Hepatitis A

Hepatitis A is a common infectious disease that affects the liver, caused by the hepatitis A virus (HAV). It is primarily transmitted through the faecal-oral route, either by ingestion of contaminated food or water or direct contact with an infectious person. According to the World Health Organisation (WHO), approximately 1.5 million people are infected with HAV each year, with high endemic rates in developing countries with poor sanitation and hygiene practices. In this article, we will discuss the basics of hepatitis A, its symptoms, and other relevant information to raise awareness about this disease.

What is Hepatitis A?

Hepatitis A, also known as infectious hepatitis or yellow jaundice, is a viral infection that causes inflammation of the liver. It is caused by HAV, a positive-sense, single-stranded RNA virus that belongs to the family Picornaviridae. HAV is highly contagious and can be spread through the faecal-oral route, either by ingestion of contaminated food or water or direct contact with an infectious person. The virus replicates primarily within hepatocytes and can cause acute liver damage, leading to symptoms such as jaundice, abdominal pain, and fatigue. Unlike hepatitis B and C, HAV does not cause chronic liver disease, and acute hepatitis usually presents as a self-limited illness. While there is no specific treatment for hepatitis A, supportive therapy can help manage symptoms, and the infection usually resolves on its own within a few weeks to months.

Early recognition of its warning signs of hepatitis A is crucial for prompt diagnosis and treatment. The early symptoms of hepatitis A can often be mistaken for a mild flu, making it essential to be aware of the specific signs to watch out for.

• General flu-like symptoms: In the initial stages, hepatitis A may cause symptoms similar to a mild flu, such as fatigue, malaise, fever, weight loss, nausea, and vomiting.

• Specific signs: As the infection progresses, more distinct signs may appear, including jaundice (yellowing of the skin and whites of the eyes), dark urine, pale stools, and itchy skin. Blood tests may also reveal elevated levels of liver enzymes like alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, alkaline phosphatase (ALP), and gamma-glutamyl transpeptidase (GGT).

• Variability in symptoms: The severity of symptoms can vary significantly among individuals. Adults tend to experience more pronounced symptoms compared to children, who may not show any symptoms at all.

Understanding these early warning signs can help individuals seek timely medical attention and prevent the spread of the infection to others.

The symptoms of hepatitis A can vary from person to person, but here are some common signs and symptoms:

• Early symptoms: Early symptoms can be mistaken for influenza, but some people, especially children, exhibit no symptoms at all.

• Common symptoms:

  • Nausea and vomiting

  • Abdominal pain and discomfort

  • Fatigue and malaise

  • Jaundice (yellowing of the skin and eyes)

  • Dark urine and pale stools

  • Fever

• Age-related symptoms: The likelihood of symptomatic illness from HAV infection is directly related to age. In children younger than age 6 years, most (70%) infections are asymptomatic, while in older children and adults, infection is usually symptomatic, with jaundice occurring in more than 70% of patients.

• Duration of symptoms: Symptoms usually last less than 2 months, although 10%–15% of symptomatic persons have prolonged or relapsing disease for up to 6 months.

Hepatitis A infection progresses through several stages, each with its distinct characteristics. Recognising these stages is crucial for effective disease management and understanding the potential risks associated with the infection.

• Incubation period: After exposure to the hepatitis A virus, there is an average incubation period of 28 days, ranging from 15 to 50 days. During this time, the infected individual is contagious but may not exhibit any symptoms.

• Acute infection: This stage is marked by the abrupt onset of symptoms such as jaundice, dark urine, clay-coloured stools, diarrhoea, fatigue, fever, joint pain, loss of appetite, nausea, stomach pain, and vomiting.

• Recovery: Most individuals recover completely within 2 months without experiencing any long-term liver damage. However, some may have prolonged or relapsing symptoms that can last for up to 6 months.

• Age considerations: Hepatitis A can pose a greater risk to older adults or those with pre-existing chronic liver diseases. In rare cases, it may lead to acute liver failure, which can be life-threatening.

It is important to note that the severity of hepatitis A infection can vary depending on factors such as age and overall health status.

Several factors can increase an individual's risk of contracting hepatitis A. Identifying these risk factors is essential for implementing preventive measures and reducing the likelihood of infection.

• Travel to high-risk areas: Travelling to countries with high rates of hepatitis A, particularly those with poor sanitation and limited access to clean water, can significantly increase the risk of infection.

• Close contact with an infected person: Hepatitis A is highly contagious and can spread easily through close personal contact with an infected individual, such as living in the same household or engaging in sexual activity.

