Contents
- What is hepatitis A?
- How is hepatitis A transmitted?
- Symptoms of Hepatitis A
- Consequences of hepatitis A
- Diagnosis of hepatitis A
- Hepatitis A vaccination
- Hepatitis A treatment
- Diet for hepatitis A
- Hepatitis A Prevention
Acute viral liver damage – Botkin’s disease. Currently, the disease is identified as hepatitis A. The main signs of the disease are: weakness, high fever, chills, profuse sweating, icteric staining of the skin and visible mucous membranes, urine the color of dark beer, colorless feces.
What is hepatitis A?
Hepatitis A – This is an RNA virus, belongs to the Picornoviridae family, the genus Enteroviruses. Its size is 27-30 nm. The virus has no shell. Typing was carried out in 1973. Further, four more human virus genotypes and three monkey genotypes were identified.
It has been established that, regardless of genotypes, all type A viruses have similar antigenic, immunogenic and protective properties. That is, one serotype, of the virus, is determined by the same standard sets of reagents, can be prevented by the same vaccines.
The stability of the virus in a humid environment, at a temperature of:
from 20 to 220C – 3-4 weeks;
from 4 to 6 ° С – 3-4 months;
to 600C – up to 12 hours;
1000C – up to 5 minutes.
Active chlorine at a concentration of up to 2,0 mg / ml and above inactivates the virus within 15 minutes. The concentration of active chlorine below 2,0 mg/ml suppresses the virus after 30 minutes. The causative agent is resistant to drying acids and alkalis, ether.
The spread of the virus occurs mainly in the warm season. However, due to the long incubation and subclinical stage, it is characterized by bursts of infections in spring and autumn. Characterized by peaks during long-term observations. Approximately once every three to five years, hepatitis A is diagnosed more often than in other years.
Only people are susceptible to the virus, regardless of age. Animals, including laboratory ones, are not susceptible to the virus.
Children can get sick from the moment they are born. The following patterns of epidemiology of this form of hepatitis related to newborns have been established:
If a child is born to a mother who has not previously been ill and not vaccinated against hepatitis A, then there is a possibility of infection with one of the possible ways of transmitting the virus.
If a child is born to a mother who has previously been ill with hepatitis A or vaccinated against this pathogen, then he is considered immune to the hepatitis A virus. Immunity is transmitted to the child from the mother and lasts up to one year of his life.
Up to 80% of all cases of diseases are diagnosed in groups of children from three to fifteen years old. Scientists explain this phenomenon:
close contacts between kids and schoolchildren in kindergartens and schools;
not developed sanitary and hygienic skills in children.
The pathogenesis of hepatitis in them is characterized by a latent (latent) course. Clinically, the disease proceeds inconspicuously due to non-specific hepatitis symptoms.
Another epidemic phenomenon is the incidence of people aged 15 to 30 years. The sharp increase in the disease in this age group is associated, oddly enough, with the improvement in living conditions for the population of the last two to three decades. This creates conditions for delaying the initial contact of people with the pathogen and reducing the body’s immunity at this age.
Clinically characterized by the classic manifestation of symptoms. Epidemic risk groups, regardless of age, include:
persons, for various reasons, who traveled to countries with a high incidence of the indigenous population;
residents of small towns with an irrational sewerage and water supply system.
Up to 70% of the adult population of our country are carriers of immunity factors to this form of infection. Immunity factors are protective antibodies formed as a result of an illness or vaccination of a person. Immunity to hepatitis in the body persists for life or for a long time.
Hepatitis A is characterized by an acute course of pathogenesis – this is an epidemic feature of hepatitis A.
The chronic form of the disease is rare, usually due to a mix of viruses that have accumulated on the main pathogen.
Hepatitis A incubation period
People who are contagious to others are:
carriers of the virus in the subclinical stage or anicteric form of the disease;
patients in the early stages of the disease (incubation and the first stage of the acute course to jaundice).
The stage from the moment of infection to the first clinical manifestations is called the incubation period, it lasts about 35 days, intervals from 15 to 50 days are possible.
During the incubation period, the virus penetrates and spreads through the bloodstream in parallel with the accumulation of viruses.
During this period, a person feels healthy. Outwardly peppy, he is contagious to others. The disease in the subclinical stage proceeds with minimal symptoms, imperceptibly to the patient and others.
Periods of pathogenesis of hepatitis A
Classical pathogenesis proceeds according to the following algorithm:
incubation period (about 35 days, see intervals above);
prodromal period or primary symptoms (5-7 days, intervals from 1 to 21 days);
icteric period or the height of the disease (2-3 weeks, intervals from 7 days to 2 months);
convalescence period (up to 12 months, sometimes up to two years).
How is hepatitis A transmitted?
