Infection with hepatitis A virus can cause an unpleasant illness, but most people fully recover. Some people have no symptoms at all. Symptoms include flu-like symptoms and yellowing of your skin and the whites of your eyes (jaundice) which then gradually clear without treatment. Serious problems are very rare. Good personal hygiene (in particular, washing hands after going to the toilet) helps to prevent spreading the virus to others. Immunisation is advised before going to countries where hepatitis A is common and for those people at increased risk of developing hepatitis A.
What does the liver do?
The liver is in the upper right part of the tummy (abdomen). It has many functions which include:
- Storing glycogen (fuel for the body) which is made from sugars. When required, glycogen is broken down into glucose which is released into the bloodstream.
- Helping to process fats and proteins from digested food.
- Making proteins that are essential for blood to clot (clotting factors).
- Processing many medicines which you may take.
- Helping to remove or process alcohol, poisons and toxins from the body.
- Making bile which passes from the liver to the gut down the bile duct. Bile breaks down the fats in food so that they can be absorbed from the bowel.
What is hepatitis and hepatitis A?
Hepatitis means inflammation of the liver. There are a number of things that can cause hepatitis. For example, drinking too much alcohol, various drugs and chemicals, and also several different viruses. One virus that causes hepatitis is called the hepatitis A virus. After first contact with the virus, hepatitis A virus is carried in the bloodstream to the liver. It can then affect your liver to cause hepatitis.
How do you get hepatitis A and how common is it?
Hepatitis A can affect anyone. The virus is passed out in the stools (faeces) of infected people. In areas of poor sanitation, or where disposal of sewage is poor, hepatitis A can become common due to dirty (contaminated) water and food. This means you may become infected with hepatitis A by eating uncooked food prepared or washed in contaminated water, or by drinking contaminated water. Shellfish caught in contaminated water can also carry the hepatitis A virus. Someone who has hepatitis A infection may pass on the infection to others. This can occur through preparing food, or through close contact with another person, if they have not washed their hands properly after going to the toilet.
The highest risk areas of the world for hepatitis A infection include: the Indian subcontinent (in particular, India, Pakistan, Bangladesh, and Nepal), Africa, parts of the Far East (except Japan), South and Central America, and the Middle East.
Hepatitis A has become uncommon in parts of the world where sanitation is generally good, such as the UK and Western Europe. Most cases of hepatitis A infection in the UK are diagnosed in people returning home after travelling to a country where sanitation is poor and risk of hepatitis A infection is higher. Outbreaks in schools and families can sometimes occur in the UK, as the virus is quite easily passed on from person to person if personal hygiene is not good. For example, if infected people do not wash their hands after going to the toilet.
Apart from travellers, there are certain groups of people who may be at increased risk of getting hepatitis A. For example, people who share drug injecting equipment, men who have sex with men, and other people whose sexual practices involve oral-anal contact. Someone's occupation may make them more likely to get hepatitis A infection - for example, sewage workers and laboratory workers may have an increased risk. Also, people who have blood clotting problems such as haemophilia and so need to receive blood clotting factors may have an increased risk. This is because the hepatitis A virus may not be completely destroyed during the preparation of these blood products.
People who are known to have liver problems are not more likely to get hepatitis A infection. However, if they do become infected, the infection is more likely to be severe.
What are the symptoms of hepatitis A?
Symptoms may develop shortly after you become infected with the virus, usually within 2-7 weeks. This time period between first coming into contact with the virus and developing symptoms is known as the incubation period. You may not know you are infected with hepatitis A during the incubation period. However, you can pass on the virus to others during this time if your standard of hygiene is not good. For example, if you do not wash your hands after going to the toilet, and then prepare food.
Following the incubation period, the first symptoms that may develop include:
- Flu-like symptoms. For example, general aches and pains and headaches. (These are the most common symptoms.)
- Tiredness, feeling sick, sometimes being sick (vomiting) and diarrhoea.
- An ache over your liver (the upper part of the right side of your tummy (abdomen) below your ribs).
The above symptoms can last anywhere from a few days to up to two weeks. Jaundice may then develop. Jaundice is a yellow colouration of your skin and the whites of your eyes. Your urine may also turn dark and your stools (faeces) may turn a pale colour. This is due to pigments in your blood not being properly cleared by your inflamed liver. Jaundice can also cause itching of your skin. After jaundice appears, tiredness, feeling sick (nauseated) and vomiting symptoms tend to improve in most people. Jaundice usually lasts somewhere between one and three weeks, but it may last longer in some people. You may also have aching over your liver during the period of jaundice.
Even after the jaundice has faded, hepatitis A infection can leave you feeling tired, off your food and generally weak for some weeks, and sometimes for longer. Most people have fully recovered within two months, although in others it may take up to six months.
