Patient education: Hepatitis A (Beyond the Basics)

HEPATITIS A OVERVIEW — Hepatitis is a common form of liver injury that simply means "inflammation of the liver" (the suffix "itis" means inflammation and "hepa" means liver). Hepatitis A is a specific type of hepatitis that is caused by a virus.

Hepatitis A virus infection occurs worldwide. The number of people who become infected with hepatitis A in the United States has declined substantially since vaccination became available; the vaccine is routinely recommended for all infants and any adult who is at high risk of becoming infected. However, the infection rate is much higher in resource-limited countries, including among travelers.

This topic review discusses how hepatitis A is spread, the signs and symptoms of hepatitis A infection, how it is diagnosed and treated, and how it can be prevented. Other types of hepatitis are discussed separately. (See "Patient education: Hepatitis B (Beyond the Basics)" and "Patient education: Hepatitis C (Beyond the Basics)".)

HOW DID I GET INFECTED WITH HEPATITIS A? — The hepatitis A virus is carried in the stool (bowel movements) of infected people. The most common way for the virus to be spread is when a person who has the infection does not wash their hands after using the bathroom and then touches food, a surface, or another person's mouth. A person with hepatitis A may be contagious before their symptoms begin, as well as for a period of time after they improve.

Hepatitis A virus is more common in areas that lack adequate sanitation or have poor hygiene practices. The majority of people who acquire the illness have had direct personal contact with an infected person.

Community outbreaks have occurred as a result of drinking contaminated well water or eating contaminated food (often raw shellfish that is harvested from contaminated water).

HEPATITIS A SYMPTOMS — Hepatitis A virus usually causes a sudden and short-lived illness. The severity of symptoms depends upon the person's age; in children, there may be few or no symptoms. In adults, infection usually causes a mild flu-like illness. Less commonly in adults, hepatitis A virus infection causes liver failure, which can lead to death.

When there are symptoms, they most often develop between two and seven weeks after acquiring the infection. Initial symptoms usually include:

●Fatigue

●Feeling run down

●Nausea

●Vomiting

●Lack of appetite

●Fever (temperature greater than 100.4ºF or 38ºC)

●Pain under the ribs on the right side of the abdomen (where the liver is located) (figure 1)

As the illness progresses, other signs and symptoms develop, including dark-colored urine, light-colored stools, yellowing of the skin or whites of the eyes (jaundice), and itchy skin.

HEPATITIS A DIAGNOSIS — A person is diagnosed with hepatitis A virus based upon their signs or symptoms, a physical examination, and blood testing.

HEPATITIS A TREATMENT — There is no cure for hepatitis A virus; most people recover with supportive treatments at home, including rest. The amount of time it takes to feel better can vary from person to person; in general, a person with hepatitis A should not return to work or school until the fever and jaundice have resolved and the appetite has returned.

During the recovery period, it is important to avoid drinking alcohol and taking certain prescription and over-the-counter medications (including acetaminophen [sample brand name: Tylenol]) that can injure the liver.

Less commonly, people infected with hepatitis A virus require treatment in a hospital so doctors can monitor their liver function, manage any complications, and provide adequate nutrition.

HEPATITIS A COMPLICATIONS — Most people feel better within three months of becoming infected with hepatitis A virus, and almost everyone completely recovers within six months. About 15 percent of people infected with hepatitis A virus will have prolonged or relapsing symptoms for six to nine months.

The most serious complication of hepatitis A virus infection is death. This occurs rarely but is more likely in older adults and those with chronic liver infections such as hepatitis C. Children die as a result of hepatitis A virus in less than 0.1 percent of cases. (See "Patient education: Hepatitis C (Beyond the Basics)".)

Unlike with other forms of hepatitis, people with hepatitis A do not develop chronic liver disease as a result of their infection. Once a person is infected with hepatitis A virus, it is not possible to become infected again.

HEPATITIS A PREVENTION — There are several strategies to prevent the spread of hepatitis A virus, discussed below. Hand washing is one of the most effective strategies for reducing transmission since the virus can live on a person's fingers for up to four hours.

