eMedicine Specialties > Gastroenterology > Liver

Hepatitis A: Follow-up

Author: Richard K Gilroy, MBBS, FRACP, Associate Professor, Medical Director of Liver Transplantation and Hepatology, Department of Internal Medicine, Kansas University Medical Center
Coauthor(s): Sandeep Mukherjee, MB, BCh, MPH, FRCPC, Associate Professor, Department of Internal Medicine, Section of Gastroenterology and Hepatology, University of Nebraska Medical Center; Consulting Staff, Section of Gastroenterology and Hepatology, Veteran Affairs Medical Center
Contributor Information and Disclosures

Updated: Aug 26, 2008

Follow-up

Inpatient & Outpatient Medications

• Tylenol may be safely used to treat some of the symptoms associated with the hepatitis A virus infection. However, the dose should be no greater than 4 g/d.

Transfer

• Refer patients with fulminant hepatic failure to facilities with expertise in liver transplantation.

Deterrence/Prevention

• Control at the source, with treatment of contacts to prevent further cases of disease is the primary goal. Long-term secondary goals include immunization, which increases herd immunity and reduces the likelihood of further outbreaks in high-risk communities. Education about transmission and prevention of transmission (eg, hand washing, safe food sources) is also important.
• The efficacy of immunization has been clearly demonstrated in high-risk groups.  
• In the United States, vaccination programs targeting children during urban outbreaks have demonstrated significant benefits.
• Immunization programs applied to high-risk groups show morbidity and cost benefits. Approximately 20% of individuals with acute hepatitis A virus infection may require hospitalization.
• Global immunization appears to be prohibitively expensive. The hepatitis A vaccine is not yet licensed for use in persons younger than 2 years.
• The efficacy of the hepatitis A vaccine ranges from 80-100% after 1-2 doses compared to placebo. The current dosing recommendations for the available vaccinates are provided in Medication. 
• People with chronic liver disease of any cause should consider hepatitis A vaccination. Response rates in patients with advanced liver disease and in those on immunosuppressive therapies are likely to be lower. The potentially disastrous outcome of acute hepatitis A virus infection in this group cannot be overemphasized.
• Hepatitis A vaccination in some low-risk groups who are potential sources of larger outbreaks of infection (eg, food handlers) has been implemented by some employers, although cost-benefit analysis for the employer does not seem to support such measures.
• Annually, an estimated 100 people die in the United States as a result of acute liver failure due to the hepatitis A virus. The frequency of acute hepatitis appears more common in states neighboring Mexico. Although the case-fatalities from fulminant hepatitis A virus have been reported in all age groups, where overall the mortality is estimated at approximately 0.3%, the rate is 1.8% among adults older than 50 years and is also higher in persons with chronic liver diseases.
• Passive immunization with Gammagard reduces infection when administered within 14 days of exposure (ie, postexposure prophylaxis).
• In many instances, preexposure prophylaxis has been somewhat replaced by immunization. For travelers, cost-benefit analysis suggests that vaccination is preferred over gamma globulin when an extended stay in the area of risk (ie, high endemicity) is longer than 3 months or when repeat travel to the area (ie, >2 visits outside a 3-mo period) is likely.
• Postexposure prophylaxis is recommended for nonimmunized close contacts of those recently diagnosed with acute hepatitis A virus infection.
• Immunization is indicated for individuals traveling to areas of high endemicity who have less than 2 weeks before departure. Both the vaccination and intramuscular immunoglobulin should be administered to provide long-term immunity, particularly in persons who intend to travel to these areas repeatedly.
• Notify the appropriate public health authority following diagnosis of hepatitis A virus infection.
• Initiate contact tracing after diagnosis of hepatitis A virus infection.
• Hepatitis A is the most frequent vaccine-preventable disease in travelers, and it has the highest mortality and morbidity rates for any vaccine-preventable infection in travelers. Vaccination is highly effective at preventing hepatitis A virus disease.
• In any suspected food handler transmission, it is imperative that health department officials are notified immediately. As many as 10% of cases of acute hepatitis A virus are seen in commercial food handlers in the United States. Recommendations for providing post-exposure prophylaxis are developed based upon risk. To be effective in preventing disease, immunoglobulin needs to be administered within 14 days of exposure.
• See related CME at Hepatitis A Vaccine and Immune Globulin Offer Protection Against HAV Exposure. 
• See related CME at Updated Guidelines for Preventing Hepatitis A Virus Infection After Exposure to the Virus.
• See related CME at Hepatitis A & B Vaccines.