In a very small number of people, the illness can be more severe. However, in general, complications are rare (see below). Hepatitis A infection does not become persistent (chronic). This is unlike some other forms of hepatitis such as hepatitis B and C which can cause a chronic infection.
Note: in some people, hepatitis A infection only causes mild symptoms and no jaundice. In others, particularly in children aged under 5, no symptoms develop at all (this is known as subclinical infection).
How is hepatitis A diagnosed?
Your doctor my suspect hepatitis A infection by your typical symptoms. A simple blood test can detect if you are infected with the hepatitis A virus. The test detects an antibody against the virus which you make when you are first infected.
A different antibody persists long-term after the infection has cleared. This antibody keeps you immune from future infection. A blood test can detect this second antibody which shows if you have had hepatitis A in the past, and that you are now immune.
If hepatitis A is suspected, your doctor may also suggest other blood tests called liver function tests. These measure the activity of chemicals (enzymes) and other substances made in the liver. This gives a general guide as to whether your liver is inflamed, and how well it is working. See the separate leaflet called Liver Function Tests for more details.
Are there any possible complications?
Serious illness is rare with hepatitis A infection. The illness can be unpleasant and make you feel quite ill, but most people make a full recovery. However, in a small number of cases, the infection can cause severe liver inflammation leading to liver failure. This is more common in older people who develop this infection. An extremely small number of people die from severe hepatitis A infection. A liver transplant can be life-saving if liver failure develops.
Somewhere between 1 to 2 in 10 people who get hepatitis A infection will seem to recover but will then have a return (relapse) of their symptoms between about 1 and 3 months after their original illness. This is because the infection hadn't cleared completely. This relapse will have similar symptoms to the initial illness. Some people can have a relapse of their symptoms more than once.
What is the treatment for hepatitis A?
There is no specific treatment needed for hepatitis A. It is usually a self-limiting illness which means it usually goes away on its own. Your immune system will normally clear away the infection. Most people with hepatitis A infection don't need to be admitted to hospital. However, admission to hospital may be suggested if you are severely ill or you are being sick (vomiting) and are lacking in body fluid (dehydrated).
Treatment is aimed at relieving your symptoms. It is common to feel more tired than usual when you have hepatitis A so you may need to have plenty of rest. Your doctor may be able to suggest some painkillers and some antisickness medication if needed. To help ease the symptom of itch, keep cool, wear loose clothing and avoiding hot baths or showers. Avoiding fatty foods may help to reduce the feeling of sickness. Also, you should not drink alcohol whilst you are ill.
During your illness, your doctor may also want to keep a check on how your liver is working by repeating blood tests from time to time to look at this.
It is important to have excellent personal hygiene to reduce the risk of passing the virus on to others. Thoroughly wash your hands after going to the toilet. You should also avoid handling food and having unprotected sex when you are infected with the virus. Ask your doctor when it is safe for you to return to work, or for your child to return to school or nursery.
In the UK, hepatitis A infection is a notifiable disease. This means that your doctor will need to notify, or inform, the health protection unit (HPU) in your area. This unit should then get involved in contacting people with whom you have been in close contact. For example, there may be household contacts who may be at risk of getting hepatitis A infection themselves. Depending on the individual circumstances, it may be suggested that such people have a hepatitis A vaccine or other injection called an immunoglobulin injection. However, you should be reassured that the HPU has a duty of confidentiality to you as the infected person. This means that they do not have to disclose your name or any other details about you to your contacts if you do not wish them to.
How can I prevent hepatitis A infection?
Immunisation against hepatitis A is recommended before travelling to certain countries where hepatitis A is common. See your doctor or practice nurse, ideally 4-6 weeks before the date of travel. Also, immunisation is sometimes advised for contacts of people who develop the illness. In certain other circumstances, there might be groups of people who may be at increased risk of infection. See separate leaflet called Hepatitis A Immunisation for details.
Take care when eating and drinking
You should avoid eating and drinking the following when travelling to high-risk countries:
- Raw or inadequately cooked shellfish.
- Raw salads and vegetables that may have been washed in dirty (contaminated) water. (Wash fruits and vegetables in safe water and peel them yourself.)
- Other foods that may have been grown close to the ground such as strawberries.
- Untreated drinking water, including ice cubes made from untreated water. (Remember also to use only treated or bottled water when brushing your teeth.)
- Unpasteurised milk, cheese, ice cream and other dairy products.
Also be careful when buying food from street traders. Make sure that food has been recently prepared and that it is served hot and on clean serving plates. Food that has been left out at room temperature (for example, for a buffet) or food that may have been exposed to flies could also pose a risk.
Note: if you have had hepatitis A infection, you will be immune to further infection. This means that you can't catch the infection again.
Dr Tim Kenny
Dr Louise Newson
Dr Adrian Bonsall