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Definition
Hepatitis refers to inflammation of the liver, which is usually the result of a viral infection or liver damage caused by excessive consumption of alcohol. However, hepatitis can also be caused by other toxic agents, such as medication or chemicals (Farlex Partner Medical Dictionary, 2012; NHS, 2022).
Hepatitis A virus is one of the infectious agents that causes inflammation in the liver. It is a small, unenveloped (there is no lipid bilayer membrane on the outer part of the virus) ribonucleic acid (RNA) virus within the genus hepatovirus, a member of the picornaviridae family (Virology Research Services, 2022; Travel Health Pro, 2023). Unenveloped viruses can be more virulent and tend to be more resistant to heat, dryness, extreme pH levels and simple disinfectants (Virology Research Services, 2022). Following ingestion, it penetrates and replicates in the gut mucosa, then travels to the liver cells via the portal blood.
The infection induces adaptive and innate immune responses, which trigger an acute inflammatory process in the liver. This normally resolves spontaneously without long-term damage (World Health Organization, 2022).
Symptoms
Hepatitis A virus often causes mild illness and is commonly an asymptomatic disease, especially in children. However, it tends to become more severe with advancing age and can have fatal outcomes (Travel Health Pro, 2023; World Health Organization, 2023).
The infection has an average incubation time of 28 days, but can last from 15–50 days (Travel Health Pro, 2023). There are four phases of hepatitis A infection, but not all patients will experience all stages.
First, there is the incubation period, which can last for 2–6 weeks (British Liver Trust, 2017). Although there may not be symptoms during this stage, the carrier can potentially be infectious. The second stage is known as the early symptom or prodromal phase, usually lasting around 10 days (British Liver Trust, 2017). The symptoms during this phase are often mild and influenza-like, and can include:
- malaise
- fatigue
- weight loss
- vomiting
- abdominal discomfort
- diarrhoea (British Liver Trust, 2017)
Symptoms can less commonly include:
- fever
- headaches
- arthralgia
- myalgia (World Health Organization, 2022)
The National Institute for Health and Care Excellence (2021) suggests that people with hepatitis should avoid work, school or nursery, until they are no longer infectious. People are typically no longer infectious 7 days after the onset of jaundice, or 7 days after the onset of symptoms if jaundice is not present.
The third stage, known as the icteric phase, typically lasts 1–3 weeks (but can last up to 12 weeks), with symptoms including:
- jaundice
- dark urine
- pale stools
- itchy skin
- enlarged and tender liver, spleen and lymph nodes (British Liver Trust, 2017)
The final stage is where most people fully recover from infection, which can take up to 6 months (British Liver Trust, 2017). Over 99% of people recover completely from hepatitis A infection, but relapse of symptoms has been reported in 3–20% of clinical cases worldwide (World Health Organization, 2022). A small proportion of those infected can develop serious and life-threatening complications, especially people with pre-existing liver disease and those with older age (>50 years) (Webb et al, 2020; Travel Health Pro, 2023; World Health Organization, 2023). Once a patient has completely recovered, they usually have lifelong immunity to hepatitis A viral infection (British Liver Trust, 2017).
Aetiology
Hepatitis A is contracted via the faecal–oral route either by direct person-to-person contact or more commonly via contaminated food and water (Travel Health Pro, 2023; World Health Organization, 2023; UK Health Security Agency, 2024a). Hepatitis A is highly infectious; people only need to be in contact with a very small amount of the virus to contract it. It is passed out of the bowel in faeces, and passed on orally. This is usually through close contact with someone who has the virus or by ingesting contaminated food and water either directly from the host or indirectly via sewage. This virus can also be spread through blood-to-blood contact, but this is very rare (British Liver Trust, 2017).
Hepatitis A still persists in vulnerable populations – anyone who has not had the disease or been vaccinated – with an estimated 1.4 million annual cases globally and 7000 deaths (World Health Organization, 2023). A report in 2019 stated that there were 503 confirmed new cases since the previous year in the UK (Public Health England, 2021). Hepatitis A also remains one of the most common travel-related vaccine-preventable diseases (Travel Health Pro, 2023).
