eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Hepatitis A: Follow-up

Author: Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Coauthor(s): Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University; Lisa C Turner, MD, Clinical Instructor, Departments of Pediatrics and Communicable Diseases, University of Michigan Medical Center
Contributor Information and Disclosures

Updated: Jun 2, 2009

Follow-up

Further Inpatient Care

  • Inpatient care is not needed for most patients with hepatitis A virus (HAV) infection.
  • Some patients may require hospitalization for intravenous rehydration. Once emesis subsides and the patient can tolerate oral fluids, discharge is appropriate.

Further Outpatient Care

  • Follow-up liver enzyme studies should be performed at monthly intervals until levels normalize. If elevations persist longer than 3 months, complications or additional diagnoses should be considered.

Transfer

  • In the rare case of fulminant hepatitis, transfer to a facility with pediatric subspecialty care is indicated.

Deterrence/Prevention

  • General prevention measures consist of good personal hygiene, handwashing, ingestion of safe drinking water, and proper sanitation.
  • Prevention specific to hepatitis A infection includes the use of hepatitis A virus immune globulin (IG) and hepatitis A virus vaccine.
    • IG is given as an intramuscular injection of 0.02 mL/kg. It is 80-90% effective in preventing hepatitis A virus infection by means of passive immunity.
    • hepatitis A virus vaccine is currently licensed for use in children aged 12 months or older. One dose of vaccine leads to seroconversion in 88% of adult patients by 15 days and in 99% of adult patients by one month. When followed with a second dose at 6 months, the vaccine leads to 100% seroconversion.
    • The Advisory Committee on Immunization Practices (in the United States) has recommended universal immunization in all children older than one year (the lower limit of the approved age range) and catch-up immunization in those who have not been vaccinated.6
    • Vaccination in areas of extremely high incidence of infection may only be cost-effective if prevaccination serology is obtained to target nonimmune individuals7
  • Specific measures to prevent hepatitis A virus can be divided into 2 groups: pre-exposure prophylaxis and postexposure prophylaxis.
    • Pre-exposure prophylaxis with hepatitis A virus vaccine is recommended for persons aged 1 year or older who are traveling to countries where hepatitis A virus infection is endemic. If the trip is shorter than 2 weeks, or if the patient is younger than 1 year, Ig should be given. If the trip is longer than 3 months, a larger dose of Ig (0.06 mL/kg) is needed for those who cannot receive the vaccine. Repeat dosing is recommended if the trip lasts longer than 5 months.  Others who should receive the vaccine include children aged 12-35 months, patients with chronic liver disease, homosexual or bisexual men, users of injectable illicit drugs, and those with a high occupational risk (those who work with nonhuman primates and hepatitis A virus laboratory workers).
    • Postexposure prophylaxis consists of the administration of hepatitis A virus vaccine (preferred if >1 y and <40 y) or Ig to contacts as soon as possible, but not longer then 2 weeks after exposure. Candidates for postexposure prophylaxis include household and sexual contacts of infected patients, contacts in childcare centers during outbreaks, and, if the patient is a food handler, others who work at the same establishment. Information regarding administration of hepatitis A vaccine following postexposure (either alone or in addition to immune globulin) has recently been published.4,5,6
  • The use of contact precautions is recommended for hospitalized patients for one week after the onset of symptoms.
  • People with chronic liver conditions such as infection with hepatitis B virus or hepatitis C virus should also be vaccinated against hepatitis A virus.

Complications

  • Complications are few.
  • Fulminant hepatitis with massive hepatic necrosis and liver failure due to hepatitis A virus infection is rare.
  • Cholestatic hepatitis occurs in a small percentage of patients. It is identified by persistent hyperbilirubinemia, pruritus, and constitutional symptoms that last for 12-16 weeks in the absence of biliary obstruction on sonograms.

Prognosis

  • The prognosis is excellent.
  • Relapsing hepatitis A virus occurs in approximately 10% of patients 1-4 months after the initial episode and results in full recovery.
  • Except in rare cases of fulminant hepatitis, pediatric patients recover without sequelae.
  • Chronic active hepatitis, which can be seen in hepatitis B or hepatitis C infection, does not occur in hepatitis A virus infection.

Patient Education

  • Patients and parents should be educated regarding the transmission of hepatitis A virus and proper hygiene.
  • Indications for postexposure prophylaxis should be explained, and affected individuals should be identified and treated appropriately. Local and state health departments are instrumental in epidemiologic identification of the appropriate contacts who need postexposure prophylaxis.
  • Physicians should be prepared to explain transmission and prevention issues to the staff at the patient's school and childcare center. This can help identify individuals who may need prophylaxis, as well as alleviate unnecessary worries for those who are not at risk.
  • For excellent patient education resources, visit eMedicine's Hepatitis Center and Liver, Gallbladder, and Pancreas Center. Also, see eMedicine's patient education article Hepatitis A.
 


More on Hepatitis A

Overview: Hepatitis A
Differential Diagnoses & Workup: Hepatitis A
Treatment & Medication: Hepatitis A
Follow-up: Hepatitis A
Multimedia: Hepatitis A
References
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References

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  2. Wasley A, Grytdal S, Gallagher K. Surveillance for acute viral hepatitis--United States, 2006. MMWR Surveill Summ. Mar 21 2008;57(2):1-24. [Medline]. [Full Text].

  3. Wasley A, Samandari T, Bell BP. Incidence of hepatitis A in the United States in the era of vaccination. JAMA. Jul 13 2005;294(2):194-201. [Medline].

