What is the recommended prevention and treatment for hepatitis A infection?

Hepatitis A Prevention and Treatment

Prevention: Vaccination is the Cornerstone

All children should receive hepatitis A vaccine at age 12-23 months, with catch-up vaccination for unvaccinated children aged 2-18 years, as this represents the most effective strategy to reduce morbidity and mortality from hepatitis A. 1

Routine Childhood Vaccination

• Universal vaccination of children aged 12-23 months should be integrated into the routine childhood vaccination schedule 1
• Children not vaccinated by age 2 years can receive catch-up vaccination at subsequent visits 1
• The vaccine series must be completed according to licensed schedules (typically 2 doses, 6-18 months apart) for long-term protection 1, 2
• Routine childhood vaccination programs have dramatically reduced large community outbreaks and hepatitis A rates to the lowest levels ever recorded 3, 2

High-Risk Adult Populations Requiring Vaccination

The following groups should receive hepatitis A vaccination to prevent severe outcomes and mortality 1, 2:

• Travelers to endemic areas (countries with high or intermediate HAV endemicity) - vaccination should begin as soon as travel is considered 1, 2
• Men who have sex with men 1, 2
• Users of injection and non-injection illicit drugs 1, 2
• Persons with chronic liver disease (including hepatitis B, hepatitis C, cirrhosis) - this group has substantially higher risk for fulminant hepatic failure with case-fatality rates reaching 1.8% in adults >50 years 3, 1, 4
• Persons awaiting or who have received liver transplants 1, 2
• Persons with clotting-factor disorders 1, 2
• Persons experiencing homelessness - added to recommendations due to increased risk and difficulty implementing hygiene measures 5

Pre-Travel Prophylaxis Strategy

For travelers to endemic areas, start hepatitis A vaccination as soon as travel is considered, with protection assumed within 4 weeks after the first dose. 1, 2

Timing-Based Algorithm

• Departure >4 weeks away: Administer hepatitis A vaccine alone; protection develops within 4 weeks 1, 2
• Departure <4 weeks away: Administer hepatitis A vaccine PLUS immune globulin (IG) 0.02 mL/kg at a separate anatomic injection site for optimal protection 3, 1, 2
• For older adults, immunocompromised persons, or those with chronic liver disease departing <2 weeks: Administer both vaccine and IG simultaneously at separate sites 3
• Travelers who cannot receive vaccine (age <12 months, vaccine allergy): Administer IG 0.02 mL/kg for protection up to 3 months, or 0.06 mL/kg for travel >2 months 3

Postexposure Prophylaxis

Persons recently exposed to HAV who have not previously received hepatitis A vaccine should receive immune globulin (0.02 mL/kg) as soon as possible, ideally within 2 weeks of exposure. 1, 2, 4

Specific Exposure Scenarios

• Household and close personal contacts of serologically confirmed hepatitis A cases should receive IG 1
• Persons who shared illicit drugs with an infected person should receive both IG and hepatitis A vaccine 1
• IG is >85% effective at preventing infection when administered within 2 weeks of exposure 4

Treatment: Supportive Care Only

Supportive treatment is the cornerstone of HAV management, as no specific antiviral medications are effective against this self-limiting infection. 4

Outpatient Management

• Symptomatic relief addressing nausea, vomiting, and malaise as they occur 4
• No dietary restrictions - patients may eat according to tolerance 4
• No activity restrictions - patients may resume activities as tolerated 4
• Oral hydration is typically sufficient for fluid maintenance 4

Indications for Hospitalization (Critical for Reducing Mortality)

Hospitalization is required for 4:

• Severe dehydration from intractable nausea and vomiting unresponsive to oral rehydration
• Signs of acute liver failure including encephalopathy, coagulopathy, or rapidly rising bilirubin
• High-risk patients with underlying chronic liver disease who are at increased risk for fulminant hepatic failure

Clinical Course and Prognosis

• Most infections are self-limited, lasting <2 months 3
• Up to 20% of patients may experience prolonged or relapsed course lasting up to 6 months 1
• Overall case-fatality ratio is 0.3-0.6%, but reaches 1.8% in adults >50 years 3, 1
• Persons with chronic liver disease (HBV, HCV) are at substantially increased risk for acute liver failure and require closer monitoring 3, 4

Critical Pitfalls to Avoid

• Do not overlook chronic liver disease - patients with pre-existing HBV or HCV have dramatically higher mortality risk and should be monitored more closely 4
• Do not delay IG administration for postexposure prophylaxis - efficacy decreases significantly after 2 weeks 1, 4
• Do not assume protection is immediate - vaccine protection requires 4 weeks to develop; use IG for immediate protection when needed 1, 2
• Do not forget contact tracing - identify household members, sexual contacts, and close personal contacts for IG administration 4