The condition rarely arises in the UK, with most cases occurring in travellers who have recently visited countries where it is more prevalent (Travel Health Pro, 2023). Hepatitis A is common in areas with poor sanitation and hygiene practices. The highest risk areas include:
- Africa
- south and south-east Asia
- central and South America
- some parts of the middle east
- eastern Europe (Travel Health Pro, 2023; UK Health Security Agency, 2024b)
Travellers visiting countries where hepatitis A virus is endemic will be at greater risk of infection. Their risk will vary depending on the country they visit, length of stay, living conditions and activities (Travel Health Pro, 2023). In recent decades, the UK has had several outbreaks of hepatitis A, usually among susceptible groups, such as men who have sex with men and people who inject drugs (Public Health England, 2021).
Outbreaks associated with food have also increased in the last decade, particularly in frozen berries, both within the UK and across Europe (UK Health Security Agency, 2024b). Foods that grow close to the ground, such as strawberries and lettuce, can be at greater risk from contamination, as can raw or undercooked meat and fish (Travel Health Pro, 2023). Some occupations may put workers at greater risk from being exposed to sewage or faeces, such as sewage workers or healthcare workers (British Liver Trust, 2017).
Diagnosis
Clinically, it can be difficult to distinguish hepatitis A from other acute viral hepatitis. The only definitive diagnosis is via a blood screen for hepatitis A virus-specific immunoglobulin G or M antibodies (World Health Organization, 2023). Additional tests may include reverse transcriptase polymerase chain reaction to detect the hepatitis A virus RNA, but this may require specialised laboratory facilities (World Health Organization, 2023).
Hepatitis A is a notifiable disease in the UK (Public Health England, 2018; Travel Health Pro, 2023). If a healthcare professional suspects a patient to have hepatitis A, they should fill out the Hepatitis virus investigation request form from the UK Health Security Agency (2023).
Management
There is no specific treatment for hepatitis A infection; it is managed using supportive interventions and symptom control. It is advised that patients avoid hepatoxic medication and alcohol while they are unwell. Hospitalisation and higher-level medical interventions would usually only be required in severe disease and acute liver failure, or occasionally for fluid balance maintenance (World Health Organization, 2022, 2023).
Prevention
The main methods by which the transmission of hepatitis A virus can be prevented are good hygiene practices and sanitation. Vaccination also plays a key role in preventing infection and transmission of the virus. From a public health perspective, case investigation and contact tracing during outbreaks is also vital in containing transmission rates (Webb et al, 2020).
Travellers should maintain good hygiene practices, especially when it comes to hand hygiene. Hands should be washed after visiting the toilet, changing nappies and always before eating or preparing food (Travel Health Pro, 2023). Making informed choices around consumption of food and water is imperative while in endemic countries to reduce the risk of infection. Some foods and drinks to avoid include:
- tap water (drinking or cleaning teeth) and ice cubes
- salads, uncooked vegetables and fruit
- unpasteurised dairy products, such as milk or ice cream
- food that is preprepared and left out for long periods of times, such as at buffets and street food stands
- raw or undercooked meat and fish, especially shellfish (Travel Health Pro, 2019)
Other ways to reduce the risk of infection would be adhering to safe sex, such as the use of condoms or a dental dam. Practicing good hand hygiene post sexual encounters, especially when anal or oral sex are involved, is strongly advised (British Liver Trust, 2017; Public Health England, 2018). Materials should not be shared for injecting or snorting drugs, including needles, spoons, straws or banknotes (British Liver Trust, 2017).
Vaccination
The hepatitis A vaccine is the most effective method of preventing infection. Vaccination would be beneficial to anyone travelling to an endemic country or those who may be at greater risk of infection in the UK, including those who are homeless and men who have sex with men.
The vaccine can either be a monovalent (havrix, avaxim and vaqta, which include both adult and paediatric preparations) or in combination with hepatitis B (twinrix, includes adult and paediatric preparations; and ambrix, only paediatric preparation). They are all inactivated vaccines, so they do not contain any live organisms. These vaccines are always given as an intramuscular injection. A singular monovalent vaccine gives the patient or traveller protection for at least 1 year and ideally should be given 2 weeks before travel, but can be given up to the day of travel (UK Health Security Agency, 2024b).
