Hepatitis A virus: Difference between revisions
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− | == |
+ | ==Background== |
− | === |
+ | ===Microbiology=== |
− | * Non-enveloped RNA virus within the Picornavirus family |
||
− | * Three genotypes, I through III |
||
− | * Difficult to kill: needs higher temperatures and lower pH than other viruses, or bleach- or ammonium-based cleaners |
||
+ | *Non-enveloped RNA virus within the [[Family::Picornaviridae]] family |
||
− | === Epidemiology === |
||
+ | *Three genotypes, I through III |
||
− | * Fecal-oral transmission with person-to-person spread (including sex) |
||
+ | *Difficult to kill: needs higher temperatures and lower pH than other viruses, or bleach- or ammonium-based cleaners |
||
− | * Can be transmitted by contaminated food and water, as well |
||
+ | |||
− | * Most often linked to travel or to household contacts |
||
+ | ===Epidemiology=== |
||
+ | |||
+ | *Fecal-oral transmission with person-to-person spread (including sex) |
||
+ | *Can be transmitted by contaminated food and water, as well |
||
+ | *Most often linked to travel or to household contacts |
||
+ | *Rare transmission by blood transfusion |
||
+ | |||
+ | ===Risk Factors=== |
||
+ | |||
+ | *Outbreak |
||
+ | *Close contact with a hepatitis A-infected person, including household, sexual, or other |
||
+ | *Travel to endemic country |
||
+ | *Men who have sex with men |
||
+ | *Homelessness |
||
+ | *Injection drug use |
||
+ | |||
+ | ==Clinical Manifestations== |
||
+ | |||
+ | *Incubation period is from [[Usual incubation period::15 to 50 days]], with an average of 28 days |
||
+ | *Children are usually asymptomatic |
||
+ | *Symptoms include non-specific influenza-like illness followed eventually by bilirubinuria, pale stools, jaundice, and scleral icterus |
||
+ | *May have hepatomegaly and splenomegaly, may have rash or arthralgia |
||
+ | *Self-limited, usually starting to resolve by the third week of illness with full recovery often taking several months |
||
+ | |||
+ | ==Diagnosis== |
||
+ | ===Serology=== |
||
+ | |||
+ | * IgM and IgG antibodies are usually detectable by onset of symptoms |
||
+ | * IgM becomes undetectable by about 6 months while IgG persist lifelong and are protective<ref>Jack T. Stapleton, Host Immune Response To Hepatitis A Virus, ''The Journal of Infectious Diseases'', Volume 171, Issue Supplement_1, March 1995, Pages S9–S14, https://doi.org/10.1093/infdis/171.Supplement_1.S9</ref> |
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− | == Diagnosis == |
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− | === Serology === |
||
{| class="wikitable" |
{| class="wikitable" |
||
− | ! |
+ | !IgM!!IgG!!Interpretation |
|- |
|- |
||
− | | |
+ | |–||–||No recent infection (unless in the incubation period). No prior infection or vaccination. |
|- |
|- |
||
− | | |
+ | |–||+||No infection. Prior infection or vaccination. |
|- |
|- |
||
− | | |
+ | |?||+||Cannot rule out active infection. Prior infection or vaccination. |
|- |
|- |
||
− | | |
+ | | +||+/–||Acute or recent infection. IgM positive from 2 weeks until 3-12 months. IgG positive from 8-12 weeks and remains positive for lifetime. |
|} |
|} |
||
+ | |||
− | [[Category:RNA viruses]] |
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+ | ==Prevention== |
||
+ | |||
+ | ===Vaccination=== |
||
+ | |||
+ | *Vaccination is indicated for people at increased risk of acquiring hepatitis A, or at increased risk of severe disease |
||
+ | **Travellers to endemic countries |
||
+ | **People with chronic liver disease |
||
+ | **Men who have sex with men |
||
+ | **People who use recreational drugs |
||
+ | **People living in communities with outbreaks or endemic hepatitis A |
||
+ | **Close contacts of children adopted from endemic countries |
||
+ | **Military personnel and humanitarian relief workers |
||
+ | **People receiving repeated doses of plasma-derived clotting factors |
||
+ | **Laboratory workers studying hepatitis A |
||
+ | **Zookeepers, veterinarians, and researchers who interact with non-human primates |
