Hepatitis A Facts
- Hepatitis is a general term that means inflammation (irritation and swelling) of the liver. Inflammation of the liver can result from infection, exposure to alcohol, certain medications, chemicals, poisons, or from a disorder of the immune system.
- Hepatitis A refers to liver inflammation caused by infection with the hepatitis A virus (HAV). HAV is one of several viruses that can cause hepatitis, and is one of the three most common hepatitis viruses in the United States.
- The other two common types are hepatitis B and hepatitis C; however, there are other named types such as D, E, F, and G, and more types may be discovered in the future. Moreover, these infections are somewhat different from hepatitis A, and from each other.
- Unlike hepatitis B and hepatitis C, hepatitis A does not cause chronic (ongoing, long-term) disease. Although the liver becomes inflamed and swollen, it heals completely in most people without any long-term damage. Once a person contracts hepatitis A, they develop lifelong immunity, and rarely contract the disease again.
- Because of the way it is spread, the hepatitis A virus tends to occur in epidemics and outbreaks. As many as 1 in 3 adults (>age 19) in the United States have antibodies to HAV, meaning they have been exposed to the virus, but most do not become ill.
- In 2011, researchers report no significant change in seroprevalence (the frequency of people in a population that have particular antibodies, usually reactive against a disease-producing organism in their blood serum) of HAV antibodies in adults before or after the HAV vaccine became available (see reference 3).
- The number of cases of hepatitis A in the United States varies among different communities, and has been reduced by the introduction of the hepatitis A vaccine. The rate of infection (number of infections per 100,000 people) has declined since 1999.
- Vaccination at age one year may cause the rate and yearly case numbers of HAV to decline.
Hepatitis A Causes
The cause of hepatitis A is hepatitis A virus (HAV) that is transmitted person to person by contaminated foods, water or other drinks (including ice), blood, stool, and direct contact. The virus is a Picornavirus that contains single-stranded RNA as its genome covered by a protein shell. The virus enters through the epithelium in the mouth or gut and migrates to the liver over a period of about two to six weeks. Symptoms (jaundice and other symptoms, see below) then begin to develop as the virus replicates in the liver cells (hepatocytes and Kupffer cells, also termed liver macrophages). HAV reproduces itself by utilizing the liver cell's ribosomes for viral replication; however this interferes with normal liver cell function. If large numbers of liver cells are infected with HAV, the person will develop symptoms. The viruses are secreted into the GI tract by the bile fluid made in the liver. The majority of people infected recover with no lasting damage to the liver.
Hepatitis A Virus (HAV) Courtesy of the CDC
Hepatitis A Symptoms
- Many people with HAV infection have no symptoms at all.
- Sometimes symptoms are so mild that they go unnoticed.
- Older people are more likely to have symptoms than children.
- People who do not have symptoms can still spread the virus so it is difficult to know when a person has been exposed to the virus.
Symptoms of hepatitis A usually develop between 2 and 6 weeks after infection. The symptoms are usually not too severe and go away on their own, over time. The most common symptoms are as follows:
- Diarrhea, especially in children
- Pale or gray-colored stools
- Low-grade fever
- Loss of appetite
- Tiredness, fatigue
- Jaundice (a yellow discoloration of the skin and the whites of the eyes, see image below)
- Urine is dark brownish in color, like cola or strong tea.
- Pain in area of liver, on the right side of the abdomen just under the rib cage
Picture of Jaundice (yellowing of the skin and the whites of the eyes)
Photo courtesy of the Centers for Disease Control and Prevention
If the vomiting is severe, dehydration may occur. Dehydration may become serious and life-threatening in some affected individuals, so symptoms of dehydration need to be quickly addressed, often by a medical caregiver. Symptoms of dehydration include the following:
- Feeling weak or tired
- Feeling confused or unable to concentrate
- Rapid heartbeat
- Urinating less frequently than usual
Symptoms of hepatitis A infection usually last less than 2 months, although they may last as long as 9 months. Some people infected with hepatitis A have symptoms that come and go for 6-9 months.
Hepatitis A Contagious Transmission
The hepatitis A virus is found predominantly in the stools (feces) of people with hepatitis A. HAV 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. However, variations of this primary way in which a contagious person transmits the disease are as follows:
- Food or drinking water 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.
