Hepatitis A

Dr. Muhammad Asif Gul TR Gastroenterology

Hepatitis A
It is an acute liver disease caused by the hepatitis A virus (HAV), lasting from a few weeks to several months. It does not lead to chronic infection.

Nature of HAV virus

HAV is a 27 30 nm spherical particle with cubic symmetry Contain linear single stranded RNA genome with size of 7.5 kb. Only one serotype

HAV characteristics
HAV are stable to treatment with 20% ether, acid and heat at 600c for 1 hour. The virus are destroyed by autoclaving at 1210c for 20 minutes, boiling in water for 5 minutes Treatment with chlorine 1 ppm for 30 minutes Heating food > 850c for 1 minute destroys

Epidemiology
A major communicable disease in the developing world. Well cooked food and sanitary water supply will protect the individual living Community hygiene is important in schools, hostels and jails, as overcrowding and poor sanitation favour the spread.

Hepatitis A Virus Transmission

Close personal contact (e.g., household contact, child day care centers)
Contaminated (e.g., infected shellfish) food, water food handlers, raw

Blood exposure (rare) (e.g., injecting drug use, transfusion) Not transmitted by Transplacental route

Etiology
HAV is one kind of picornavirus and used to be classified as enterovirus type72, but recently, it is considered to be classified as heparnavirus Hepatitis A virion is a naked spherical particle, diameter 27nm Consists of a genome of linear, single-stranded RNA, 7.5kb. The genome may be divided into 3 coding region: P1 region (encoding structural protein), P2 and P3 regions (encoding nonstructure protein)

Etiology
During acute stage of infection, HAV can be found in blood and feces of infected human and primates Marmoset and chimpanzee are susceptible animals

Etiology
HAV can not cause cytopathy, replicate within cytoplasm of hepatocytes and via bile are discharged with feces Only one antigen-antibody system. Anti-HAV IgM is diagnostic evidence of recent infection, IgG is protective antibody.

Pathogenesis
HAV invade into human body by mouth and cause viremia. After one week, the HAV reach liver cells replicate within. Then enter intestine with bile and appear in feces. Some believe that damage of liver cells maybe caused by immune response. HAV does not cause cytopathy

Pathogenesis
After HAV replicating and discharging, liver cells damage begin Animal experiment proved that immune complex may attend the pathogenesis of HA Complement level reduce the pathogenesis maybe following: activated T cell secrete -INF that promote the representation of HLA-antigen on the liver cells, CTL may kill the target cell infected with HAV

Clinical Manifestations
Incubation period 2 6 weeks May be asymptomatic Overt illness in 5% Present as two stages: 1 Preicteric 2 Icteric

Laboratory Diagnosis
Acute infection is diagnosed by the detection of HAV-IgM in serum by EIA. Past Infection i.e. immunity is determined by the detection of HAV-IgG by EIA. Cell culture difficult and take up to 4 weeks, not routinely performed Direct Detection EM, RT-PCR of faeces. Can detect

illness earlier than serology but rarely performed.

Treatment
No specific antiviral drug is available Treatment is symptomatic Specific passive prophylaxis by pooled normal human immunoglobulin given before exposure or in early incubation period can prevent or attenuate clinical illness.

Clinical Complications

Complications:

Fulminant hepatitis Cholestatic hepatitis Relapsing hepatitis None

Chronic sequelae:

Vaccination for HAV

Hepatitis A vaccination is recommended for all children starting at age 1 year, travellers to certain countries, and others at risk. A safe and effective formalin inactivated alum conjugated vaccine containing HAV grown in human diploid cell culture is available A full course containing two intramuscular injections of the vaccine Protection starts after 4 weeks after injection and lasts for 10 20 years

Vaccination Strategies Epidemiologic Considerations

Many cases occur in community-wide outbreaks no risk factor identified for most cases highest attack rates in 5-14 year olds children serve as reservoir of infection Persons at increased risk of infection travelers homosexual men injecting drug users

Hepatitis A Prevention - Immune Globulin

Pre-exposure
travelers to intermediate HAV-endemic regions and high

Post-exposure (within 14 days)

Routine household and other intimate contacts Selected situations institutions (e.g., day care centers) common source exposure (e.g., food prepared by infected food handler)

Preventing Hepatitis A
Hygiene (e.g., hand washing) Sanitation (e.g., clean water sources) Hepatitis A vaccine (pre and post exposure) Immune globulin (pre and post exposure)

Prevention
Control of source of infection Cut off the route of transmission Protection of susceptible population
Active immunity Passive immunity