The source of infection are sick people at the stages of subclinical course and initial manifestations of the disease, including those with anicteric form.
After staining the sclera and skin, contagiousness is significantly reduced. In the third week of pathogenesis, a dangerous virus is isolated only in 5% of patients.
The period of contagiousness, taking into account the incubation period, lasts about a month, less often up to one and a half months.
Proven sources of the spread of the virus, in descending order:
Faeces, urine, discharge from the nasopharynx. This method of transmission is called fecal-oral. The main proven factors of transmission of the hepatitis A virus include direct contact between a healthy person and a sick person. The virus can also be transmitted with food, water, airborne droplets (some authors exclude), sexual contact, non-sterile intravenous injections, and through flies – mechanical carriers of the virus.
Direct contact with the patient. It is typical for people with undeveloped hygiene skills and people who are professionally in contact with them. This is how the pathogen is transmitted in preschool and school groups, boarding schools for people with disabilities.
Seed food. This method of transmission is of great epidemic importance. However, it is almost impossible to establish the type of dangerous food due to the long incubation period.
Meanwhile, products have been identified that are more likely to be factors in the transmission of the virus:
products prepared without heat treatment or consumed after storage (salads, vinaigrettes, cold appetizers, dried fruits and berries, especially from Kazakhstan and Central Asia);
garden berries in fresh and frozen (after thawing) form, especially if mollusks, slugs are found in the beds, next to berry plants, which can accumulate the virus if the beds are watered with fertilizer from human feces.
Water. It is typical for territories with undeveloped communal infrastructure, poor organization of water supply, sewerage and wastewater disposal. Significantly increase the risk of infection during accidents and natural disasters.
Aerosol. It is hypothetically possible in children’s groups with a layering of outbreaks of respiratory diseases in groups with reduced resistance. The virus is transmitted by coughing, sneezing with discharge from the nasopharynx of a sick person.
Sexual. In the literature, it is indicated as a possible transmission factor in homosexuals, while the causal relationship between homosexuality and hepatitis A is not deciphered.
Transmissible (transmission of the virus through flies). Researchers do not exclude the possibility of transmission of infection through flies, but the prevalence of this factor has not been studied.
parenteral. Transmission of the virus during blood transfusions, intravenous injections of solutions is not excluded, especially in an environment that precludes the observance of sterility (drug addicts).
Symptoms of Hepatitis A
The symptoms of hepatitis A can vary greatly depending on different circumstances, for example:
massive virus attack;
the state of immunity of the organism attacked by the virus;
the age of the person and others.
Depending on the combination of these circumstances, the disease can manifest itself in the form of typical (classic) and atypical manifestations of pathogenesis.
The typical course of hepatitis A. It has three variants of symptoms and manifests itself in the form of symptoms:
mild illness;
medium form of the disease;
severe form of the disease.
Atypical course of hepatitis A. It has two main symptoms. The atypical course proceeds exclusively as a slight malaise and manifests itself in the form of:
anicteric disease (there is no yellow staining of the sclera and skin);
subclinical disease (no visible symptoms, diagnosis is based on laboratory tests).
All types of hepatitis are more common in school-age children. But the greatest concern is caused by hepatitis in preschool children. More details below.
I. Signs and symptoms of hepatitis A in children: typical course
In view of the underdevelopment of personal hygiene skills, close collective communication, preschoolers and younger schoolchildren are the most vulnerable groups for hepatitis A infection.
Signs of a mild form of hepatitis A in children
The reasons for contacting a pediatrician or an infectious disease specialist are:
lethargy, sweating;
increase in body temperature (up to 370C, maybe a little higher);
signs of intestinal pathology (vomiting, diarrhea, signs of liver damage may be absent);
dark urine, colorless feces;
jaundice develops approximately seven days after infection (variations are possible).
Symptoms of mild hepatitis A in children
Approximately half of children who have had type A hepatitis will have a mild form of the disease. The study is conducted by a pediatric infectious disease specialist. The doctor’s task is to determine the severity of the symptoms, the likelihood of complications, determine the methods of treatment, isolate the patient from susceptible people.
Clinically, the symptoms are manifested by a cyclical course (periods of exacerbation and attenuation), moderate fever, and intoxication. On palpation, percussion, the liver is slightly enlarged. (Methods for determining the topographic boundaries of an organ in children are known to specialists; they are not indicated in this text). Ictericity (jaundice) disappears on about 30 days. The disease often ends with a complete restoration of lost liver functions. The duration of complete recovery of the body is about one year.
Signs and symptoms of moderate hepatitis A in children
The child should be considered sick on the basis of the above signs of damage to the liver or gastrointestinal tract.
