Hepatitis A

Question 1

Aetiology of hepatitis A

Answer 1

Hepatitis A is a picorna (RNA) virus

particularly common in areas of the world with poor sanitation where it mainly affects children

Question 2

Transmission of Hep A

Answer 2

• Faeco-oral (via food, water, close personal contact)

 - Outbreaks reported in MSM linked to: 
   > oro-anal contact
   > digital-rectal contact
   > multiple sexual partners
   > anonymous partners
   > sex in public places 
   > group sex

Question 3

Impact of HIV on hepatitis A

Answer 3

HIV-positive patients are NOT at increased risk
but MAY be more infectious

HAV viraemia may continue for over 90 days

Question 4

Duration of infectivity of hepatitis A

Answer 4

approximately 2 weeks before and 1 week after the period of jaundice

but virus can be found in blood and stool until after the serum amino-transferase levels have peaked

Question 5

Incubation Period of hepatitis A

Answer 5

15-45 days

average 28 days

Question 6

Symptoms of Hep A

Answer 6

asymptomatic - Most children + 50% adults

two phases of symptoms -
> prodromal illness = flu-like symptoms (malaise, myalgia, fatigue) +/- RUQ pain
lasts for 3-10 days

followed by -
> icteric illness = jaundice, anorexia, nausea, fatigue
lasts for 1-3 weeks

Question 7

Signs of Hep A

Answer 7

Non- specific prodrome

Icteric phase - jaundice, pale stools and dark urine.
Liver enlargement / tenderness
signs of dehydration

Question 8

Complications of Hep A

Answer 8

Acute liver failure - 0.4%

Hospital care required - 15%

Chronic infection (>6 months) - case-reports only

mortality is < 0.1% (but 40% if ALF develops)

Question 9

Impact of Hep A on pregnancy

Answer 9

No teratogenic effects

increased rate of miscarriage and premature labour

Question 10

Diagnosis of Hep A

Answer 10

positive serum Hepatitis A virus - specific IgM (HAV-IgM)

Usually remains positive for 45-60 days

does not distinguish between current or past infection and may remain positive for life

Question 11

Additional tests advised for a patient with Hep A / being tested for Hep A

Answer 11

HBV
HCV 
Hepatitis E (HEV) as common as HAV in the UK - most cases arise from eating processed pork products
HIV
STS
Sexual health screen

LFTS (AST/ALT / bilirubin)
Prothrombin time

Question 12

What prothrombin time usually indicates acute liver failure

Answer 12

50 seconds or more

Question 13

General Management Advice for patients with Hep A

Answer 13

Employment history - advise to avoid food handling
Avoid UPSI

until they are non-infectious = from 2 weeks before to 1 week after onset of jaundice

notifiable disease for PHE

Question 14

Management of mild icteric hepatitis A

Answer 14

80% = Mild / moderate - manage as an outpatient - rest and oral hydration

IF severe vomiting / dehydration / signs of hepatic
decompensation - admit to hospital

Question 15

Management of hepatitis A in pregnancy / breastfeeding

Answer 15

Advise of the increased risk of miscarriage / premature labour

Risk from breast feeding is uncertain - no reported
cases
If the infant is infected - usually mild / asymptomatic

Question 16

Partner notification for Hep A

Answer 16

PN for at-risk MSM contacts
2 weeks before to 1 week after the onset of jaundice

+ other people at risk (household contacts / those at risk from food / water contamination)

Question 17

Management of a patient exposed to Hep A

Answer 17

Hepatitis A vaccine - given up to 14 days after exposure - 0 and 6-12 month doses

Consider Human normal immunoglobulin (HNIG) 250-500 mg IM
in addition to the vaccine for patients at higher risk of complications (concurrent chronic HBV or HCV / chronic liver disease / HIV+ / age >50 yo)

Question 18

How can Human normal immunoglobulin (HNIG) be obtained

Answer 18

can only be obtained from Public Health England

HNIG that is effective against HAV is in short supply in the UK

Question 19

Hepatitis A vaccine schedule

Answer 19

doses at 0 and 6-12 months

95% protection for at least 10 years

Question 20

How long does Hep A vaccination offer protection for?

Answer 20

95% protection

for at least 10 years

Question 21

Follow up of a patient diagnosed with Hep A

Answer 21

See at 1 or 2 weekly intervals
until amino-transferase levels are normal

usually 4 -12 weeks

Question 22

Immunity following a Hep A infection

Answer 22

Immunity is usually lifelong

Question 23

Which patients should be offered the Hep A vaccination in GUM clinics
and why

Answer 23

All non-immune MSM - opportunistically offered Hep A vaccination course
due to an outbreak of hepatitis A in 2016-17

+ people who inject drugs
+ patients with chronic Hep B or C
+ patients with HIV