• Consumption of contaminated food or water: Ingesting food or water contaminated with the hepatitis A virus is a common mode of transmission. This can occur through eating raw or undercooked shellfish, consuming contaminated fruits and vegetables, or drinking water from untreated sources.

• Occupational exposure: Certain occupations, such as healthcare workers, sewage workers, and those handling food, may have a higher risk of exposure to the hepatitis A virus due to the nature of their work.

• Recreational illegal substance use: Engaging in recreational use of illegal substances, particularly when it involves sharing needles or other injection equipment, can increase the risk of hepatitis A infection.

• Chronic liver disease: Individuals with pre-existing chronic liver conditions, such as hepatitis B or C, are at a higher risk of developing severe complications if they contract hepatitis A.

By understanding these risk factors, individuals can take appropriate precautions to reduce their chances of contracting hepatitis A.

While hepatitis A is typically an acute and self-limiting infection, it can lead to several complications, especially in certain populations:

1. Rare but severe complications

• Fulminant hepatitis: This rare but severe complication can lead to acute liver failure. It is more common in adults over 50 and those with pre-existing liver diseases. Fulminant hepatitis may require emergency liver transplantation and has a high mortality rate, particularly in older adults.

2. Relapsing hepatitis A

• Around 10% to 15% of people who have had hepatitis A may experience a relapse, becoming unwell again with the virus. Most people who relapse fully recover, but symptoms can persist for up to 6 months.

3. Atypical complications

• Other rare complications include immunologic, neurologic, haematologic, pancreatic, and renal manifestations. Conditions such as cholestatic hepatitis A, hepatitis A triggering autoimmune hepatitis, and subfulminant hepatitis have also been reported.

4. Mortality and morbidity

• Although rare, the overall case-fatality rate for hepatitis A is estimated to be between 0.3% and 0.6% for all ages and up to 1.8% among adults aged 50 or older. Nonfatal hepatitis A can still result in significant morbidity, including substantial medical costs and work loss.

Prevention of hepatitis A infection is highly effective through several measures:

1. Vaccination

• The hepatitis A vaccine is the most reliable method of prevention, providing lifelong immunity against the virus. It is recommended for people in high-risk groups, such as travellers to areas where hepatitis A is common, men who have sex with men, people who use illegal substances, and those experiencing homelessness.

2. Good hygiene practices

• Practising good hygiene, including frequent handwashing, especially after using the toilet and before handling food, can significantly reduce the risk of transmission.

3. Avoiding Contaminated Food and Water

• Avoid consuming food or water that may be contaminated with the hepatitis A virus. This includes avoiding raw shellfish from polluted waters and ensuring that all food handlers follow proper hygiene practices.

4. Post-exposure prophylaxis

• If you have been exposed to the hepatitis A virus, your doctor may recommend post-exposure prophylaxis, which involves receiving a dose of the hepatitis A vaccine or immunoglobulin within two weeks of exposure to prevent infection.

By following these preventive measures, you can significantly reduce your risk of contracting hepatitis A.

Diagnosing hepatitis A involves a combination of clinical evaluation, medical history, and specific laboratory tests to confirm the presence of the HAV. The primary goal of hepatitis A testing is to determine if a person has been infected by the HAV, either currently or in the past. The types of tests used for diagnosing hepatitis A include:

• Immunoglobulin M (IgM) antibody test: Detects IgM anti-HAV antibodies, which are usually present 2 weeks after symptoms begin and disappear 3–6 months later. This test is indicative of an acute or recent hepatitis A infection.

• Immunoglobulin G (IgG) antibody test: Detects IgG anti-HAV antibodies, which appear later in the course of the disease and remain in the body for life, providing long-term immunity. This test is used to detect past HAV infections and immunity from previous infection or vaccination.

• Total hepatitis A antibody test: Detects both IgM and IgG antibodies, identifying both current and past infections.

The diagnostic process involves taking a blood sample to look for HAV-specific antibodies and checking for high levels of liver enzymes. In some cases, reverse transcriptase polymerase chain reaction (RT-PCR) can be used to detect HAV RNA in blood, stool, or liver tissue, though this may require specialised laboratory facilities. Interpretation of test results is crucial, with a positive IgM test indicating an acute or recent infection, a positive IgG test suggesting past infection or immunity from vaccination, and negative results indicating no current or past HAV infection and no immunity. With proper testing and diagnosis, doctors can effectively manage and treat hepatitis A cases.

