Hepatitis A

Hepatitis A

Introduction

Hepatitis A is a type of viral liver infection uncommon in England but widespread in other parts of the world, such as Africa and India.

Initial symptoms of hepatitis A are similar to flu and include:

  • mild fever – usually no higher than 39.5ºC (103.1ºF)
  • joint and muscle pain
  • feeling and being sick
  • diarrhoea

This may then be followed by symptoms related to the liver becoming infected, such as:

  • jaundice – yellowing of the skin and eyes
  • passing very dark urine and pale stools
  • itchy skin
  • a swollen and tender liver

Symptoms usually clear up within two months, although occasionally last up to six months. Older adults tend to have more severe symptoms.

In most cases the liver will make a full recovery.

Read more about symptoms of hepatitis A.

Treating hepatitis A

There is no cure for hepatitis A, so treatment involves making a person feel as comfortable as possible until the infection clears up.

This involves:

  • getting plenty of rest
  • using painkillers to relieve pain – always make sure you never exceed the recommended dose as this could further damage your liver
  • taking steps to help reduce itching
  • taking a type of medication called an antiemetic to help with the symptoms of nausea and vomiting
  • allowing your liver to rest – for example, avoiding alcohol and certain medications

Read more about treating hepatitis A.

What causes hepatitis A?

Hepatitis A is caused by the hepatitis A virus.

The virus is most commonly spread through the “faecal-oral” route. This is when you put something in your mouth that has been contaminated by the stools of someone with hepatitis A.

Eating foods such as shellfish contaminated by raw sewage can also lead to you becoming infected, as can drinking contaminated water.

Less commonly, hepatitis A can be spread through:

  • sharing a needle with an infected person to inject drugs
  • during sex (particularly anal sex)

The condition can also spread through close personal contact in closed environments, such as student halls, boarding schools and army barracks.

Read more about the causes of hepatitis A.

Who is affected?

Hepatitis A is widespread in parts of the world that are poor, overcrowded and have limited access to sanitation and clean water.

Regions where hepatitis A is most common include:

  • sub-Saharan and north Africa
  • the Indian subcontinent (particularly Bangladesh, India, Nepal and Pakistan)
  • some parts of the Far East (excluding Japan)
  • the Middle East
  • South and Central America

Hepatitis A is much less common in high-income countries. There were only 367 reported cases of hepatitis A infection in England and Wales during 2010. It is unclear how many of these infections were actually caught abroad.

Hepatitis A is most common in young children, but often goes undetected as it tends not to cause any symptoms in this age group.

Other groups with an increased risk of catching hepatitis A include:

  • men who have sex with men
  • people who regularly inject drugs
  • sewage workers
  • people who travel to or work in less developed countries

Vaccination may be recommended for high-risk groups.

Vaccination

As hepatitis A is rare in England, children are not routinely vaccinated against it.

Vaccination is normally only recommended if you are travelling to certain parts of the world or you are at a high risk of infection.

Read more about the hepatitis A vaccine and who should have it.

Preventing the spread of infection

An infection of hepatitis A can often be prevented if vaccination and immunoglobulin are provided within two weeks of being exposed to the virus.

If you are diagnosed with hepatitis A, it is important that anyone you could have infected is tested for the condition.

Testing may be recommended for:

  • people who live with you
  • people you have recently prepared food for
  • any person you have had sex with

It is also important to practise good hygiene, such as washing your hands after going to the toilet and before preparing food. Extra precautions include not sharing towels, eating utensils or toothbrushes.

Read more about hygiene and how to prepare food safely.

Complications

In most people the infection will pass without causing any long-term problems. Once the infection passes, you normally develop life-long immunity against the virus.

However, around 15% of people experience a relapse of symptoms a few months after the original infection, and this can happen more than once.

Serious complications tend to only occur in people with pre-existing liver disease, or elderly people, with the most serious being liver failure (where the liver loses most or all of its functions).

Once liver failure has occurred, it is usually possible to sustain life for several years using medication. However, a liver transplant is currently the only option for curing liver failure.

Read more about the complications of hepatitis A.

Symptoms of hepatitis A

It takes two to six weeks for symptoms of hepatitis A to develop after coming into contact with the virus (the incubation period).

