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Hepatitis A infection

On alert for outbreaks

Walker, Barbara Wyand BSN, RN, CIC

doi: 10.1097/01.NURSE.0000531014.78460.95
Department: COMBATING INFECTION
Free

Barbara Wyand Walker is an infection control coordinator at Greenbrier Valley Medical Center in Ronceverte, W.V.

The author has disclosed no financial relationships related to this article.

THE WORD HEPATITIS comes from the Greek words for liver (hepa) and inflammation (itis).1 Not all hepatitis illnesses are contagious; some are caused by various toxins and chronic alcohol use. However, certain viruses, notably hepatitis A, B, C, D, and E, can be transmitted person-to-person.

Hepatitis A (HAV), hepatitis B (HBV), and hepatitis C (HCV) are the most common of these viral diseases. Although they cause similar signs and symptoms, they're caused by different viruses and differ in several ways. For example, HBV and HCV are spread by contact with blood and body fluids containing blood; HAV is spread mainly by oral ingestion of the virus.2

This article focuses on HAV. Although the number of HAV infections in the United States has decreased in recent years, recent outbreaks underscore the need for an understanding of the disease; identification of signs and symptoms; and methods of prevention and treatment.3

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Transmission

Highly infectious, HAV is usually spread via the fecal-oral route by contact with feces through handling stool, consumption of contaminated food or water, and possibly exposure during sex or other close personal contact.2 In the United States—although individual cases are usually associated with travel to countries where HAV is endemic, or close contact with an infected person—most common-source outbreaks are related to undercooked or uncooked contaminated food. Examples include salads or fruits handled by infected food handlers, or contaminated foods not cooked to a temperature sufficient to kill the virus (185° F [85° C] for 1 minute).3 Although outbreaks associated with water contamination are rare in areas with a well-maintained water supply and good sanitation, contamination can occur with sewage runoff into wells, streams, or swimming areas.3

HAV can live outside the body for months in certain environmental conditions such as poor sanitation and improper sewage disposal. It's not likely spread by drinking tap water because chlorination as recommended in the United States kills HAV that enters the water supply. Heating water or foods to greater than 185° F (85° C) for 1 minute can also kill the virus, but even cooked food can spread infection if it's contaminated after cooking.3

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Prevalence

In 2016, 1,808 cases of HAV were reported in the United States and its territories.4 In 2016, the CDC and FDA investigated two HAV outbreaks that stemmed from the consumption of contaminated foods: the first was attributed to strawberries imported from Egypt used in smoothie drinks, and the second to raw scallops from the Philippines that were distributed in Hawaii. The first outbreak made 134 individuals ill in nine states, with 52 hospitalized.5 In the second outbreak, localized to three of the Hawaiian Islands, 292 individuals became ill with 94 hospitalized.6

An ongoing outbreak in California that started in 2017 doesn't appear related to a common source, but rather to individuals reporting homelessness and/or using illicit drugs in areas of poor sanitation. According to the California Department of Health, HAV is being spread person-to-person and through contact with fecally contaminated environments. The outbreak has involved several counties in California as well as several other states. As of February 2018, 694 individuals have been reported infected, with 45 hospitalizations and 21 deaths. Lab testing has shown that the causative strains are linked epidemiologically.7

Anyone who's not been vaccinated or previously infected can become infected with HAV. The highest risk is associated with consumption of raw or undercooked foods, poor sanitation, lack of safe water, use of recreational drugs, cohabitation with an infected person, life in isolated or crowded populations (such as a prison or a closed religious community), sexual activity with someone with acute HAV, and travel to areas of high endemicity without being immunized.2,8

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Signs and symptoms

The disease varies in severity from asymptomatic illness to severely disabling disease lasting several months. In endemic areas, infection usually manifests as a mild or asymptomatic illness in childhood, but in nonendemic areas, onset of illness in adults is usually abrupt. In the early stages, HAV may manifest as influenza-like signs and symptoms, such as malaise, fever, myalgia, abdominal pain, anorexia, nausea with or without vomiting, and diarrhea. As the disease progresses, substances normally metabolized and eliminated by the liver begin to build up in the blood, which causes jaundice and other signs and symptoms, such as headache; arthralgia and myalgia; dark (tea-colored) urine; pale, white, or clay-colored (acholic) stool; and abdominal tenderness with hepatosplenomegaly.9 However, many infected individuals are asymptomatic, and children are less likely to experience symptoms than adults.10

Incubation averages 28 days with a range of 15 to 50 days. HAV is usually a self-limiting disease, with signs and symptoms typically lasting less than 2 months; a small number of individuals (10% to 15%) have prolonged or relapsing disease for up to 12 months.9 Unlike HBV and HCV, HAV doesn't cause chronic infection, and lifelong immunity results after recovery.2,8 Fatalities are rare, ranging from 0.1% to 0.3% of cases, and are more likely in individuals over 50 and those with underlying chronic hepatic disease, such as HCV infection.8,9,11