It is recommended that a booster is given at 6–12 months after the initial vaccine, which then gives 25 years of immunity (UK Health Security Agency, 2024b). The standard schedule for the combined hepatitis A and B vaccine depends on the product. The UK Health Security Agency (2024b) Green Book recommends that until further evidence is available, a booster should be offered to those at continued risk at 25 years. The Green Book also suggests that if the boosters are significantly interrupted or delayed, there is no need for the course to be restarted.
NMC proficiencies
Nursing and Midwifery Council: standards of proficiency for registered nurses
Part 1: Procedures for assessing people’s needs for person-centred care
1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages
Part 2: Procedures for the planning, provision and management of person-centred nursing care
9. Use evidence-based, best practice approaches for meeting needs for care and support with the prevention and management of infection, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions
9.1 observe, assess and respond rapidly to potential infection risks using best practice guidelines
Resources
British Liver Trust. New hepatitis A leaflet from the British Liver Trust. 2017. https://britishlivertrust.org.uk/new-hepatitis-leaflet-british-liver-trust/ (accessed 17 April 2024)
Farlex Partner Medical Dictionary. Hepatitis. 2012. https://medical-dictionary.thefreedictionary.com/hepatitis (accessed 17 April 2024)
National Institute for Health and Care Excellence. Scenario: managing hepatitis A infection. 2021. https://cks.nice.org.uk/topics/hepatitis-a/management/managing-hepatitis-a-infection/ (accessed 17 April 2024)
NHS. Hepatitis. 2022. https://www.nhs.uk/conditions/hepatitis/ (accessed 17 April 2024)
Public Health England. National minimum standards and core curriculum for immunisation training for registered healthcare practitioners. 2018. https://assets.publishing.service.gov.uk/media/5a7aea0c40f0b66eab99d8ab/Training_standards_and_core_curriculum_immunisation.pdf (accessed 17 April 2024)
Public Health England. Laboratory reports of hepatitis A infections in England and Wales, 2019. 2021. https://assets.publishing.service.gov.uk/media/608c22e38fa8f51b9988cc42/hpr0715_HAV19_v2.pdf (accessed 17 April 2024)
Travel Health Pro. Food and water hygiene. 2019. https://travelhealthpro.org.uk/factsheet/44/food-and-water-hygiene (accessed 17 April 2024)
Travel Health Pro. Hepatitis A. 2023. https://travelhealthpro.org.uk/factsheet/21/hepatitis-a (accessed 17 April 2024)
UK Health Security Agency. Hepatitis viruses investigation request form. 2023. https://www.gov.uk/government/publications/hepatitis-viruses-investigation-request-form (accessed 17 April 2024)
UK Health and Security Agency. Hepatitis A infection: prevention and control guidance. 2024a. https://www.gov.uk/government/publications/hepatitis-a-infection-prevention-and-control-guidance (accessed 17 April 2024)
UK Health Security Agency. Hepatitis A: Green Book, chapter 17. 2024b. https://www.gov.uk/government/publications/hepatitis-a-the-green-book-chapter-17 (accessed 17 April 2024)
Virology Research Services. Enveloped vs. non-enveloped viruses. 2022. https://virologyresearchservices.com/2022/05/22/enveloped-vs-non-enveloped-viruses/ (accessed 17 April 2024)
Webb GW, Kelly S, Dalton HR. Hepatitis A and hepatitis E: clinical and epidemiological features, diagnosis, treatment, and prevention. Clin Microbiol Newsl. 2020;42(21):171-179. https://doi.org/10.1016/j.clinmicnews.2020.10.001
World Health Organization. WHO position paper on hepatitis A. 2022. https://www.who.int/publications/i/item/who-wer9740-493-512 (accessed 17 April 2024)
World Health Organization. Hepatitis A. 2023. https://www.who.int/news-room/fact-sheets/detail/hepatitis-a (accessed 17 April 2024)