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hepatitis A infection

Etiology: hepatitis A virus Epidemiology: 1) accounts for 1/3 of cases of acute viral hepatitis 2) fecal-oral transmission - contaminated food: rasberries, scallions [1] 3) generally transmitted by household & intimate contact 4) common source outbreaks are infrequent 5) infects 1 in 50 unimmunized travelers [2] 6) at least 481 people have been infected with hepatitis A & 17 have died since Nov 2016-Oct 2017 in San Diego, CA - 88 cases identified in Santa Cruz & Los Angeles counties - homeless are at greatest risk [7] 7) outbreaks in Kentucky mostly around Louisville 2018 [8] (300 confirmed cases) & in Michigan (800 cases, 25 fatal) 8) outbreaks in California, Indiana, Kentucky, Michigan, Missouri, Utah, & West Virginia Jan-Apr 2018 [9] 9) 300% increase 2013-2018, genotype IB most common [11] Clinical manifestations: 1) acute, but NOT chronic hepatitis 2) children generally have asymptomatic or mild infection 3) adults are generally symptomatic & jaundiced 4) fever 5) fatigue 6) nausea, vomiting, diarrhea 7) dark urine 8) right upper quadrant pain Laboratory: 1) serum AST & serum ALT generally > 1000 U/L 1) hepatitis A virus IgM in serum (IgM anti-hepatitis A) a) unexplained acute hepatitis or acute liver failure b) IgM may persist for 4-6 months 2) hepatitis A virus IgG in serum is protective is protective a) indicates past infection b) may take 4-6 months to appear in serum 3) hepatitis A virus RNA is confirmatory 4) see ARUP consult [5] Complications: 1) relapsing course of hepatitis 2) prolonged cholestasis 3) fulminant hepatitis (rare) 4) patients with underlying chronic hepatitis B have increased mortality from HAV Management: 1) infection is self-limited treatment is supportive 2) full recovery in 90% of patients, generally within 3 months [1] 3) prophylaxis: a) single dose of HAV vaccine is protective in 90% of patients within 2-4 weeks of inoculation - booster at 6-12 months - susceptible persons traveling to endemic area - preferably 4 weeks prior to departure - otherwise, as soon as travel to endemic area is considered [12] - 2nd dose 6-12 months later [1] - injection drug users - men who have sex with men - patients with chronic liver disease - patients with clotting factor disorders [1] b) immune globulin within 2 weeks of exposure - household, sexual, day care contacts of patients with hepatitis A - individuals that have consumed hepatitis A contaminated food - unvaccinated persons > 40 years departing within < 2 weeks to an endemic area [1,12] - not necessary for healthy person < 40 years of age; - administer single dose of HAV vaccine [1,12] 4) adhere to careful handwashing 5) avoid work that involves food handling or close personal contact for 2-3 weeks after resolution of disease 6) post-exposure, including household contacts - HAV vaccine works as well as immune serum globulin [4]

Related

hepatitis A vaccine (Harvix, VAQTA) hepatitis A virus (HAV) hepatitis A virus RNA

General

enteroviral infection viral hepatitis

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Prescriber's Letter 9(7):40 2002
  3. Advisory Committee on Immunization Practices (ACIP); Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006 May 19;55(RR-7):1-23. PMID: 16708058 Corresponding NGC guideline withdrawn Dec 2011 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5507a1.htm
  4. Victor JC et al, Hepatitis A vaccine versus immune globulin for postexposure prophylaxis. N Engl J Med 2007, 357:1685 PMID: 17947390
  5. ARUP Consult: Hepatitis A Virus - HAV The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/hepatitis-virus
  6. Matheny SC, Kingery JE. Hepatitis A. Am Fam Physician. 2012 Dec 1;86(11):1027-34; Review. PMID: 23198670 Free Article
  7. Schroeder L How San Diego hepatitis A outbreak became the worst the U.S. has seen in decades. Los Angeles Times. Oct 8, 2017 http://www.msn.com/en-us/news/us/how-san-diego-hepatitis-a-outbreak-became-the-worst-the-us-has-seen-in-decades/ar-AAt5uoG
  8. Indiana State Department of Health. April 18, 2018 HOOSIERS TRAVELING TO STATES WITH HEPATITIS A OUTBREAKS URGED TO TAKE PRECAUTIONS AGAINST DISEASE https://calendar.in.gov/site/isdh/event/hoosiers-traveling-to-states-with-hepatitis-a-outbreaks-urged-to-take-precautions-against-disease/
  9. Centers for Disease Control and Prevention (CDC) Outbreak of Hepatitis A Virus (HAV) Infections among Persons Who Use Drugs and Persons Experiencing Homelessness. CDC Health Alert Network. June 11, 2018. https://emergency.cdc.gov/han/han00412.asp
  10. Nelson NP, Link-Gelles R, Hofmeister MG, et al. Update: Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel. MMWR Morb Mortal Wkly Rep 2018;67:1216-1220 https://www.cdc.gov/mmwr/volumes/67/wr/mm6743a5.htm
  11. Foster MA, Hofmeister MG, Kupronis BA et al Increase in Hepatitis A Virus Infections - United States, 2013-2018. MMWR Morb Mortal Wkly Rep 2019;68:413-415 https://www.cdc.gov/mmwr/volumes/68/wr/mm6818a2.htm
  12. Nelson NP, Link-Gelles R, Hofmeister MG et al Update: Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel. MMWR Morb Mortal Wkly Rep. 2018 Nov 2;67(43):1216-1220. PMID: 30383742 PMCID: PMC6319798 Free PMC article
  13. Abutaleb A, Kottilil S. Hepatitis A: Epidemiology, Natural History, Unusual Clinical Manifestations, and Prevention Gastroenterol Clin North Am. 2020 Jun;49(2):191-199 PMID: 32389358 PMCID: PMC7883407 Free PMC article
  14. Centers for Disease Control and Prevention (CDC) Interim outbreak-specific guidance on hepatitis A vaccine administration. https://www.cdc.gov/hepatitis/outbreaks/InterimOutbreakGuidance-HAV-VaccineAdmin.htm
  15. Hepatitis A https://www.niddk.nih.gov/health-information/liver-disease/viral-hepatitis/hepatitis-a