Family doctor

Overview:

• Hepatitis A is an infectious liver disease
• Travellers, children and homosexual men are at higher risk
• The virus is spread by the "faecal-oral route". This implies poor hand washing.
• The virus spreads from an infected person into food and then infects another person
• Eating contaminated food or drinking untreated water can also spread the virus.
• Hepatitis A causes a flu-like illness followed by jaundice and dark urine.
• Bed rest and supportive measures are the main treatment
• Recovery is likely after two to three weeks.
• The Havrix vaccine provides good immunity to the virus
• Immune globulin can provide some short term protection (approximately 3-6 months)
• Once recovered, there is full immunity, no long term damage to the liver and people do not become carriers.

What is hepatitis A?

Hepatitis A is a liver disease which is caused by a virus. Children, travellers, and homosexual men are at greater risk.

The virus is spread from the faeces of an infected person. Poor personal hygiene such as not washing hands then spreading small amounts to food and on to another person. You can get it by touching an infected person's stool, such as changing a nappy and then eating with your hands. You can get it by eating food made by an infected person and drinking water contaminated by sewage, or having anal sex with someone who has the virus.

The virus is more prevalent in the developing world. Travellers visiting developing countries are at risk from eating or drinking contaminated food or water.

The disease is very rarely fatal and most people recover in a few weeks without further complications.

What are the symptoms?

The main sign is jaundice (yellow skin) due to the waste pigment, bilirubin, in the body. The urine also becomes darker, and faeces may become lighter.

A flu-like illness may occur before the jaundice, including fatigue, poor appetite, nausea, muscle aches and pains, fever, diarrhoea and vomiting.

Patients are most infectious 1-2 weeks before the onset of symptoms.

Once jaundice has appeared, the infectious stage is already declining rapidly.

Some people show no signs of illness despite having been infected. It is often a mild disease in children and they are less likely to develop jaundice than adults. This is particularly the case in children under 5. Thus someone who has had hepatitis A in very early childhood may not realise they have had it.

Symptoms usually appear within three to four weeks after infection, but can be noticed within two weeks and up to six weeks after exposure. The illness usually lasts several weeks, but slow recovery and minor relapses may occur for up to 6 months. Very rarely (less than 1 in a 1000), liver failure can develop.

Blood tests confirm the type of hepatitis and can also show if you have had hepatitis in the past. The liver function tests are usually very raised and should return to normal with recovery.

How can it be treated?

There is no drug treatment to cure hepatitis A. Bed rest is generally the recommended advice. Keeping up with fluid intake is very important, to avoid dehydration.

Occasionally, hospitalisation may be needed for intravenous fluids if vomiting is severe.

Stay in bed until the jaundice begins to fade. Try to eat healthy food, fatty foods may upset your stomach. Avoid alcohol until recovery. Alcohol may be poorly tolerated for some months and cause minor relapses - it should be totally avoided for at least 3 months or longer until the liver has fully recovered.

Carriers begin to recover after two to three weeks, with full recovery within four to eight weeks.

Doctors may advise women to stop taking their contraceptive pill (because the pill is metabolised in the liver). Care needs to be taken with a variety of medications.

How can it be prevented?

The best way to prevent getting the virus is washing hands after using the toilet and before preparing food, wearing gloves to change nappies, and drinking bottled water in developing countries.

For people with the virus scrupulous personal hygiene is important to stop others catching hepatitis A. This includes washing hands after going to the toilet and disinfecting the bathroom door knob, not handling food with your fingers, not sharing cutlery or plates, protecting food from flies, and not using tea-towels to dry dishes. Unfortunately it is most infectious just before one knows one has it!

Travellers to developing countries should strongly consider the new hepatitis A vaccine, Havrix, or immune globulin which contains antibodies against the virus.

The vaccine needs to be given at least 2 weeks before travel to allow time for immunity to develop.

Frequent or long-term travelers should consider the Havrix injection, travellers who plan to stay less than five months may choose the cheaper (but less effective) immune globulin option.

Havix vaccination is usually given by injection in the upper arm. A single dose will give protection for one year. A booster shot is recommended 12 months later, if longer term immunity is needed. This will give protection for at least 10 years (probably lifelong). This vaccine will not protect against hepatitis B or C.

The vaccine can be given to children aged 2 to 18. It's safety in younger children is still being studied.

Alternatively, an immune globulin injection (which is not as effective as the vaccine) is given within three to five days of leaving for a country with a high hepatitis A risk.

Immune globulin can also be given for up to 2 weeks after exposure to the virus and is 80-90% effective in preventing symptoms in this setting. This is advised for close household and sexual contacts, but not for casual contacts. The first dose of the vaccination can safely be given at the same time.

Others who may benefit from the vaccine include homosexual men and intravenous drug users.

There is no evidence that immune globulin can transmit any disease, like HIV or AIDS, and it can be given to pregnant women.

Once a person recovers from hepatitis A they are immune for life and will no longer carry the virus. A blood test is available to confirm immunity if uncertainty exists. For example, if you are not sure if you actually had hepatitis A as a child. Condoms should be used to prevent sexual transmission.

Future trends

Scientists are studying the body's immune response to hepatitis viruses, and hope to establish better methods of treating them. Routine vaccination is not done at present. Combined hepatitis A/hepatitis B vaccinations look promising.

Getting help

Plan ahead if you are traveling to a high risk area and consider vaccination.

Most family doctors can test and arrange vaccination if needed.