by Dr. Adele Visser
Introduction
Globally, Hepatitis A Virus (HAV) affects up to 1,4 million people every year. The incidence in South Africa correlates directly with socioeconomic conditions, where clean water and proper sanitation is protective. Although there is an effective vaccine which provides long-term protection, it is not currently included in the Extended Programme on Immunization (EPI). Despite this, up to 80% of children aged 11-13 demonstrated HAV-IgG antibodies, indicating natural exposure to the virus.
Transmission
HAV persists in the environment for prolonged periods, however is inactivated by boiling water (for at least 1 minute) and exposure to bleach (1:100 dilution). Transmission occurs through person-to-person spread, ingestion of fecally contaminated food or water, anal-oral intercourse and very rarely through blood products.
Transmission
There is no clear clinical feature of HAV infection and serological confirmation is therefore necessary. The patient typically presents with raised transaminases (ALT and AST) indicating hepatic inflammation, in excess of 10-100 the upper limit of normal. Acute hepatitis A virus infection with have coinciding anti-HAV-IgM. The presence of anti-HAV IgG indicates either prior infection or vaccination, however is very often found to be present during acute infection as well.
Prevention of HAV
Sanitation and safe water and food sources is essential in limiting endemic spread of HAV. The second tier of prevention remains vaccination. Despite the availability of a safe and effective vaccine, it is not currently included in the South African EPI. The vaccines can be used in both pre-and post-exposure prophylaxis. The vaccine is safe for use in pregnancy and immunocompromised individuals.
Treatment of HAV
Pooled intramuscular immunoglobulin (HNIG) provides passive immunity to HAV and should be considered as post-exposure prophylaxis. This should preferably be given within 72 hours of exposure, however administration up to 4 weeks after exposure may reduce severity of disease.
No specific anti-viral treatment is currently available for HAV and treatment is therefore supportive. Administration of IV fluid and limitation of alcohol intake are the only real management modalities. In cases of fulminant hepatitis, the option of a liver transplant may be offered. Isolation of patients are only indicated if fecally incontinent.
Return to work and/or physical activity should only be undertaken upon complete normalization of both AST and ALT.
References
1. http://www.who.int/news-room/fact-sheets/detail/hepatitis-a
2. National Guidelines for the Management of Hepatitis NICD