While there is no specific antiviral treatment for hepatitis A, management focuses on alleviating symptoms and supporting the body's recovery. General care for patients with hepatitis A includes:

• Rest and hydration: Patients are advised to rest and stay well-hydrated to help the body recover from the infection.

• Dietary recommendations: Avoid fatty foods and alcohol, and opt for a balanced diet that is easy to digest.

Symptom management is an essential aspect of hepatitis A treatment, which may involve:

• Pain relief: Over-the-counter pain medications like paracetamol should be used cautiously and under medical supervision to avoid further liver damage.

• Antiemetics: If nausea and vomiting are severe, antiemetic medications may be prescribed to help alleviate these symptoms.

• Pruritus management: For patients experiencing itching (pruritus), antihistamines or other medications may be recommended to provide relief.

In severe cases of hepatitis A, hospitalisation may be necessary for close monitoring and supportive care, such as:

• Intravenous fluids: If dehydration occurs due to severe vomiting or diarrhoea, intravenous fluids may be administered to maintain proper hydration and electrolyte balance.

• Liver function monitoring: Regular blood tests will be performed to monitor liver function and ensure that the liver is recovering properly.

Although there is no specific medication for hepatitis A, proper supportive care and symptom management can help patients recover fully from the infection. It is important to note that once an individual has recovered from hepatitis A, they develop lifelong immunity against the virus.

Side Effects of Hepatitis A Medications

While there are no specific antiviral medications for treating hepatitis A, the medications used for symptomatic relief and supportive care may have some side effects in rare cases:

1. Pain relievers:

   • Paracetamol: When taken as directed, paracetamol rarely causes side effects. However, taking too much can lead to liver damage, especially in patients with pre-existing liver problems.

   • Nonsteroidal anti-inflammatory medicines: These medications, such as ibuprofen and naproxen, may cause stomach irritation, gastrointestinal bleeding, and an increased risk of cardiovascular events when used for prolonged periods.

2. Antiemetics:

   • Metoclopramide: Common side effects include drowsiness, dizziness, and restlessness. In rare cases, it may cause involuntary muscle movements (dystonia) or a serious neurological condition called tardive dyskinesia.

   • Ondansetron: Side effects are generally mild and may include headache, constipation, and dizziness. In rare instances, it may cause QT prolongation, a heart rhythm disorder.

3. Antihistamines:

   • First-generation antihistamines (e.g., diphenhydramine): These medications may cause drowsiness, dry mouth, blurred vision, and constipation.

   • Second-generation antihistamines (e.g., loratadine, cetirizine): These newer antihistamines have fewer side effects compared to first-generation antihistamines but may still cause headache, fatigue, and dry mouth in some patients.

It is essential for patients to discuss any side effects they experience with their doctor, as they may need to adjust the dosage or switch to an alternative medication. Additionally, patients should inform their doctor about any pre-existing medical conditions or other medications they are taking to avoid potential interactions and minimise the risk of adverse effects.

If you suspect that you have been exposed to the hepatitis A virus or are experiencing symptoms of hepatitis A infection, it is essential to consult a doctor promptly. Symptoms that should prompt you to seek medical attention include:

• Fatigue

• Sudden nausea and vomiting

• Abdominal pain or discomfort, especially on the upper right side beneath your lower ribs (by your liver)

• Clay-coloured bowel movements

• Loss of appetite

• Low-grade fever

• Dark urine

• Joint pain

• Yellowing of the skin and the whites of your eyes (jaundice)

Your doctor will conduct a thorough physical examination and may order blood tests to diagnose hepatitis A infection. While there is no specific treatment for hepatitis A, your doctor can provide supportive care to help manage your symptoms and monitor your liver function.

• Hepatitis A is a viral infection that causes inflammation of the liver and is typically spread through contaminated food, water, or close contact with an infected person.

• Symptoms of hepatitis A include jaundice, abdominal pain, dark urine, pale stools, fatigue, fever, nausea, and loss of appetite.

• While most cases of hepatitis A resolve on their own, rare complications can occur, such as fulminant hepatitis A, encephalopathy, and cerebral oedema.

• Prevention of hepatitis A is highly effective through vaccination, good hygiene practices, and safe food and water practices, especially when travelling to high-risk areas.

• If you suspect exposure to the hepatitis A virus or experience symptoms, consult a doctor promptly for diagnosis and supportive therapy.

• Early recognition and management of hepatitis A are essential in preventing potential complications and ensuring a full recovery.