Hand hygiene — Hand washing is an essential and effective way to prevent the spread of infection. Hands should ideally be wet with water and plain or antimicrobial soap and rubbed together for 15 to 30 seconds. Special attention should be paid to the fingernails, between the fingers, and the wrists. Hands should be rinsed thoroughly and dried with a single-use towel.

It is not clear if alcohol-based hand rubs are effective against hepatitis A virus. For this reason, food handlers, daycare providers, travelers, and anyone else who is at risk of transmitting or becoming infected with hepatitis A is advised to wash their hands with soap and water when possible. Alcohol-based hand rubs are a reasonable alternative if a sink is not available.

Hands should be cleaned after changing a diaper or touching any soiled item. They should also be washed before and after preparing food and eating, after going to the bathroom, and after handling garbage or dirty laundry.

Safe food preparation — Taking precautions when preparing foods can reduce the risk of becoming ill. The following precautions have been recommended by the Food Safety and Inspection Services and the United States Centers for Disease Control and Prevention.

●Do not drink raw (unpasteurized) milk or foods that contain unpasteurized milk.

●Wash raw fruits and vegetables thoroughly before eating.

●Keep the refrigerator temperature at 40ºF (4.4ºC) or lower; the freezer at 0ºF (-17.8ºC) or lower.

●Use precooked, perishable, or ready-to-eat food as soon as possible.

●Keep raw meat, fish, and poultry separate from other food.

●Wash hands, knives, and cutting boards after handling uncooked food, including produce and raw meat, fish, or poultry.

●Thoroughly cook raw food from animal sources to a safe internal temperature: ground beef 160ºF (71ºC); chicken 170ºF (77ºC); turkey 180ºF (82ºC); pork 160ºF (71ºC).

●Cook chicken eggs thoroughly, until the yolk is firm.

●Refrigerate foods promptly. Never leave cooked foods at room temperature for more than two hours (one hour if the room temperature is above 90ºF/32ºC).

People who are preparing to travel to areas where hepatitis A is common should take precautions when eating and drinking to avoid becoming ill. If you are planning international travel, you can visit a travel medicine clinic to better understand your risk as well as what precautions you can take. Travel advice is discussed in more detail separately. (See "Patient education: General travel advice (Beyond the Basics)", section on 'Food and water precautions'.)

Hepatitis A vaccination — Available vaccines to prevent infection with hepatitis A virus include VAQTA and HAVRIX. Both are equally effective and protect nearly 100 percent of people who receive the recommended two doses for a lifetime. The initial dose of either vaccine usually provides adequate short-term protection, and the subsequent dose provides long-term protection. Thus, if a person does not have time to receive both doses before traveling, it is worth getting the first dose and then completing the second 6 to 12 months later.

The most common side effect of the hepatitis A virus vaccine is brief redness or discomfort at the injection site.

●VAQTA is given in two doses, with the second dose given 6 to 18 months after the first.

●HAVRIX is given in two doses, with the second dose given 6 to 12 months after the first.

If the second dose is not given within the recommended time frame, it can be given without restarting the series. A vaccination series started with one brand of vaccine may be completed with the same or the other brand of hepatitis A vaccine.

In the United States, hepatitis A vaccine is recommended for all children between 12 and 23 months of age. It is also recommended for children ages 2 to 18 who did not previously receive the vaccine. (See "Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)".)

The hepatitis A virus vaccine is also recommended for all at-risk individuals, including:

●Travelers to countries where hepatitis A virus is common; the vaccine can be given at any time before traveling.

•Babies 6 to 11 months who are travelling internationally should receive the vaccine; the travel-related dose should not be counted toward the routine two-dose series.

●People who use injection or noninjection illegal drugs.

●Men who have sex with men.

●People with chronic liver disease.

●Anyone who is in close personal contact with a person who was adopted from a country in which hepatitis A is common during the first 60 days following arrival in the United States (eg, family members or caregivers).

●People who are in direct contact with others who have hepatitis A.

●People who are homeless.

