faeces, there is an acute onset of non-specific symptoms such as fever, chills, headache, fatigue, malaise, and aches and pains. A few days later, anorexia, N+V and right upper abdominal pain appear, followed by the onset of jaundice with pale stools and dark urine. With the appearance of the jaundice, there is usually a subjective improvement of symptoms. The jaundice deepens for the first few days and then persists for 1 - 2 weeks. Convalescence may be prolonged and complete recovery in adults usually takes place within a few months. In children the infection is commonly asymptomatic or the prodromal phase mild or absent. The mortality rate is very low for hepatitis A and no carrier state exists.

Complications of hepatitis A include prolonged cholestatic jaundice which responds to corticosteroid therapy, and relapsing disease which occurs in 6 to 10% of patients and lasts 16 to 40 weeks. Relapsing disease appears to be immunologically mediated and must not be treated by corticosteriods. Extrahepatic complications include a rash and arthropathy.

Treatment

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