||
+ | *Vaccination requires two doses spaced at least 6 months apart |
||
+ | *It provides immunity for decades, and possibly for life |
||
+ | |||
+ | ==== Coformulation with Hepatitis B Vaccine ==== |
||
+ | |||
+ | *Often given combined with [[hepatitis B vaccine]] (HAHB) |
||
+ | *HAHB is given as three doses (for the hepatitis B component) |
||
+ | *The hepatitis A component contains a full dose of hepatitis A vaccine, so a HAHB series essentially contains an extra unnecessary dose of hepatitis A vaccine |
||
+ | |||
+ | ==== High Risk Groups Who Cannot Receive Vaccine ==== |
||
+ | |||
+ | *In people with contraindications or who are expected to have suboptimal response to vaccination, consider using immunoglobulin as preexposure prophylaxis |
||
+ | *Groups include: |
||
+ | **Infants less than 6 months of age |
||
+ | **Immunocompromised people in whom the vaccine may not be as effective (though they should also still be vaccinated) |
||
+ | **Anaphylaxis after previous hepatitis A vaccination or component thereof |
||
+ | *Administering just before travel can confer immunity for up to 6 months of travel |
||
+ | *Dose is IMIg (GamaSTAN) 0.02 mL/kg for 3 months of protection, or 0.06 mL/kg every 6 months |
||
+ | **CDC recommends a dose of IMIg (GamaSTAN S/D) 0.2 mL/kg q2mo due to decreases in hepatitis A IgG among donors |
||
+ | |||
+ | ==== Publicly Funded in Ontario ==== |
||
+ | |||
+ | * Only a subset of patients are publicly funded in Ontario: |
||
+ | ** Intravenous drug use |
||
+ | ** Chronic liver disease, including hepatitis B and C |
||
+ | ** Men who have sex with men |
||
+ | |||
+ | ===Post-Exposure Prophylaxis=== |
||
+ | |||
+ | *Post-exposure prophylaxis is indicated for susceptible contacts including: |
||
+ | **Household members and close contacts of people infected with hepatitis A |
||
+ | **Contacts in group childcare centres and kindergartens |
||
+ | **Co-workers and clients of infected food handlers |
||
+ | *Prophylaxis is with monovalent hepatitis A vaccine |
||
+ | *In people with contraindications or who are expected to have suboptimal response to vaccination, immunogloulin should be given |
||
+ | **Groups include: |
||
+ | ***Infants less than 6 months of age |
||
+ | ***Immunocompromised people and people with liver disease, who should receive both vaccine and immunoglobulin |
||
+ | ****If they have received IVIg ≥400 mg/kg within the 3 weeks before exposure, then they do not require further immunoglobulin |
||
+ | ***Elderly susceptible adults age 60 years and older may also receive both |
||
+ | **It should be given as soon as possible, and can be given until 14 days after last exposure |
||
+ | **Dose is IMIg (GamaSTAN) 0.02 mL/kg body weight |
||
+ | ***CDC recommends a dose of IMIg (GamaSTAN S/D) 0.1 mL/kg body weight due to decreases in hepatitis A IgG among donors |
||
+ | |||
+ | [[Category:Picornaviridae]] |
||
+ | [[Category:Gastrointestinal infections]] |
||
+ | [[Category:Viral hepatitis]] |
Revision as of 09:24, 11 October 2023
Background
Microbiology
- Non-enveloped RNA virus within the Picornaviridae family
- Three genotypes, I through III
- Difficult to kill: needs higher temperatures and lower pH than other viruses, or bleach- or ammonium-based cleaners
Epidemiology
- Fecal-oral transmission with person-to-person spread (including sex)
- Can be transmitted by contaminated food and water, as well
- Most often linked to travel or to household contacts
- Rare transmission by blood transfusion
Risk Factors
- Outbreak
- Close contact with a hepatitis A-infected person, including household, sexual, or other
- Travel to endemic country
- Men who have sex with men
- Homelessness
- Injection drug use
Clinical Manifestations
- Incubation period is from 15 to 50 days, with an average of 28 days
- Children are usually asymptomatic
- Symptoms include non-specific influenza-like illness followed eventually by bilirubinuria, pale stools, jaundice, and scleral icterus
- May have hepatomegaly and splenomegaly, may have rash or arthralgia
