Hepatitis A

I. Introduction

Hepatitis A is a liver disease caused by the hepatitis A virus. The virus is primarily
spread when an uninfected (and unvaccinated) person ingests food or water that is
contaminated with the faeces of an infected person. The disease is closely associated with
unsafe water or food, inadequate sanitation and poor personal hygiene.

Unlike hepatitis B and C, hepatitis A infection does not cause chronic liver disease and is rarely
fatal, but it can cause debilitating symptoms and fulminant hepatitis (acute liver failure), which
is often fatal.

Hepatitis A occurs sporadically and in epidemics worldwide, with a tendency for cyclic
recurrences. The hepatitis A virus is one of the most frequent causes of foodborne infection.
Epidemics related to contaminated food or water can erupt explosively, such as the epidemic
in Shanghai in 1988 that affected about 300 000 people1. Hepatitis A viruses persist in the
environment and can withstand food-production processes routinely used to inactivate and/or
control bacterial pathogens.

The disease can lead to significant economic and social consequences in communities. It can
take weeks or months for people recovering from the illness to return to work, school, or daily
life. The impact on food establishments identified with the virus, and local productivity in
general, can be substantial.

II. Risk Factors

Anyone who has not been vaccinated or previously infected can get infected with hepatitis
A virus. In areas where the virus is widespread (high endemicity), most hepatitis A infections
occur during early childhood. Risk factors in intermediate and high endemicity areas include:

 poor sanitation;

 lack of safe water;

 use of recreational drugs;

 living in a household with an infected person;

 being a sexual partner of someone with acute hepatitis A infection; and

  travelling to areas of high endemicity without being immunized.

III. Signs and Symptoms

It usually starts appearing 4 weeks after exposure, but can occur as early as 2 and as late
as 7 weeks after exposure. Symptoms usually develop over a period of several days. Symptoms
usually last less than 2 months, although some people (10%–15%) with hepatitis A can have
symptoms for as long as 6 months.

Older children and adults typically have symptoms. If symptoms develop, they can appear
abruptly and can include:

 Fever

 Fatigue

 Loss of appetite

 Nausea

 Vomiting

 Abdominal pain

 Dark urine

 Diarrhea

 Clay-colored stools

 Joint pain

 Jaundice (yellowing of the skin and eyes)

Most children younger than age 6 do not have symptoms when they have hepatitis A. When
symptoms are present, young children typically do not have jaundice but most older children
and adults with hepatitis A have jaundice.

IV. Complication

Complications of hepatitis A are rare. The viral infection can be unpleasant, but most
people make a full recovery within two months with no permanent liver damage.
Older people and people with other medical conditions, such as diabetes, anemia or congestive
heart failure, may take longer to recover from the infection.

Rare cases

Occasionally, the infection can be fatal due to severe liver inflammation (swelling) that leads
to liver failure. Liver failure usually happens in people with a weakened immune system, such
as the elderly or people with a medical condition that affects the immune system (for
example, HIV).

V. Diagnosis

Cases of hepatitis A are not clinically distinguishable from other types of acute viral
hepatitis. Specific diagnosis is made by the detection of HAV-specific Immunoglobulin G
(IgM) antibodies in the blood. Additional tests include reverse transcriptase polymerase chain
reaction (RT-PCR) to detect the hepatitis A virus RNA, and may require specialised laboratory
facilities.

5.1.Laboratory
5.1.1. Complete Blood Count and Coagulation Study
 Complete blood count

Mild lymphocytosis is not uncommon. Pure red cell aplasia and pancytopenia may rarely
accompany infection. Indices of low-grade hemolysis are not uncommon.

 Prothrombin time

The prothrombin time (PT) usually remains within or near the reference range. Significant rises
should raise concern and support closer monitoring. In the presence of encephalopathy, an
elevated PT has ominous implications (eg, fulminant hepatic failure [FHF]).

5.1.2. Serologic Tests

 Anti-hepatitis A virus immunoglobulin M

The diagnosis of acute HAV infection is based on serologic testing for immunoglobulin M
(IgM) antibody to HAV. Test results for anti-HAV IgM are positive at the time of onset of
symptoms and usually accompany the first rise in the alanine aminotransferase (ALT) level.

This test is sensitive and specific, and the results remain positive for 3-6 months after the
primary infection and for as long as 12 months in 25% of patients. In patients with relapsing
hepatitis, IgM persists for the duration of this pattern of disease. False-positive results are
uncommon and should be considered in the event that anti-HAV IgM persists.

 Anti-hepatitis A virus immunoglobulin G

Anti-HAV immunoglobulin G (IgG) appears soon after IgM and generally persists for many
years. The presence of anti-HAV IgG in the absence of IgM indicates past infection or
vaccination rather than acute infection. IgG provides protective immunity.

5.1.3. Ultrasonography

Imaging studies are usually not indicated in HAV infection. However, ultrasonography
may be required when alternative diagnoses must be excluded. The goals should be to assess
vessel patency and to evaluate any evidence supporting the presence of unsuspected underlying
chronic liver disease. Ultrasound scanning is essential in patients with FHF.

5.1.4. Liver Function Tests

 Liver enzymes

Rises in the levels of ALT and aspartate aminotransferase (AST) are sensitive for hepatitis
A. Levels may exceed 10,000 mIU/mL, with ALT levels generally greater than AST levels.
These levels usually return to reference ranges over 5-20 weeks.

Rises in alkaline phosphatase accompany the acute disease and may progress during the
cholestatic phase of the illness following the rises in transaminase levels.

 Hepatic synthetic function

Bilirubin level rises soon after the onset of bilirubinuria and follows rises in ALT and AST
levels. Levels may be impressively high and can remain elevated for several months;
persistence beyond 3 months indicates cholestatic HAV infection.

Older individuals have higher bilirubin levels. Both direct and indirect fractions increase
because of hemolysis, which often occurs in acute HAV infection.

Modest falls in serum albumin level may accompany the illness.

 VI. Treatment

There is no specific treatment for hepatitis A. Recovery from symptoms following infection
may be slow and may take several weeks or months. Most important is the avoidance of
unnecessary medications. Acetaminophen / Paracetamol and medication against vomiting
should not be given.

Hospitalization is unnecessary in the absence of acute liver failure. Therapy is aimed at

maintaining comfort and adequate nutritional balance, including replacement of fluids that are
lost from vomiting and diarrhoea.

1. http://www.who.int/news-room/fact-sheets/detail/hepatitis-a
2. https://www.hse.ie/eng/health/az/h/hepatitis-a/introduction.html
3. https://www.cdc.gov/hepatitis/hav/index.htm