Hepatitis

•    The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
•    Almost everyone recovers fully from hepatitis A with a lifelong immunity. However, a very small proportion of people infected with hepatitis A could die from fulminant hepatitis.
•    The risk of hepatitis A infection is associated with a lack of safe water and poor sanitation and hygiene (such as contaminated and dirty hands).
•    A safe and effective vaccine is available to prevent hepatitis A.

Hepatitis A is an inflammation of the liver caused by the hepatitis A virus (HAV). The virus is primarily spread when an uninfected (and unvaccinated) person ingests food or water that is contaminated with the faeces of an infected person. The disease is closely associated with unsafe water or food, inadequate sanitation, poor personal hygiene and oral-anal sex.
Unlike hepatitis B and C, hepatitis A does not cause chronic liver disease but it can cause debilitating symptoms and rarely fulminant hepatitis (acute liver failure), which is often fatal. WHO estimates that in 2016, 7134 persons died from hepatitis A worldwide (accounting for 0.5% of the mortality due to viral hepatitis).
Hepatitis A occurs sporadically and in epidemics worldwide, with a tendency for cyclic recurrences. Epidemics related to contaminated food or water can erupt explosively, such as the epidemic in Shanghai in 1988 that affected about 300 000 people (1). They can also be prolonged, affecting communities for months through person-to-person transmission. Hepatitis A viruses persist in the environment and can withstand food production processes routinely used to inactivate or control bacterial pathogens.

Who is at risk?
Anyone who has not been vaccinated or previously infected can get infected with the hepatitis A virus. In areas where the virus is widespread (high endemicity), most hepatitis A infections occur during early childhood. Risk factors include:
•    poor sanitation;
•    lack of safe water;
•    living in a household with an infected person;
•    being a sexual partner of someone with acute hepatitis A infection;
•    use of recreational drugs;
•    sex between men; and
•    travelling to areas of high endemicity without being immunized.
Transmission
The hepatitis A virus is transmitted primarily by the faecal-oral route; that is when an uninfected person ingests food or water that has been contaminated with the faeces of an infected person. In families, this may happen though dirty hands when an infected person prepares food for family members. Waterborne outbreaks, though infrequent, are usually associated with sewage-contaminated or inadequately treated water.
The virus can also be transmitted through close physical contact (such as oral-anal sex) with an infectious person, although casual contact among people does not spread the virus.
Symptoms
The incubation period of hepatitis A is usually 14–28 days.
Symptoms of hepatitis A range from mild to severe and can include fever, malaise, loss of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a yellowing of the eyes and skin). Not everyone who is infected will have all the symptoms.
Adults have signs and symptoms of illness more often than children. The severity of disease and fatal outcomes are higher in older age groups. Infected children under 6 years of age do not usually experience noticeable symptoms, and only 10% develop jaundice. Hepatitis A sometimes relapses, meaning the person who just recovered falls sick again with another acute episode. This is normally followed by recovery.
Diagnosis
Cases of hepatitis A are not clinically distinguishable from other types of acute viral hepatitis. Specific diagnosis is made by the detection of HAV-specific immunoglobulin G (IgM) antibodies in the blood. Additional tests include reverse transcriptase polymerase chain reaction (RT-PCR) to detect the hepatitis A virus RNA and may require specialized laboratory facilities.
Treatment
There is no specific treatment for hepatitis A. Recovery from symptoms following infection may be slow and can take several weeks or months. It is important to avoid unnecessary medications. Acetaminophen, paracetamol and medication against vomiting should be avoided.
Hospitalization is unnecessary in the absence of acute liver failure. Therapy is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids that are lost from vomiting and diarrhoea.
Prevention
Improved sanitation, food safety and immunization are the most effective ways to combat hepatitis A.
The spread of hepatitis A can be reduced by:
•    adequate supplies of safe drinking water;
•    proper disposal of sewage within communities; and
•    personal hygiene practices such as regular handwashing before meals and after going to the bathroom.
Several injectable inactivated hepatitis A vaccines are available internationally. All provide similar protection from the virus and have comparable side effects. No vaccine is licensed for children younger than 1 year of age. In China, a live attenuated vaccine is also available.