●People who work in settings that provide services for adults who may be at increased risk, for example, in substance abuse treatment or support centers, group homes, or non-residential care facilities for people with developmental disabilities.

The hepatitis A vaccine can be given to women during pregnancy, as it has not shown to be associated with an increased risk of problems. Women who are at risk for hepatitis A and are pregnant should talk with their health care provider about whether they should get the vaccine.

Immune globulin — People who are at risk for hepatitis A but who are allergic to components of the hepatitis A vaccine, or who prefer not to receive the vaccine, should consider taking a dose of immune globulin. Immune globulin is an injection that provides temporary protection against hepatitis A and reduces the risk of infection by more than 90 percent. However, the hepatitis A vaccine is preferred to immune globulin in most cases because it provides long-lasting protection and because immune globulin is not always available.

Immune globulin is given in a single injection shortly before travel. A single dose provides protection for about two months. People who plan to travel for more than two months in areas where hepatitis A is endemic should have an additional dose(s) of immune globulin.

Older adults and people with a weakened immune system, chronic liver disease, or other underlying medical problem who plan to travel within two weeks should get a dose of hepatitis A vaccine in addition to a dose of immune globulin. The second dose of the hepatitis A vaccine should be given 6 to 12 months later. Immune globulin is not required for healthy travelers who are immunized with the hepatitis A vaccine.

TREATMENT AFTER EXPOSURE TO HEPATITIS A — If a person has a known exposure to hepatitis A and has not previously received the hepatitis A vaccine, "postexposure protection" with either the vaccine or immune globulin should be given as soon as possible, within two weeks of exposure.

In general, for healthy people over the age of one year, the vaccination is preferred over immune globulin since it is more effective, easier to administer, and more readily available than immune globulin. However, in some situations, immune globulin is appropriate (either instead of or in addition to the vaccine). Your health care provider can talk to you about which approach is best for you.

Certain people are candidates for postexposure protection after a potential exposure to hepatitis A. They include:

●Close personal contacts of a person with hepatitis A confirmed by blood testing, including:

•Household contacts (eg, family members)

•Sexual partners

•People who have shared illicit drugs (injection and noninjection)

●Child care center contacts, if one or more children in the center have confirmed hepatitis A or there are two or more cases of hepatitis A in households of people who attend the center:

•For centers providing care to children in diapers – Any staff members or other children in the center should receive postexposure protection if they haven't already been vaccinated. In the setting of an outbreak (cases in ≥3 families), postexposure protection is also appropriate for household members of diaper-wearing children.

•For centers providing care to children who no longer wear diapers – All classroom contacts of the child with hepatitis A should receive postexposure protection if they haven't already been vaccinated. It is not required for children and staff in other classrooms.

●Food handlers:

•In locations (eg, restaurants) with a food handler diagnosed with hepatitis A, postexposure protection is warranted for other food handlers. Administration of postexposure protection to patrons and customers is typically not indicated.

•Postexposure protection is reasonable in settings in which repeated exposures to hepatitis A might have occurred, for example, school or office cafeterias.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Hepatitis A (The Basics)
Patient education: Treatment for hepatitis C (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Hepatitis B (Beyond the Basics)
Patient education: Hepatitis C (Beyond the Basics)
Patient education: General travel advice (Beyond the Basics)
Patient education: Vaccines for infants and children age 0 to 6 years (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Hepatitis A virus infection: Treatment and prevention
Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis
Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis, section on 'Information for patients'

The following organizations also provide reliable health information.

●United States Centers for Disease Control and Prevention (CDC) (available in Spanish)

     (www.cdc.gov)

●National Library of Medicine

     (www.nlm.nih.gov/medlineplus/hepatitisa.html)

●National Institute of Diabetes and Digestive and Kidney Diseases (available in Spanish)

(www.niddk.nih.gov/health-information/liver-disease/viral-hepatitis/hepatitis-a)

●American Liver Foundation

     (www.liverfoundation.org)

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Dr. Catherine Cheney, who contributed to earlier versions of this topic review.