  4. 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. May 19 2006;55:1-23. [Medline]. [Full Text].

  5. Victor JC, Monto AS, Surdina TY, Suleimenova SZ, Vaughan G, Nainan OV, et al. Hepatitis A vaccine versus immune globulin for postexposure prophylaxis. N Engl J Med. Oct 25 2007;357(17):1685-94. [Medline]. [Full Text].

  6. [Guideline] Update: Prevention of hepatitis A after exposure to hepatitis A virus and in international travelers. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. Oct 19 2007;56(41):1080-4. [Medline].

  7. Ahmed M, Munshi SU, Nessa A, Ullah MS, Tabassum S, Islam MN. High prevalence of hepatitis A virus antibody among Bangladeshi children and young adults warrants pre-immunization screening of antibody in HAV vaccination strategy. Indian J Med Microbiol. Jan-Mar 2009;27(1):48-50. [Medline].

  8. AAP. Hepatitis A vaccine recommendations. Pediatrics. Jul 2007;120(1):189-99. [Medline].

  9. AAP. Hepatitis A. In: Red Book: Report of the Committee on Infectious Diseases. American Academy of Pediatrics; 2006:326-35.

  10. Barkai G, Belmaker I, Givon-Lavi N, Dagan R. The Effect of Universal Toddlers-Only Hepatitis A Virus Vaccination Program on Seropositivity Rate in Unvaccinated Toddlers: Evidence for Reduced Virus Circulation in the Community. Pediatr Infect Dis J. Mar 18 2009;[Medline].

  11. Bell BP, Shapiro CN, Margolis HS. Hepatitis A virus. In: Textbook of Pediatric Infectious Diseases. 2004:2069-86.

  12. Black S, Shinefield H, Hansen J, et al. A post-licensure evaluation of the safety of inactivated hepatitis A vaccine (VAQTA, Merck) in children and adults. Vaccine. Jan 26 2004;22(5-6):766-72. [Medline].

  13. Bovier PA. Epaxal: a virosomal vaccine to prevent hepatitis A infection. Expert Rev Vaccines. Oct 2008;7(8):1141-50. [Medline].

  14. CDC. Notice to readers: FDA approval of Havrix (hepatitis A vaccine, inactivated) for persons aged 1-18 years. MMWR. December 9, 2005;54(48):1235-1236. [Full Text].

  15. CDC. Notice to readers: FDA approval of VAQTA (hepatitis A vaccine, inactivated) for children aged >1 year. MMWR. October 14, 2005;54(40):1026. [Full Text].

  16. Dmochowski L. Viral type A and type B hepatitis: morphology, biology, immunology and epidemiology--a review. Am J Clin Pathol. May 1976;65(5 Suppl):741-86. [Medline].

  17. Frenck RW. Universal hepatitis A immunization recommendation made by ACIP. AAP News. 2005;26 (12):1. [Full Text].

  18. Hadler SC, Webster HM, Erben JJ, et al. Hepatitis A in day-care centers. A community-wide assessment. N Engl J Med. May 29 1980;302(22):1222-7. [Medline].

  19. Hammitt LL, Bulkow L, Hennessy TW, Zanis C, Snowball M, Williams JL, et al. Persistence of antibody to hepatitis A virus 10 years after vaccination among children and adults. J Infect Dis. Dec 15 2008;198(12):1776-82. [Medline].

  20. Hoang PL, Trong KH, Tran TT, Huy TT, Abe K. Detection of hepatitis A virus RNA from children patients with acute and fulminant hepatitis of unknown etiology in Vietnam: Genomic characterization of Vietnamese HAV strain. Pediatr Int. Oct 2008;50(5):624-7. [Medline].

  21. Jacobs RJ, Greenberg DP, Koff RS, et al. Regional variation in the cost effectiveness of childhood hepatitis A immunization. Pediatr Infect Dis J. Oct 2003;22(10):904-14. [Medline].

  22. Lolekha S, Pratuangtham S, Punpanich W, et al. Immunogenicity and safety of two doses of a paediatric hepatitis A vaccine in thai children: comparison of three vaccination schedules. J Trop Pediatr. Dec 2003;49(6):333-9. [Medline].

  23. Snyder JD, Pickering LK. Hepatitis A through E. In: Nelson Textbook of Pediatrics. 17th ed. 2004:1324-7.

  24. Todd EC, Greig JD, Bartleson CA, Michaels BS. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 4. Infective doses and pathogen carriage. J Food Prot. Nov 2008;71(11):2339-73. [Medline].

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Further Reading

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Keywords

hepatitis A, hepatitis A virus, HAV, viral hepatitis, catarrhal jaundice, epidemic jaundice, infectious hepatitis, viral hepatitis type A, virus A hepatitis, Picornaviridae, picornavirus, cholestasis, fulminant hepatitis, splenomegaly, fulminant hepatitis, abdominal pain, diarrhea, treatment, diagnosis

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Contributor Information and Disclosures

Author

Nicholas John Bennett, MB, BCh, PhD, Fellow in Pediatric Infectious Disease, Department of Pediatrics, State University of New York Upstate Medical University
Nicholas John Bennett, MB, BCh, PhD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Lisa C Turner, MD, Clinical Instructor, Departments of Pediatrics and Communicable Diseases, University of Michigan Medical Center
Lisa C Turner, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Rosemary Johann-Liang, MD, Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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