- Self-limited, usually starting to resolve by the third week of illness with full recovery often taking several months
Diagnosis
Serology
- IgM and IgG antibodies are usually detectable by onset of symptoms
- IgM becomes undetectable by about 6 months while IgG persist lifelong and are protective[1]
IgM | IgG | Interpretation |
---|---|---|
– | – | No recent infection (unless in the incubation period). No prior infection or vaccination. |
– | + | No infection. Prior infection or vaccination. |
? | + | Cannot rule out active infection. Prior infection or vaccination. |
+ | +/– | Acute or recent infection. IgM positive from 2 weeks until 3-12 months. IgG positive from 8-12 weeks and remains positive for lifetime. |
Prevention
Vaccination
- Vaccination is indicated for people at increased risk of acquiring hepatitis A, or at increased risk of severe disease
- Travellers to endemic countries
- People with chronic liver disease
- Men who have sex with men
- People who use recreational drugs
- People living in communities with outbreaks or endemic hepatitis A
- Close contacts of children adopted from endemic countries
- Military personnel and humanitarian relief workers
- People receiving repeated doses of plasma-derived clotting factors
- Laboratory workers studying hepatitis A
- Zookeepers, veterinarians, and researchers who interact with non-human primates
- Vaccination requires two doses spaced at least 6 months apart
- It provides immunity for decades, and possibly for life
Coformulation with Hepatitis B Vaccine
- Often given combined with hepatitis B vaccine (HAHB)
- HAHB is given as three doses (for the hepatitis B component)
- The hepatitis A component contains a full dose of hepatitis A vaccine, so a HAHB series essentially contains an extra unnecessary dose of hepatitis A vaccine
High Risk Groups Who Cannot Receive Vaccine
- In people with contraindications or who are expected to have suboptimal response to vaccination, consider using immunoglobulin as preexposure prophylaxis
- Groups include:
- Infants less than 6 months of age
- Immunocompromised people in whom the vaccine may not be as effective (though they should also still be vaccinated)
- Anaphylaxis after previous hepatitis A vaccination or component thereof
- Administering just before travel can confer immunity for up to 6 months of travel
- Dose is IMIg (GamaSTAN) 0.02 mL/kg for 3 months of protection, or 0.06 mL/kg every 6 months
- CDC recommends a dose of IMIg (GamaSTAN S/D) 0.2 mL/kg q2mo due to decreases in hepatitis A IgG among donors
Publicly Funded in Ontario
- Only a subset of patients are publicly funded in Ontario:
- Intravenous drug use
- Chronic liver disease, including hepatitis B and C
- Men who have sex with men
Post-Exposure Prophylaxis
- Post-exposure prophylaxis is indicated for susceptible contacts including:
- Household members and close contacts of people infected with hepatitis A
- Contacts in group childcare centres and kindergartens
- Co-workers and clients of infected food handlers
- Prophylaxis is with monovalent hepatitis A vaccine
- In people with contraindications or who are expected to have suboptimal response to vaccination, immunogloulin should be given
- Groups include:
- Infants less than 6 months of age
- Immunocompromised people and people with liver disease, who should receive both vaccine and immunoglobulin
- If they have received IVIg ≥400 mg/kg within the 3 weeks before exposure, then they do not require further immunoglobulin
- Elderly susceptible adults age 60 years and older may also receive both
- It should be given as soon as possible, and can be given until 14 days after last exposure
- Dose is IMIg (GamaSTAN) 0.02 mL/kg body weight
- CDC recommends a dose of IMIg (GamaSTAN S/D) 0.1 mL/kg body weight due to decreases in hepatitis A IgG among donors
- Groups include:
- ↑ Jack T. Stapleton, Host Immune Response To Hepatitis A Virus, The Journal of Infectious Diseases, Volume 171, Issue Supplement_1, March 1995, Pages S9–S14, https://doi.org/10.1093/infdis/171.Supplement_1.S9