The task of the child’s parents as soon as possible to go to an ambulance, to isolate the patient from susceptible people, not to wait for the appearance of dark staining of urine, colorless feces and yellowness.
The severity of pathogenesis correlates with the results of laboratory tests of blood, urine, and feces. The doctor describes the general intoxication of the child’s body as moderate, ranking the symptoms of intoxication according to a special method.
By physical methods, the liver is examined at the place of its localization, in the right hypochondrium. The organ is filled with blood (when probing, the edges are blunted), not always enlarged (topographic landmarks may not go beyond the normal range), the surface is smooth, dense. The spleen is slightly enlarged.
The amount of urine decreases, the color is dark, the feces, on the contrary, are light. The main symptom is jaundice. It develops by 7-10 days after the first signs of the disease. The duration of staining of the covers is two to three weeks.
It may take about two years to completely restore the morphological structure of the liver parenchyma. The transition of acute inflammation to chronic is observed in approximately 3% of patients.
Signs and symptoms of severe hepatitis A in children
It is observed extremely rarely. However, this is not a reason for parents to be optimistic. It can proceed without development and with the development of hepatic coma.
Call an ambulance immediately if your child is lethargic, sweaty, vomits repeatedly with bile or colorless contents.
Additional signs – this is lethargy, apathy, dizziness, bleeding from the nose, a rash on the body. Icteric staining appears much later (after 5-7 days) signs of urine staining (color of dark beer or dark blood) and discoloration of feces (like white clay).
Body temperature rises to 400C, periods of temperature drop are possible. The liver is enlarged, which is manifested not only by the blunting of its edges, but also by an increase in the boundaries of the organ. When pressed, it is moderately painful. The spleen is enlarged. The severity is specified by laboratory methods according to the content of markers of liver damage in the blood, urine, feces. Auscultation of the heart reveals a decrease in the rhythm of heart contractions – this is one of the characteristic, additional symptoms.
II. Signs and symptoms of hepatitis A in children: atypical course
Always a mild illness. In epidemic terms, the atypical course of hepatitis A is the most dangerous. The fact is that a child who does not feel like an infectious patient continues to communicate in a team, spreading the virus in the environment (water, food, household items), infecting other people (children and adults) through personal contact.
The atypical form does not mean the transmission of the same mild form of hepatitis A to another person. It is likely that an infected person develops one of the classic forms of the disease (see above).
But back to the description of atypical pathogenesis. Atypical forms can occur in two main forms.
Signs and symptoms of anicteric form of hepatitis A in a child
Remind a slight lesion of the gastrointestinal tract and liver. Perhaps a slight increase in body temperature. The main difference from the typical course is no jaundice of the sclera, visible mucous membranes and colorless urine.
Involvement in the pathogenesis of the liver and the type of virus is determined on the basis of laboratory tests of blood, urine, feces. Confirmation of hepatitis A is the detection of specific IgM in the child’s blood. The main symptom of hepatitis in the absence of staining is an increase in volume (blunting of the borders) and expansion (increase in topographic landmarks) of the liver.
Signs and symptoms of subclinical hepatitis A in a child
A feature of inapparent (subclinical) infections is the absence of signs and symptoms. More precisely, they are, but they are not obvious. From this, the disease becomes only more dangerous in an epidemic sense. The patient remains a hidden carrier of the disease.
The task of parents is to carefully monitor the health status of a child attending a preschool or school institution.
With some degree of probability, an asymptomatic disease can be guessed from poor digestion of food (diarrhea, constipation), increased gas formation in a child, a slight change in the color of urine and feces, causeless lethargy or a short-term increase in temperature.
The main diagnostic method is the determination of specific immunoglobulins for hepatitis A. Blood tests to determine the level of digestive enzymes in the blood are important. Other methods for examining feces and urine are also used, which have good diagnostic value.
Cholestatic hepatitis A syndrome in a child
Hepatitis in which bile does not enter the duodenum as a result of a decrease in its production or as a result of a mechanical obstruction in the duct.
A syndrome is a collection of symptoms. In children, the most common cause of the syndrome is viral liver damage. The syndrome includes the following symptoms:
icterus (jaundice) of the sclera, other visible mucous membranes and skin due to impregnation of bile pigments of the integuments;
acholia (white feces) due to the lack of bile pigments in the gastrointestinal tract, bile is involved in the breakdown of intestinal contents, mainly fats;
dark urine due to increased excretion by the kidneys of under-oxidized products by a liver that cannot cope with its function as a biological filter;
an increase in the liver due to an increased load on the organ with an increase in blood flow and a weakening of the outflow;
skin itching due to irritation of nerve endings by incompletely oxidized metabolic products, skin itching often ends with rashes on the skin, at first this is a consequence of internal pathology, and then a consequence of scratching.