- Eating raw or undercooked shellfish collected from water that has been contaminated by sewage
- Blood transfusions, although this is extremely rare
- Sexual contact, especially oral/anal
People who are infected can start spreading the infection (shedding virus) 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 include:
- 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
- People who use illegal drugs (injected or non-injected)
- People who may come into close contact with HAV infected people at work
Individuals who work 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.
Hepatitis does not occur simply from being near someone who has the disease at work or at school.
When to Seek Medical Care for Hepatitis A
A health care practitioner should be contacted if any of the following symptoms occur:
- Nausea and vomiting that does not improve within 1-2 days
- Yellow skin or eyes
- Dark colored urine
- Pain in the belly (abdomen)
The following situations also warrant a call to the health care practitioner:
- A person has symptoms and thinks that they might have been exposed to someone with hepatitis.
- A person has other medical problems and thinks that they might have hepatitis.
- A person who has had close contact with someone diagnosed with hepatitis.
If an individual cannot reach their primary health care practitioner and have any of the following symptoms they should go to an Emergency Department or an urgent care facility.
- Vomiting and inability to keep down any liquids
- Severe pain or high fever
- Confusion, delirium, or difficulty awakening
Hepatitis A Diagnosis
The health care practitioner will ask questions about the illness and symptoms, and about any possible exposures to other people diagnosed with hepatitis, especially the type of hepatitis (type A, B, C, or others).
If the health care practitioner determines that the patient may be at risk for contracting hepatitis, then it is likely the patient will undergo blood tests.
- The blood will be tested to determine how well the liver is functioning.
- A test will be ordered to detect antibody to hepatitis A. The results of this test will also determine if the patient has been recently exposed to HAV.
- Blood probably will be tested for the hepatitis B and hepatitis C viruses, and others. For example, if a patient has had a large amount of vomiting or has not been able to take in liquids, the blood electrolytes may be out of balance. Blood chemistry may be tested to check electrolytes.
Hepatitis A Treatment
There are no specific medicines to cure infection with hepatitis A. Most people require no treatment except to relieve symptoms. However, if symptoms become severe or dehydration develops, the person should seek medical care emergently.
There is a vaccine for hepatitis A (see below, vaccine and prevention). If a person has been exposed to someone who is infected with HAV, a treatment called immune serum globulin is available and may prevent them from becoming infected. Immune serum globulin is more likely to be effective when given within 2 weeks of exposure.
Hepatitis A Self-Care at Home
The following measures can help a patient feel better while they are having symptoms.
- Take it easy; curtail normal activities and spend time resting at home.
- Drink plenty of clear fluids to prevent dehydration.
- Avoid medicines and substances that can cause harm to the liver such as acetaminophen (Tylenol) and preparations that contain acetaminophen.
- Avoid alcoholic beverages, as these can worsen the effects of HAV on the liver.
- Avoid prolonged, vigorous exercise until symptoms start to improve.
Call a health care practitioner if symptoms worsen or new symptoms appear.
Be very careful about personal hygiene to avoid fecal-oral transmission to other members of the household.
Hepatitis A Medical Treatment
- If a person becomes dehydrated, the doctor may prescribe IV fluids.
- If a patient is experiencing significant nausea and vomiting, they will receive medicines to control these symptoms.
- People whose symptoms are well controlled can be cared for at home.
- If dehydration or other symptoms are severe, or if the patient is extremely confused or difficult to arouse, they will most likely be hospitalized.
Hepatitis A Follow-up
Follow the recommendations of the health care practitioner.
- Take it easy; get plenty of rest.
- Drink plenty of clear fluids.
- Avoid alcoholic beverages.
- Avoid medicines such as acetaminophen (Tylenol) that can be harmful to the liver.
- Avoid prolonged or vigorous physical exercise until your symptoms improve.
- Call the health care practitioner if symptoms worsen or a new symptom appears.
- Be extra careful about personal hygiene and close personal contacts, especially while the person is still shedding HAV, and thus is still capable of transmitting the disease.
