Hepatitis A
Hepatitis A has a worse name than it deserves. It is inflammation of the liver caused by a virus that travels on unwashed hands, in water and in food.
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Hepatitis A has a worse name than it deserves. It is inflammation of the liver caused by a virus that travels on unwashed hands, in water and in food. Unlike hepatitis B and C it never becomes chronic: a person either goes through it and recovers completely, or never notices having had it at all. The liver repairs itself, no carrier state is left behind, no lifelong monitoring is needed. The danger lies elsewhere — in the uncommon but severe course seen in people whose liver is already damaged and in older adults, and in the fact that someone is infectious before they realise they are ill.
How the virus gets in
The virus leaves an infected person in the stools and ends up in someone else's mouth. The route is shorter than it sounds: unwashed hands on the person who cooked, or the water a salad was rinsed in, are enough. In practice it happens like this:
- drinking water, and ice made from water that should not have been trusted;
- raw vegetables, herbs and berries washed in that water;
- shellfish and oysters from contaminated coastal water: they filter the water and concentrate the virus, and light cooking does not destroy it;
- any food touched by someone infected who did not wash their hands after the toilet — this is how outbreaks start in cafés and at family gatherings;
- close household contact at home, in a nursery or in shared accommodation;
- sex, particularly oral-anal contact;
- sharing needles when injecting drugs.
The virus is hardy: it survives hours on hands and surfaces, months in water, and it tolerates freezing. Alcohol hand gel works less well against it than against most germs, so washing with soap under running water is more reliable than rubbing on gel.
Geography counts for a great deal. Where water and sanitation are dependable the infection is rare and most adults have no protection against it. Across Africa, South and South-East Asia, the Middle East and Central and South America the virus is widespread, which is why hepatitis A remains the classic traveller's illness.
What it feels like
Two to six weeks pass between infection and the first signs, usually about a month. By then the holiday is long over and the connection with the trip is not obvious.
The start does not look like liver trouble at all: a few days of fever, aching muscles, headache, no appetite, a dull ache under the right ribs, sometimes nausea, vomiting and loose stools. Many people put it down to a stomach bug or flu. Then the urine darkens to the colour of strong tea, the stools by contrast turn pale as clay, the skin and the whites of the eyes yellow, and intense itching may appear. Once the jaundice arrives the fever usually settles and the person starts to feel better, although the tiredness outlasts everything else.
The younger the person, the quieter the illness. In children under six hepatitis A usually runs without jaundice and without any obvious symptoms, yet they are fully infectious, and they pass it to the adults at home, in whom it will be a far harder illness.
It generally takes a few weeks, less often two or three months. In roughly one person in ten it comes in waves: after a clear improvement the jaundice and the tiredness return, and this can go on for up to six months. It is neither a complication nor a slide into chronic disease, but a drawn-out recovery, and it too ends in full repair.
When a doctor is needed urgently
In a very small proportion of people the liver cannot keep up and acute liver failure develops. The risk is higher over the age of fifty, in anyone who already has liver disease or chronic hepatitis B or C, and in people with a weakened immune system. This is treated in hospital only, and delay is expensive here.
Call an ambulance (in Europe, the single number 112) or take the person to hospital if, on top of jaundice, any of these appear:
- confusion, unusual drowsiness, odd behaviour, trembling hands, speech that does not make sense;
- vomiting that has made it impossible to drink and keep fluids down for more than a day;
- easy bleeding: bruises with no knocks, nosebleeds or bleeding gums, black stools, blood in the vomit;
- severe and worsening pain under the right ribs, with a visibly swollen abdomen;
- in a child, marked drowsiness, refusal to drink, dry lips and no wet nappies or no urine.
The same day, though without an ambulance, you should be seen if the skin or eyes turn yellow, if the urine goes dark and the stools pale, or if jaundice appears in a pregnant woman, an older person, or someone already being treated for liver disease.
