What are the prevention and treatment options for an adult patient with possible exposure to hepatitis A and E through travel or contaminated food and water?

Prevention and Treatment of Hepatitis A and E After Travel Exposure

Immediate Post-Exposure Management for Hepatitis A

For adults with possible hepatitis A exposure through contaminated food or water during travel, administer hepatitis A vaccine within 2 weeks of exposure for postexposure prophylaxis, with consideration of adding immune globulin (IG) for those over 40 years, immunocompromised patients, or those with chronic liver disease. 1

Timing-Critical Decision Algorithm

• Within 2 weeks of exposure: Hepatitis A vaccine is effective as postexposure prophylaxis 1
• After 2 weeks: Postexposure prophylaxis should NOT be provided as the window for effectiveness has passed 1
• High-risk patients (older adults, immunocompromised, chronic liver disease): Consider adding IG to vaccine for optimal protection 1

Pre-Travel Prevention Strategy

All travelers to countries with high or intermediate hepatitis A endemicity should receive hepatitis A vaccination before departure, with vaccine alone sufficient for healthy adults under 40 years regardless of departure timeline. 1, 2

• Healthy travelers <40 years: Single dose of hepatitis A vaccine at any time before departure provides adequate protection 2
• Older adults, immunocompromised, chronic liver disease patients: IG can be added to vaccine if traveling within 2 weeks for optimal protection 1
• Complete the series: Second dose at 6-12 months for long-term protection 2

Common-Source Food Exposure Specifics

Hepatitis A vaccine or IG administration to restaurant patrons is typically NOT indicated after a food handler diagnosis, but may be considered only if the handler directly touched uncooked/cooked foods while having diarrhea or poor hygiene AND patrons can be treated within 2 weeks. 1

• The 2-week window is absolute—beyond this, prophylaxis is ineffective 1
• In institutional cafeterias with repeated exposures, stronger consideration for prophylaxis is warranted 1

Hepatitis E Management

Prevention Challenges

There is no widely available vaccine or postexposure prophylaxis for hepatitis E in most countries, making prevention through avoidance of contaminated food and water the primary strategy. 3, 4

• HEV is the most common cause of viral hepatitis in Asia and is transmitted fecal-orally 3
• Pregnant women are at highest risk: HEV can cause fulminant hepatitis with significant mortality in this population 3
• Immunocompromised patients can develop chronic HEV infection 3

Treatment Approach for Established Infection

For acute hepatitis E infection, treatment is primarily supportive, but ribavirin should be considered for immunocompromised patients developing chronic infection or those with severe acute disease. 4

• Most acute HEV infections are self-limiting and require only supportive care 4
• Ribavirin is the main therapeutic option for chronic HEV in immunocompromised patients 4
• Pegylated interferon-alpha has shown conflicting results 4

Diagnostic Approach After Travel

Order IgM anti-HAV as the first-line test for suspected hepatitis A; if negative, proceed with anti-HEV IgM testing if the patient traveled to endemic areas. 3

Clinical Presentation Clues

• Adults >70% develop jaundice, dark urine, clay-colored stools, and tender hepatomegaly 3
• Peak infectivity occurs 14-21 days before jaundice onset, when patients may be asymptomatic 5
• HAV accounts for 75% of travel-related viral hepatitis cases, particularly from Mexico, Central America, and South America 3

Critical Pitfalls to Avoid

• Never restart an interrupted vaccine series—continue where you left off to avoid wasting doses and delaying protection 2
• Do not assume vaccination status protects—verify actual vaccination records, as many travelers remain unvaccinated despite recommendations 3
• Do not dismiss luxury travel as low-risk—HAV transmission occurs even in upscale accommodations 3
• Do not provide postexposure prophylaxis beyond the 2-week window—it is ineffective and wastes resources 1

Preventive Hygiene Measures

Travelers should avoid untreated water and ice, raw or undercooked foods (especially shellfish), and food from street vendors or establishments with poor sanitation. 3, 2

• HAV requires heating to >185°F (85°C) for at least 1 minute for inactivation 5
• Surfaces can be disinfected with 1:100 dilution of household bleach 5
• Good personal hygiene remains one of the most important control measures 6