The average incubation period is around four weeks.

Initial symptoms

During the initial stage of hepatitis A (known as the prodromal phase), symptoms are similar to flu and include:

  • mild fever – usually no higher than 39.5ºC (103.1ºF)
  • feeling sick or being sick
  • sore throat
  • loss of appetite
  • feeling tired all the time (fatigue)
  • joint and muscle pain
  • abdominal pain

Other symptoms at this stage can include a headache, cough, constipation, diarrhoea or a skin rash. If you smoke, you may find you lose your taste for tobacco during this time.

Liver symptoms

Around 10 days after initial symptoms begin you will probably experience symptoms directly related to your liver (known as the icteric phase).

These include:

  • jaundice – yellowing of the skin and eyes
  • passing dark urine and pale stools
  • itchy skin
  • your liver being swollen and tender

At this stage the initial symptoms, such as fatigue, loss of appetite and nausea, may improve.

It is likely you will completely recover within a couple of months, although a small number of people have a return of symptoms (relapses). In a small number of cases, symptoms may persist for up to six months.

Once you have recovered from hepatitis A, you are normally immune from it and should never catch the virus again.

When to seek medical advice

You should always contact your GP if you think you have hepatitis A, particularly in the following circumstances:

  • you have recently travelled to a part of the world known to have high rates of hepatitis A, such as Africa, India or Pakistan – the incubation period can be up to six weeks, so it may have been a couple of months since your trip
  • you develop jaundice

While hepatitis A is not usually a serious illness, it is important to get it properly diagnosed in case your symptoms are the result of a more serious condition, such as hepatitis C (a more serious type of viral infection) or cirrhosis (scarring of the liver).

Also, it may be necessary to test your friends, family and any sexual partners in case you have spread the infection to them.

Causes of hepatitis A

Most cases of hepatitis A are thought to occur when a person is travelling in parts of the world that:

  • have high levels of poverty
  • are overcrowded
  • have limited access to sanitation and clean water 

The most common cause of hepatitis A is eating food contaminated by the stools of an infected person as a result of poor personal hygiene.

For example, you may get hepatitis A if you eat food prepared by an infected person who has not washed their hands properly.

It is also possible to become infected with hepatitis A by drinking contaminated water. This includes using ice cubes made from contaminated water and eating raw fruit or vegetables washed in contaminated water.

Also, shellfish can be infected if harvested from sea contaminated with sewage.

Hepatitis A in England

Although it is much less common, it is still possible to catch hepatitis A in England.

Known risk factors include:

  • being a man who has sex with other men – read more about issues related to gay health
  • regularly injecting illegal drugs
  • working with or near sewage – untreated sewage is often contaminated by hepatitis A
  • working in institutions where levels of personal hygiene may be poor, such as a homeless shelter
  • living or working in closed environments, such as student halls, boarding schools and army barracks
  • working with primates (monkeys, apes, baboons, chimps, gorillas), as these can also be infected with hepatitis A
  • having haemophilia – people with this blood clotting disorder often require a type of medication called a clotting agent derived from human blood, which can sometimes become infected with the hepatitis A virus

If you are in one of the above groups, it is usually recommended you receive the hepatitis A vaccine.

Diagnosing hepatitis A

If you have been in contact with someone infected with hepatitis A, or you begin to have symptoms associated with hepatitis A, such as jaundice (yellowing of the skin and eyes), see your GP.

Your GP will be able to diagnose hepatitis A with a blood test. If this shows a positive reaction to antibodies (proteins produced by your immune system to fight disease), it means your body is making antibodies to fight the hepatitis A virus present in your blood.

Further testing is usually only required if:

  • the diagnosis is uncertain
  • your symptoms show no sign of improvement after a few months
  • there is concern you may have developed complications such as liver failure (loss of normal liver function)

In these circumstances, one or more of the following tests may be recommended:

  • liver function test – a type of blood test that can be used to check how well your liver is working
  • ultrasound scan – where high-frequency sound waves are used to build up an image of the inside of your liver
  • liver biopsy – where a small sample of liver tissue is removed and checked for any problems

Treating hepatitis A

Complications of hepatitis A

Complications of hepatitis A can include the infection returning (relapse), cholestasis, or, in rare cases, liver failure.