How the diagnosis is confirmed
One blood test settles it: the laboratory looks for class M antibodies against the hepatitis A virus. They appear with the first symptoms and last a few months, and their presence means a recent infection rather than an old one. Antibodies of the other class stay for life and indicate either a past illness or a vaccination.
Alongside this, the damage to the liver is assessed: liver enzymes, bilirubin and clotting tests. Hepatitis B and C are often checked at the same time, because the routes of infection overlap in places and their treatment and outlook are entirely different. Hepatitis A is one of the infections a doctor must report to the public health service, and that is done not for the patient's sake but for the people who shared a table with them: they may need vaccinating without delay.
What to do while it runs its course
No medicine kills the hepatitis A virus, and none is needed: the body manages by itself, and the help consists of not getting in the liver's way and not passing the infection on.
- Rest and fluids. The tiredness can last for weeks, and that is normal; strength comes back gradually. Drink plenty, especially if you are vomiting.
- No alcohol at all until the blood tests are back to normal, and preferably for some months afterwards.
- Care with medicines. A damaged liver handles much of what was previously taken without a second thought far less well. Paracetamol is not forbidden, but the dose must be agreed with the doctor: it may be lower than usual. Anti-inflammatory painkillers, food supplements and herbal preparations are best set aside without the doctor's approval, and any regular medication should be discussed separately.
- Ordinary food. No special diet is called for: eat what appeals and does not bring on nausea.
- For itching, a cool shower rather than a hot one, loose cotton clothing and a well-aired room all help; if the itch keeps you awake, the doctor can prescribe something.
A person becomes infectious about two weeks before the first signs — which is the whole difficulty — and stays infectious for around a week after the jaundice appears. For that period it is worth not cooking for others, using your own crockery, washing your hands thoroughly after the toilet and not sharing a towel. Sex is better postponed: barrier protection does not fully cover this route. A child goes back to nursery or school and an adult back to work about a week after the jaundice starts; for anyone working with food, with children or in healthcare the timing is set separately.
How to avoid it
The most reliable protection is the vaccine. It contains inactivated virus, is well tolerated, is given as two doses a few months apart, and after the full course it protects for decades. The first dose starts working after about two weeks, so vaccination before a trip has to be arranged in good time rather than the night before the flight. Countries place hepatitis A differently in their schedules — some vaccinate all children, others only the risk groups — so the schedule is checked against local recommendations.
Vaccination is worth it if you are travelling somewhere the infection is common, if you have chronic liver disease or hepatitis B or C, if your work involves sewage, caring for people or catering, if you have a clotting disorder, if you inject drugs, and for men who have sex with men.
Contact with a case is a separate matter. If someone in the household or in a children's group falls ill, the rest are vaccinated urgently, within the first days after contact: given that soon, the vaccine can prevent the illness or greatly soften it. Small children, older people and those with weakened immunity may be given ready-made antibodies, that is immunoglobulin, instead of the vaccine or alongside it.
The travel rules are simple: drink bottled or boiled water and turn down ice, eat food hot and freshly cooked, peel fruit and vegetables yourself, avoid raw shellfish and street salads, and wash your hands with soap. The vaccine protects only against hepatitis A and not against the other gut infections, so these rules still apply to the vaccinated.
Online consultation
A remote appointment is useful here at two points. Before a trip, to work out whether you need the vaccine and how far ahead of the flight to have it. And when the illness is suspected: the doctor will go through what you ate and where, assess the colour of urine and stools, ask to see your eyes on camera, arrange the right tests and explain what to do about the household, who may need vaccinating at once. Later, results, regular medication and the date of returning to work are all handled online. Feeling the liver and taking blood cannot be done at a distance, and confusion, unstoppable vomiting or bleeding alongside jaundice are not something to wait for an appointment about — that is a reason to call an ambulance.
This material is for information only and does not replace medical advice.
Consult with a doctor about Hepatitis A
Discuss your symptoms and possible next steps with a doctor online.
Online doctors for Hepatitis A
Discuss your symptoms and possible next steps for Hepatitis A with a doctor online.
