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Hepatitis A

By

Sonal Kumar

, MD, MPH, Weill Cornell Medical College

Last full review/revision Dec 2020| Content last modified Dec 2020
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Hepatitis A is caused by an enterically transmitted RNA virus that, in older children and adults, causes typical symptoms of viral hepatitis, including anorexia, malaise, and jaundice. Young children may be asymptomatic. Fulminant hepatitis and death are rare in developed countries. Chronic hepatitis does not occur. Diagnosis is by antibody testing. Treatment is supportive. Vaccination and previous infection are protective.

Hepatitis A virus (HAV) is a single-stranded RNA picornavirus. It is the most common cause of acute viral hepatitis and is particularly common among children and young adults.

HAV spreads primarily by fecal-oral contact and thus may occur in areas of poor hygiene. Waterborne and food-borne epidemics occur, especially in developing countries. Eating contaminated raw shellfish is sometimes responsible. Sporadic cases are also common, usually as a result of person-to-person contact.

Fecal shedding of the virus occurs before symptoms develop and usually ceases a few days after symptoms begin; thus, infectivity often has already ceased when hepatitis becomes clinically evident.

General references

Symptoms and Signs of Hepatitis A

In children < 6 years old, 70% of hepatitis A infections are asymptomatic, and in children with symptoms, jaundice is rare. In contrast, most older children and adults have typical manifestations of viral hepatitis Symptoms and Signs Acute viral hepatitis is diffuse liver inflammation caused by specific hepatotropic viruses that have diverse modes of transmission and epidemiologies. A nonspecific viral prodrome is followed... read more , including anorexia, malaise, fever, nausea, and vomiting; jaundice occurs in over 70%.

Manifestations typically resolve after about 2 months, but in some patients, symptoms continue or recur for up to 6 months. Some patients have prolonged cholestasis (cholestatic hepatitis) due to hepatitis A; cholestatic hepatitis is characterized by marked jaundice with pruritus, continued fever, weight loss, diarrhea, and malaise.

Diagnosis of Hepatitis A

  • Serologic testing

If acute viral hepatitis is suspected, the following tests are done to screen for hepatitis viruses A, B, and C:

  • IgM antibody to HAV (IgM anti-HAV)

  • Hepatitis B surface antigen (HBsAg)

  • IgM antibody to hepatitis B core (IgM anti-HBc)

  • Antibody to hepatitis C virus (anti-HCV) and hepatitis C RNA (HCV-RNA)

If the IgM anti-HAV test is positive, acute hepatitis A is diagnosed. The IgG antibody to HAV (IgG anti-HAV) test is done (see table Hepatitis A Serology Diagnosis Hepatitis A is caused by an enterically transmitted RNA virus that, in older children and adults, causes typical symptoms of viral hepatitis, including anorexia, malaise, and jaundice. Young... read more ) to help distinguish acute from prior infection. A positive IgG anti-HAV test suggests prior HAV infection or acquired immunity. There is no further testing for hepatitis A.

HAV is present in serum only during acute infection and cannot be detected by clinically available tests.

IgM antibody typically develops early in the infection and peaks about 1 to 2 weeks after the development of jaundice. It diminishes within several weeks, followed by the development of protective IgG antibody (IgG anti-HAV), which persists usually for life. Thus, IgM antibody is a marker of acute infection, whereas IgG anti-HAV indicates only previous exposure to HAV and immunity to recurrent infection.

Table
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Other tests

Liver tests are needed if not previously done; they include serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase.

Other tests should be done to evaluate liver function; they include serum albumin, bilirubin, and prothrombin time/international normalized ratio (PT/INR).

Treatment of Hepatitis A

  • Supportive care

No treatments attenuate acute viral hepatitis, including hepatitis A. Alcohol should be avoided because it can increase liver damage. Restrictions on diet or activity, including commonly prescribed bed rest, have no scientific basis.

For cholestatic hepatitis, cholestyramine 8 g orally once or twice a day can relieve itching.

Viral hepatitis should be reported to the local or state health department.

Prevention of Hepatitis A

Good personal hygiene helps prevent fecal-oral transmission of hepatitis A. Barrier protection is recommended, but isolation of patients does little to prevent spread of HAV.

Spills and contaminated surfaces in the home of patients can be cleaned with dilute household bleach.

Vaccination

Preexposure HAV vaccination (see Adult Immunization Schedule) should be provided for adults with increased risk, including

Preexposure HAV prophylaxis can be considered for day-care center employees and for military personnel.

Previously, travelers were advised to get the hepatitis A vaccine ≥ 2 weeks before travel; those leaving in < 2 weeks should also be given standard immune globulin. Current evidence suggests immune globulin is necessary only for older travelers and travelers with chronic liver disease or another chronic disorder.

Postexposure prophylaxis

Postexposure prophylaxis should be given to family members and close contacts of patients with hepatitis A.

For healthy, unvaccinated patients aged 1 to 40 years, a single dose of hepatitis A vaccine is given.

For other patients, particularly those > 75 years old, those with chronic liver disease, and immunocompromised patients, standard immune globulin (formerly immune serum globulin) prevents or decreases the severity of hepatitis A. A dose 0.02 mL/kg IM is generally recommended, but some experts advise 0.06 mL/kg (3 to 5 mL for adults). It can be given up to 2 weeks after exposure, but the earlier, the better.

Key Points

  • Hepatitis A virus is the most common cause of acute viral hepatitis; it is spread by the fecal-oral route.

  • Children < 6 years old may be asymptomatic; older children and adults have anorexia, malaise, and jaundice.

  • Fulminant hepatitis is rare, and chronic hepatitis, cirrhosis, and cancer do not occur.

  • Treat supportively.

  • Routine vaccination beginning at age 1 is recommended for all.

  • Vaccinate people at risk (eg, travelers to endemic areas, laboratory workers), and provide postexposure prophylaxis with standard immune globulin or, for some, vaccination.

More Information

  • Centers for Disease Control and Prevention (CDC): Hepatitis A questions and answers for health professionals: This web site provides an overview of hepatitis A (including diagnosis, statistics, transmission, risk factors, symptoms, and the hepatitis vaccine), as well as information about the use of immune globulin and hepatitis and international travel. Accessed 11/29/20.

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