Complications

• Generally, hepatitis A virus infection elicits no lasting sequelae. Death is rare, occurring in fewer than 0.2% of cases.
• Death is more frequent in elderly patients and in those with underlying liver disease. In children, liver transplantation has been performed for fulminant hepatic failure. In France, 10% of cases of fulminant hepatic failure in children are caused by hepatitis A virus infection. The outcomes from liver transplantation are the same as for others with fulminant disease. Recurrent disease does not occur following liver transplantation despite immunosuppression.
• Prolonged cholestasis may follow the acute infection. The frequency at which this occurs increases with age. Prolonged cholestasis is characterized by a protracted period of jaundice (>3 mo) and resolves without intervention. Corticosteroids and ursodeoxycholic acid may shorten the period of cholestasis. The usual features of cholestatic viral hepatitis A are pruritus, fever, diarrhea, and weight loss, with serum bilirubin levels greater than 10 mg/dL. Some investigators believe that the use of corticosteroids may predispose patients to developing relapsing hepatitis A. Good data to support this hypothesis are lacking.
• Acute renal failure, interstitial nephritis, pancreatitis, red blood cell aplasia, agranulocytosis, bone marrow aplasia, transient heart block, Guillain-Barré syndrome, acute arthritis, Still disease, lupuslike syndrome, and Sjögren syndrome have been reported in association with hepatitis A virus infection. These complications are all rare.
• Autoimmune hepatitis following hepatitis A virus infection has received substantial discussion in the literature. A postulated mechanism involves molecular mimicry and genetic susceptibility, in much the same way as that proposed in type 1 diabetes. Steroid therapy for this condition was associated with good clinical response and improvement in biochemical and clinical parameters, in a way similar to that of traditional autoimmune hepatitis. However, these findings are confined to isolated case reports, and the results of larger clinical trials are not available.
• Relapsing hepatitis A virus infection
• This complication occurs in 3-20% of patients with acute hepatitis A virus infection and uncommonly takes the form of multiple relapses.
• Following a typical acute course of hepatitis A virus infection, a remission phase occurs, with partial or complete resolution of clinical and biochemical manifestations. The initial flare usually lasts 3-6 weeks; relapse occurs after a short period (usually <3 wk) and mimics the initial presentation, although it usually is clinically milder.
• A tendency to greater cholestasis exists in these patients. Vasculitic skin rashes and nephritis may be additional clinical clues to this syndrome.
• During relapses, shedding of virus can be detected. IgM antibody test findings are positive.
• The clinical course is toward resolution, with lengthening periods between flares. The total duration is 3-9 months.
• Liver transplantation has been performed in patients with this condition when signs of significant decompensation have occurred. Corticosteroid treatment has been shown to improve the clinical course, although the course is generally benign without treatment.

Prognosis

• Prognosis is excellent. Long-term immunity accompanies hepatitis A virus infection. Recurrence and chronic hepatitis do not usually occur.

Patient Education

• Travelers should be educated about good hygiene and clean, safe water supplies. Advice should be provided regarding the benefits of immunization, particularly in high-risk individuals. Travelers should avoid uncontrolled water sources, raw shellfish, and uncooked food. Boiling water or adding iodine inactivates the virus. All fruit should be washed and peeled.
• People with hepatitis A virus infection who are treated at home and those around them should follow strict enteric precautions.
• For excellent patient education resources, visit eMedicine's Hepatitis Center, Liver, Gallbladder, and Pancreas Center, and Public Health Center. Also, see eMedicine's patient education articles Hepatitis A and Foreign Travel.

Miscellaneous

Medicolegal Pitfalls

• Central to the prevention of any legal problem is establishing the correct diagnosis, which comes from a combination of careful history and subsequent examination. Appearances may be deceiving; therefore, always exclude drugs, particularly Tylenol, as a cause of acute liver injury. After establishing a diagnosis of hepatitis A virus infection, tracing contacts and notifying local public health authorities are important steps for preventing further cases. Omitting these measures may place the practitioner in a vulnerable situation.
• Patients at risk for developing acute hepatitis A virus infection should receive immunization for hepatitis A virus. In addition, immunization of those at greater risk for morbidity from acute hepatitis A virus is important. A German study of immunization rates in patients with autoimmune liver disease identified that seroconversion rates in this population were lower; however, more importantly, the study identified that vaccination was not offered to a large proportion of this population. It is not difficult to identify a low risk-benefit ratio in patients with chronic liver disease, and the author would recommend vaccination for hepatitis A virus in all who have no contraindication.
• Liver transplantation, in selected cases, is an option if the patient has fulminant hepatic failure.

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