Hepatitis A Vaccine and Prevention
If a person has hepatitis A, strict personal hygiene and hand washing help prevent transmission of HAV to others. There are ways to help reduce or prevent HAV infection.
- Wash hands thoroughly every time after use of the bathroom, before touching or preparing food, and before touching others. Wash hands with soap and warm water, and then dry the hands thoroughly (with paper or air so the drying towel is not reused by anyone).
- Contaminated surfaces should be cleaned with household bleach to kill the virus.
- Heat food or water to 185 F or 85 C to kill the hepatitis A virus.
If people are not infected with HAV, they can reduce the chance of becoming infected by the following methods:
- Wash hands carefully with soap and warm water several times a day, including every time the bathroom is used, every time a diaper is changed, and before preparing food.
- Do not eat raw or undercooked seafood or shellfish such as oysters from areas of questionable sanitation (just about everywhere, including developed countries).
- Individuals traveling to developing countries should not drink untreated water or beverages with ice in them. Fruits and vegetables should not be eaten unless cooked or peeled.
In addition to the above methods, there are vaccines that work to prevent infection with HAV, but are not substitutes for good hygiene and careful food and drink consumption..
- The vaccines, Havrix and VAQTA, contain no live virus and are very safe. No serious adverse effects have been reported. Some people have some soreness at the injection site for a few days. There is a combined vaccine available for both hepatitis A and B termed Twinrix for patients over age 18.
- The vaccines are given in a series of two shots. The second is given 6-18 months after the first. The shots can be given at the same time as other vaccines.
- Protection from HAV starts about 2-4 weeks after the first shot. The second dose is necessary to ensure long-term (years or lifetime) protection.
- The vaccines are thought to protect from infection for at least 20 years.
- The vaccines must be given before exposure to the virus. They do not work after exposure and infection.
Not everyone needs to have the hepatitis A vaccines. However, the CDC recommends HAV vaccine for the following groups:
- All children older than one year are recommended to get the vaccine, especially children who live in communities where the number of HAV infections is unusually high or where there are periodic outbreaks of hepatitis A. The vaccines are not recommended for children younger than one year old.
- People who are likely to be exposed to HAV at work. The only group of workers shown to be at higher risk than the general population is people who work in research laboratories where HAV is stored and handled. Routine vaccination is not usually recommended for health care workers, food service workers, daycare personnel, and sewage and waste-water workers.
- People traveling to developing countries (preferably given at least 4 weeks before travel); travel is a major source of hepatitis A in people who live in developed countries.
- Men who have sex with men
- People who use illegal drugs. This group of individuals has higher-than-average rates of HAV infection.
- People who are likely to become seriously ill if they are infected with HAV. This includes people with impaired immune systems or chronic liver disease.
- People with blood-clotting disorders who receive clotting factors
If a person has never had hepatitis A and is exposed to the virus, call a primary health care practitioner immediately. There is a treatment that may prevent individuals from becoming infected. It is called immune serum globulin (Gammastan, Gammar-P) and is composed of antibodies that help destroy the virus.
- Immune serum globulin is a preparation of antibodies that can fight the virus in the body.
- It is given as a one-time shot (injection).
- It must be given within 2 weeks after exposure for maximum protection.
- Immune serum globulin can be safely given to children younger than 2 years.
- Immune serum globulin can be given during pregnancy and breastfeeding.
- Immune serum globulin can provide short-term protection against infection if given before exposure. This protection lasts no longer than 3 months. If the person is likely to be exposed immediately to HAV (for example emergency travel to an endemic area in Africa) both the immune serum globulin and HAV vaccine can be given at the same time.
If a person has had hepatitis A confirmed by a blood test, they almost never get it again. People should continue to practice preventive measures, however, to prevent transmission of other infections.
Hepatitis A Prognosis
Hepatitis A symptoms are usually mild and resolve on their own; most patients fully recover in 3 to 6 months.
- Rarely will patients develop complications such as relapsing hepatitis or liver failure.
- With relapsing hepatitis, symptoms improve, but then return
- Death from hepatitis A is rare.
- The elderly, the very young, and people with advanced chronic liver diseases such as from hepatitis C are at greatest risk for complications such as liver failure or fulminant hepatitis (rapid developing and life-threatening liver failure) from hepatitis A.