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Diagnosis

In the absence of signs and symptoms, only a blood test may diagnose HAV infection. Serum immunoglobulin (Ig)M anti-HAV antibodies (IgM anti-HAV) are detectable 5 to 10 days after exposure and on symptom onset. The antibodies typically peak during the acute stage, and remain detectable for several months afterward.9,11 Serum IgG antibodies appear during the convalescent phase and remain in the bloodstream as evidence of past infection or vaccination.11 The presence of serum IgG antibodies (IgG anti-HAV) in the absence of IgM doesn't represent acute infection and isn't cause for alarm when reviewing lab tests. Additional diagnostic studies include reverse transcriptase polymerase chain reaction to detect the HAV RNA.8 Other tests include serum alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and bilirubin, which are biochemical markers of liver injury. Serum albumin, bilirubin, and prothrombin time are markers of hepatocellular function. Imaging studies aren't usually necessary to diagnose HAV, but may be ordered to rule out other disorders with similar symptoms.11

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Nursing considerations

Obtain a comprehensive food and travel history on admission. HAV is a reportable infectious disease. Following facility policy and procedure, notify the local Department of Health as soon as diagnosis is confirmed so that case-finding and community surveillance can begin as soon as possible. These activities help health authorities determine if an outbreak is in progress. In an outbreak, mass prophylaxis with HAV vaccine may be indicated for caregivers and household contacts, and possibly patrons of food establishments if a common source is found among food handlers with acute HAV infection.9

HAV infection is usually self-limited and treatment is mainly supportive. The patient is most infectious during the first 2 weeks of illness; take precautions against enteric transmission during this time. Observe standard precautions with added contact precautions for diapered or incontinent patients. Practice meticulous hand hygiene; don gloves and gowns for contact with stool or items possibly contaminated with feces, such as bed linens, diapers, and bedside commodes. Monitor intake and output, with assessment of urine and stool characteristics. Depending on the patient's clinical status, administer I.V. fluids, antiemetic agents, and analgesics as prescribed.12

Recommended postexposure prophylaxis (PEP) after confirmed exposure, as recommended by the CDC and public health departments, includes:5,9

  • HAV vaccine for healthy patients between ages 1 and 40.
  • HAV-specific immune globulin for patients outside this age range, but the HAV vaccine can be substituted if it isn't available.

Patients with evidence of previous vaccination or infection don't require PEP.

Before patient discharge, case management may need to be involved for referral for home health, particularly for older adults or those who live alone. Patient and family education should include the need for the patient to rest and avoid strenuous activities during the period it takes for the liver to return to normal functioning.12 A dietitian can teach the patient and family about the prescribed diet, which may include high-calorie, high-protein foods in small meals. Instruct patients to avoid alcohol and discuss all medications, including over-the-counter medications and vitamins, with their healthcare provider in order to identify those that are metabolized by the liver or might cause liver damage.13

The family shouldn't share items such as toothbrushes and eating utensils, and all should practice good hand hygiene.12 Teach proper hand hygiene using soap and warm water for 15 to 20 seconds with special attention to the fingernails, between fingers, and wrists after contact with the patient and items in the patient's environment, such as bathroom surfaces, bed linens, or laundry, and when removing gloves.14 Use alcohol-based handrub in the absence of soap and water, although it isn't clear if these rubs are effective against HAV. Don't assume family and patients know how to use these: Instruct them to rub until dry (approximately 20 seconds) and wash thoroughly with soap and water as soon as possible.15 Also emphasize the importance of safe food preparation. (See Food safety tips for traveling.)

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Vaccination

HAV vaccines were recommended by the CDC and the American Academy of Pediatrics in the United States beginning in 1996 and have been given as a routine childhood vaccine in this country since 2006. The vaccine is given in a series of two I.M. injections at least 6 months apart.2 Three vaccine preparations are currently available: two single-antigen vaccines against HAV alone, which are approved for anyone over 12 months; and one combination HAV and HBV vaccine, which is approved for adults over 18 years.16 Since vaccination began, the number of cases reported annually dropped from 31,000 cases to fewer than 2,000, representing an approximate 95% decrease.2,16

Young children are routinely vaccinated between their first and second birthdays; vaccination isn't recommended for children under 12 months. The vaccine is particularly recommended for children who may be exposed to outbreaks in day care facilities or other venues, children with chronic liver disease, and children who have a coagulation disorder, such as hemophilia.10 Older children and adults who haven't been vaccinated previously and want to be protected against HAV, for instance before traveling to areas where HAV is endemic, should also get the vaccine.3,14,16 For recommendations on HAV and other vaccines, check this website before traveling: wwwnc.cdc.gov/travel. Your local health department can also advise.