Relapse

Around 15% of people with hepatitis A experience a relapse, where the infection returns with the same symptoms. 

A relapse usually occurs around one to four months after the original illness, and this can happen more than once.

Cholestasis

A complication that can affect older adults with hepatitis A is bile building up inside the liver. Bile is a substance used to help digest fats and is normally moved out of the liver into the gallbladder. The medical term for this build-up is cholestasis.

Symptoms of cholestasis include:

  • persistent jaundice (yellowing of the skin and eyes) that can often last longer than three months
  • a high temperature (fever) of or above 38ºC (100.4ºF)
  • diarrhoea
  • weight loss

Cholestasis will normally resolve by itself without the need for treatment.

Liver failure

A rare and potentially fatal complication of hepatitis A is that the infection stops the liver working properly. This is known as liver failure.

This complication usually occurs in those:

  • with a pre-existing liver disease, such as cirrhosis (scarring of the liver) or hepatitis C (a more serious type of liver infection)
  • with a weakened immune system (which could be the result of a condition such as diabetes, or as a side effect of a treatment such as chemotherapy)

Some symptoms of liver failure are similar to hepatitis A and include jaundice, nausea and vomiting.

Other symptoms of liver failure include:

  • a tendency to bruise and bleed easily (for example, frequent nosebleeds or bleeding gums)
  • hair loss 
  • fever and shivering attacks because you’re more prone to infections
  • oedema – a build-up of fluid in the legs, ankles and feet
  • ascites – a build-up of fluid in the abdomen, which can make you look heavily pregnant
  • drowsiness and confusion

It is often possible to compensate for the loss of normal liver function using medication, but a liver transplant is necessary to achieve a complete cure.

Hepatitis A vaccination

There are three main types of Hepatitis A vaccination, which are all highly effective.

Who should be vaccinated

Vaccination against hepatitis A is recommended if you:

  • are planning to travel to or live in parts of the world where hepatitis A is widespread, particularly if levels of sanitation and food hygiene are expected to be poor
  • have any type of long-term (chronic) liver disease
  • have haemophilia (a blood disorder than can affect the ability of blood to clot properly)
  • are a man who has sex with other men
  • regularly inject illegal drugs 
  • work with or near sewage (untreated sewage is often contaminated by hepatitis A)
  • work in institutions where levels of personal hygiene may be poor, such as a homeless shelter
  • work with primates (monkeys, apes, baboons, chimps, gorillas) as these can also be infected with hepatitis A

If you are unsure whether you should be vaccinated against hepatitis A, check with your GP.

Vaccination is not considered necessary if you are travelling to northern or western Europe, North America, Australia, New Zealand or Japan.

Types of vaccine

The three types of vaccine that protect against hepatitis A infection are:

  • monovalent vaccine, which provides protection against hepatitis A 
  • combined hepatitis A and hepatitis B vaccine – hepatitis B is another type of liver infection most common in China, Africa and southeast Asia
  • combined hepatitis A and typhoid fever vaccine – typhoid fever is a serious type of bacterial infection

If you need vaccination because you are travelling, a single injection of the vaccine should be given two weeks before you leave, although it can be given up to the day of your departure if necessary.

This will protect you against hepatitis A for about a year. A booster dose, given six to 12 months after the first dose, will protect you for at least 20 years.

The type of vaccine that is best for you will depend on your individual circumstances. For example, combined vaccines may be recommended if you are planning to travel to parts of the world that also have high levels of hepatitis B and typhoid fever. The combined vaccines will need to be given four to six weeks before you travel.

Your GP can give you a vaccination for hepatitis A on the NHS. Travel health clinics can also give this vaccination, but there may be a charge.

The hepatitis A vaccine cannot be given to babies under the age of one.

Side effects

After having the hepatitis A vaccine, some people develop temporary soreness, redness and hardening of the skin at the injection site. A small, painless lump may also form at the injection site. This usually disappears quickly and is not a cause for concern.

Much less common side effects include:

  • tiredness
  • headache
  • loss of appetite
  • nausea
  • a slightly raised temperature – a normal temperature is 36-36.8ºC (96.8-98.24ºF)