Hepatitis A

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The most common type of hepatitis in children, hepatitis A is spread by eating food or drinking water contaminated with the hepatitis A virus that is shed in the stool. Formerly known as "infectious hepatitis," hepatitis A tends to occur in cycles. In the United States, cases peaked from 1961 to 1971, declined, and then peaked again from 1983 to 1991; numbers dropped again after 1992. Food has been implicated in more than 30 outbreaks since 1983. It was implicated in 2004 in a large out break at a Pennsylvania Chichi's Restaurant, later traced to tainted scallions from Mexico.

Hepatitis A belongs to the enterovirus group of the picornaviruses, which include polio virus, cox-sackie virus, echo virus, and rhinovirus. The virus enters through the mouth, multiplies in the body, and is passed in the feces; it can then be carried on an infected child's hands and spread by direct contact, or by eating food or drink handled by that person. While anyone can get hepatitis A, it occurs most often among children, most of whom become infected either from close personal contact between family members or in nursery schools or child-care centers.

The virus is hardy and spreads easily. Unlike many other viruses, it can live for more than a month at room temperature on kitchen counter-tops, children's toys, and other surfaces. It can be maintained indefinitely in frozen foods and ice. To inactivate the virus, food must be heated at 185°F for one minute.

A food handler can spread the disease by touching food that is not cooked before it is eaten, such as sandwiches or salads. Well water contaminated by improperly treated sewage also has been implicated, since hepatitis A can live for a long time in untreated water. It is possible to get hepatitis A from eating raw or undercooked foods, such as shellfish, especially oysters. Shellfish filter large amounts of water as they eat, and if it is contaminated with hepatitis A, the virus will be concentrated in the shellfish.

outbreaks of hepatitis A among children attending day care have occurred since the 1970s. Because infection among children is usually mild or asymptomatic and patients are infectious before they develop symptoms, outbreaks are often only recognized when adult contacts (usually parents) get sick. Poor hygienic practices among staff who change diapers and prepare food contribute to the spread of hepatitis A. Outbreaks rarely occur in child-care settings serving only toilet-trained children.

Symptoms Infants and young children tend to have very mild symptoms; three-quarters of children have no symptoms. The rest have low fever and achiness, but rarely jaundice. In the rest, the disease is characterized by fever (100 to 104°F), extreme tiredness, weakness, nausea, stomach upset, pain in the upper right side of the stomach, appetite loss. Within a few days, a yellowish tinge appears in the skin and whites of the eyes. Urine will be darker than usual and the stool is light colored. Anyone over age 12 may become quite sick for a week or two. once the jaundice appears, patients begin to feel better. The disease is rarely fatal and most children recover in a few weeks without any complications. The incubation period ranges from 15 to 50 days, and children are most infectious in the two weeks before symptoms develop.

Diagnosis Blood tests showing antibodies to hepatitis A are the best diagnosis. Symptoms of hepatitis A are so similar to other diseases that a doctor needs a test to make the correct diagnosis.

Treatment There is no drug treatment for hepatitis A. While symptoms appear, children should rest and eat a low-fat, high-carbohydrate diet in small amounts (such as crackers, noodles, rice, or soup). Antiemetics may be prescribed for severe nausea. Headaches or body aches may respond to acetaminophen. Normal activities may be resumed when the acute illness is over.

Complications Rarely hepatitis A develops into fulminant hepatitis in which the child's liver cells are completely destroyed. As liver function stops, toxic substances build up and affect the brain, causing lethargy, confusion, combativeness, stupor, and coma. This can often be fatal, although the patient may live with aggressive treatment. If the child does not die, the liver is able to regenerate and resume function and the brain recovers.

Prevention A new vaccine said to be 100 percent effective after a single primary dose became available in 1996 in the United States for children two years of age and older. The hepatitis A vaccine currently is recommended for children living in areas with consistently higher rates of hepatitis A, including 11 states where the prevalence of hepatitis A is more than twice the national average: Alaska, Arizona, California, Idaho, Nevada, New Mexico, Oklahoma, Oregon, South Dakota, Utah, and Washington. Routine vaccination also can be considered in six states where the prevalence of hepatitis A is less than twice, but still higher than the national average: Arkansas, Colorado, Texas, Missouri, Montana, and Wyoming. In addition, the vaccine is recommended for children traveling to countries where the disease is highly prevalent, including all countries and regions other than Canada, Japan, Australia, New Zealand, Scandinavia, and Western Europe. The vaccine is also recommended for children with chronic liver disease or blood-clotting disorders.

Although hepatitis A outbreaks sometimes occur in child-care settings, these outbreaks do not happen often enough to make it necessary for child-care providers or children in child care to be routinely vaccinated against hepatitis A. However, workers in child-care centers where there are diapered children must maintain strict rules about frequent hand-washing and procedures for diaper changing.

In addition, cooking contaminated food kills the virus. Shellfish from contaminated areas must be cooked (boiled) for at least eight minutes to be considered safe for eating.

Those who are exposed to hepatitis A can prevent infection by getting a shot of immunoglobulin (Ig), which is pooled human blood plasma that contains protective antibodies against the disease. People who need a shot of Ig include:

• all household members of someone with hepatitis A

• close friends of an infected school-age child

• if three or more children in day care or their families have hepatitis A, family members of the other children need Ig as well

• unimmunized travelers to developing countries

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