Most individuals who get the HAV vaccine don't have any complications, although serious allergic reactions can occur with any vaccine. The most commonly reported adverse reactions to the HAV vaccine include discomfort and erythema at the injection site.17

Before administering the vaccine, give patients (or their parents) a vaccine information sheet listing indications, contraindications, and adverse reactions. This form is available at www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-a.pdf.

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Stay alert

Despite decreasing numbers of patients with HAV infection, or perhaps because of this, nurses must continue to be alert to the possibility of this diagnosis and knowledgeable on how to diminish the risk to themselves and others. Healthcare agency staff and facilities in areas where care of immigrants and tourists is expected should remember that even though vaccination against HAV is available, most adults in the United States, as well as adults and children from areas where HAV is prevalent, haven't been vaccinated and may be infected.

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Food safety tips for traveling

DO eat and drink:

  • Food that's cooked and served hot
  • Hard-cooked eggs
  • Fruits and vegetables you've washed in clean water and peeled yourself
  • Pasteurized dairy products, including milk
  • Bottled water that's sealed (carbonated is safer)
  • Water that's been disinfected (boiled, filtered, treated)
  • Ice made with bottled or disinfected water
  • Carbonated drinks
  • Hot coffee or tea.

DO NOT eat or drink:

  • Food served at room temperature
  • Food from street vendors
  • Raw or soft-cooked (runny) eggs
  • Raw or undercooked (rare) meat or fish
  • Unwashed or unpeeled raw fruits and vegetables
  • Peelings from fruit or vegetables
  • Condiments (such as salsa) made with fresh ingredients
  • Salads
  • Unpasteurized dairy products, including milk
  • “Bushmeat” (monkeys, bats, or other wild game)
  • Tap or well water
  • Ice made with tap or well water
  • Drinks such as reconstituted juice made with tap or well water
  • Flavored ice or popsicles.

In addition:

  • Wash your hands often.
  • If soap and water aren't available, clean your hands with hand sanitizer containing at least 60% alcohol.
  • Don't touch your eyes, nose, or mouth unless your hands are clean.
  • Avoid close contact, such as kissing or hugging individuals who are sick.
  • Don't share eating utensils or cups with individuals who are sick.
  • Get the hepatitis A vaccines, if unvaccinated.

Source: Centers for Disease Control and Prevention. Hepatitis A. What can travelers do to prevent disease? 2013. wwwnc.cdc.gov/travel/diseases/hepatitis-a.

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REFERENCES

1. Online Etymology Dictionary. 2018. http://www.etymonline.com/index.php.
2. Centers for Disease Control and Prevention. Viral hepatitis: hepatitis A information. 2017. http://www.cdc.gov/hepatitis/hav/index.htm.
3. Centers for Disease Control and Prevention. Viral hepatitis: hepatitis A questions and answers for health professionals. 2017. http://www.cdc.gov/hepatitis/hav/havfaq.htm#general.
4. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report (MMWR). Table II: Provisional cases of selected notifiable diseases, and selected low frequency diseases, United States and U.S. territories, weeks ending November 11, 2017, and November 12, 2016. http://www.cdc.gov/mmwr/volumes/66/wr/mm6645md.htm.
5. Centers for Disease Control and Prevention. Viral hepatitis: 2016 – Multistate outbreak of hepatitis A linked to frozen strawberries (final update). 2016. http://www.cdc.gov/hepatitis/outbreaks/2016/hav-strawberries.htm.
6. State of Hawaii, Department of Health: Disease Outbreak Control Division. Hepatitis A outbreak 2016. 2017. http://health.hawaii.gov/docd/hepatitis-a-outbreak-2016.
7. California Department of Public Health. Hepatitis A outbreak in California. 2018. http://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/Hepatitis-A-Outbreak.aspx.
8. World Health Organization. Hepatitis A: fact sheet. 2016. http://www.who.int/mediacentre/factsheets/fs328/en.
9. American Public Health Association. In: Heymann DL, ed. Control of Communicable Diseases Manual. 20th ed. 2015.
11. Lai M, Chopra S. Hepatitis A virus infection in adults: epidemiology, clinical manifestations, and diagnosis. Up To Date. 2018. http://www.uptodate.com.
12. Lippincott Williams and Wilkins. Lippincott's Guide to Infectious Diseases. Philadelphia, PA: Lippincott Williams and Wilkins; 2011.
14. Centers for Disease Control and Prevention. Hand hygiene in healthcare settings. 2017. http://www.cdc.gov/handhygiene/providers/index.html.
15. Centers for Disease Control and Prevention. Travelers' health: hepatitis A. 2013. https://wwwnc.cdc.gov/travel/diseases/hepatitis-a.
16. Centers for Disease Control and Prevention. Hepatitis A questions for health professionals. 2017. http://www.cdc.gov/hepatitis/hav/havfaq.htm.
17. U.S. Department of Health & Human Services. 2018. http://www.vaccines.gov.
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