Multaq Warnings : The large majority of patients with hepatitis A recover without complications. Hospitalization and supportive care may be necessary for very ill patients who are unable to eat or drink fluids. Occasionally, patients may suffer from fatigue and malaise for several months after the disease resolves. About 1 percent of individuals with hepatitis A, usually those over age fifty, develop serious liver failure, sometimes fulminant. These patients require hospitalization and supportive care. In the United States, about one in three hundred cases of hepatitis A results in death or emergency liver transplantation.
Hepatitis A virus is spread primarily by the fecal-oral route. The virus is excreted in feces of infected people and infects susceptible individuals who consume contaminated water or foods. Water, shellfish, and salads are the most frequently implicated sources of transmission. Cold cuts, fruits, fruit juices, milk, and vegetables also have been implicated in various outbreaks. Hepatitis A is more common in underdeveloped parts of the world with poor sanitary conditions, and travelers to these regions are at an increased risk for infection. The time from infection with hepatitis A virus to onset of symptoms varies from ten to fifty days. Thirty days is the average. The greatest danger of infecting others occurs during the middle of the incubation period and before presentation of symptoms. The patient remains potentially infectious up until a week or more after the onset of symptoms.
Although ingestion of contaminated food and water is the most common route of transmission, hepatitis A virus can be transmitted in other ways. Infected individuals can spread the virus to others who live in the same household or with whom they have sexual contact. In particular, hepatitis A virus may be spread by sexual practices in which the mouth comes in direct contact with the anal area of an infected individual. Homosexual men are at an increased risk for hepatitis A. Casual contact at work or in social settings usually does not spread the virus. Hepatitis A virus infection, however, can be spread among children and employees in child-care centers where a child or employee is infected. Residents and staff workers in institutions for developmentally disabled persons are at a particularly increased risk for being infected with hepatitis A virus. There also have been reports of transmission by sharing contaminated materials among intravenous drug users.
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The most important issue regarding hepatitis A is prevention. There are three primary ways to prevent hepatitis A—hygiene, passive immunity, and vaccination. Hygienic measures to prevent hepatitis A infection include preventing the contamination of food and water and avoiding contact with contaminated foods. In many developing countries, widespread sewage systems have not been constructed, especially in rural areas. Water from lakes and rivers into which people defecate may be used for drinking, washing, or preparing foods. Living conditions are often crowded. Only overall improvement in the socioeconomic structure can remedy these problems. Visitors to such areas should avoid drinking from the local water supply and eating fresh fruits or vegetables that may have been washed with water from local rivers, lakes, or reservoirs. Locally caught shellfish also should not be consumed. If local water must be consumed, it should be boiled first.
People living in the same household as an individual with hepatitis A, or individuals working in situations where the disease is common, should follow commonsense rules. Hand washing should be strictly observed, especially when using the bathroom and before preparing or eating food. People working in child-care centers or institutions for developmentally disabled individuals should wash their hands after changing diapers or sheets, before eating, or after any close contact with residents.
Passive immunization with immune globulin is recommended for short-term protection against hepatitis A and for persons who have been exposed to the hepatitis A virus. Immune globulin is a concentration of antibodies pooled from the blood of individuals with IgG antibodies against the hepatitis A virus. Immune globulin should be administered to individuals who will be traveling to endemic areas chat have not received vaccination far enough in advance of departure (about four weeks) for it to be effective. The U.S. Centers for Disease Control and Prevention (cdc.gov) provides recommendations for travelers going to various parts of the world. Immune globulin should also be given to individuals who may have been exposed to hepatitis A virus within two weeks of suspected exposure.
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Hepatitis A vaccines provide long-term protection against hepatitis A. Two shots administered in six- to twelve-month intervals are given. Vaccination is recommended for individuals who will travel to or work in areas where hepatitis A is endemic. Again, the U.S. Centers for Disease Control and Prevention provides recommendations for travelers to various parts of the world. The first dose of vaccine should be given at least four weeks before travel. This usually provides protection for a short trip, but a booster is necessary six to twelve months later for long-term protection.
Children in communities with high rates of hepatitis A should also be vaccinated. These communities include Alaska Native villages, Native American reservations, and some religious communities, for example, the Kiryas Joel Hassidic community in New York. Homosexual men should also be vaccinated, as should people who use street drugs. Individuals with chronic liver diseases should be vaccinated as hepatitis A virus infection may be more severe in individuals with another underlying liver disease. This may be particularly true for individuals with chronic hepatitis C. People with some other chronic diseases, such as inherited clotting factor deficiencies like hemophilia, should also be vaccinated. Hepatitis A vaccination is not recommended for all health care workers; however, those working in high-risk environments, such as institutions for the developmentally disabled, should receive the hepatitis A vaccine. Individuals who work with hepatitis A virus-infected animals or with the hepatitis A virus in a research laboratory should also be vaccinated.
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