Laboratory markers of cholestasis are associated with increased levels of:
some enzymes (alkaline phosphatase, gamma glutamyl transpeptidase, leucinoaminopeptidases, nucleosidases);
bile components (cholesterol, bile pigments, including urobilinogen, bilirubin);
trace elements (copper).
Symptoms of hepatitis A in pregnant women
It is believed that infection in the first half of pregnancy is not dangerous to the health of the child.
No infection detected:
fetus during pregnancy;
newborn during breastfeeding.
Meanwhile, to predict viral hepatitis in pregnant women is the prerogative of gynecologists and infectious disease specialists based on the results of careful observation.
The signs of hepatitis A, according to many clinicians, resemble the manifestations of acute respiratory infections (fever, chills, sweating, lethargy). The involvement in the pathogenesis of the liver is indicated by discoloration of feces, darkening of urine to the color of dark beer. Seek immediate medical attention. There are hepatitis (for example, hepatitis neither A nor B), which is extremely dangerous for pregnant women.
Consequences of hepatitis A
Damage to the liver parenchyma is always bad for the body in the short term. The most dangerous viral hepatitis, causing death of people or severe long-term consequences, researchers associate with parenteral infection.
As for hepatitis A, which spreads mainly by the oral-fecal route, deaths in clinical practice are observed no more than 1% of all cases of this form of infection, with fulminant pathogenesis.
Long-term effects of hepatitis A. The most famous restriction is a life-long ban on donation. The reason for the ban is not commented on, probably due to insufficient knowledge of the pathogen’s ability to persist (asymptomatic preservation of the virus in the body) and its reactivation in the long term.
If diet and exercise restrictions are followed, up to two years after illness, no consequences for the body should be expected.
With forced or voluntary violations of the treatment regimen or the recovery period, the development of cirrhosis of the liver, less often liver cancer, is possible.
Employment after Hepatitis A
After discharge from the hospital, a two-week leave from work is granted, sometimes more, depending on the health of the convalescent.
After the sick leave is closed, an ill worker (student, student), within three to six months, is released from:
business trips on a business trip, internship;
heavy physical exertion at work and physical education in the main group of students;
work with substances that affect liver function;
vaccinations with the exception of (vaccinations against hydrophobia or rabies, as well as tetanus);
planned surgical interventions;
use of drugs that are toxic to the liver.
Diagnosis of hepatitis A
The acute form of the disease is identified almost unmistakably. Another thing is if a patient has a disease without a clear clinical picture.
In any case, to detect pathology, a traditional research algorithm is used, including physical, laboratory, instrumental methods:
Clinical (history and physical examination of the patient. Epidemiological studies are carried out during the same period).
Laboratory tests of blood, urine, feces.
Instrumental research.
Methods of instrumental diagnosis of hepatitis A are not essential. In addition to clinical studies, the decisive factor is associated with laboratory testing of the biological environments of patients.
Laboratory tests are divided into specific and non-specific.
Specific, aimed at identifying the causative agent of hepatitis A directly, usually it is (PCR), or identifying traces of the virus, its specific antibodies (Ig) to the virus (ELISA);
Nonspecific (aimed at identifying markers of liver damage), including:
Complete blood count (leukocytes, erythrocytes, platelets, ESR);
urinalysis (urobilin, bile pigments);
biochemical blood test (using a biochemical analyzer) – total protein and fractions, as well as AST, ALT, blood bilirubin, prothrombin index, fibrinogen, cholesterol, alkaline phosphatase;
Instrumental methods, most often ultrasound.
Hepatitis A vaccination
For preventive immunization of the population of our country, several vaccines registered in the Russian Federation are used, including:
Havrix or Havrix (720 units/dose for children from 12 months) and (1440 units/dose for adults), manufacturer: GlaxoSmithKline Biologicals SA, Belgium. The vaccine is administered intramuscularly, twice. Provides protective immunity for at least 15-20 years (according to other sources, no more than 8 years). Reg. in the Russian Federation P No. 013236/2001.
Vacta or Vakta (25 units for children over 2 years old) and (50 units for adults), manufacturer: Merck Sharp & Dohme BV (Netherlands). The vaccine is administered intramuscularly twice. Provides protective immunity for at least 6 years. Reg. in the Russian Federation No. 012585/01-2001.
Avaxim 80 or Avaxim (80 units of antigen for children from 12 months to 15 years old inclusive), manufacturer Sanofi Pasteur (France). The vaccine is administered intramuscularly at intervals of 6-18 months.
Twinrix or Twinrix. Hepatitis A and B vaccine. Produced in two dosages, including: (360 units of antigen A and 10 units of antigen B); (720 units of antigen A and 20 units of antigen B), administered intramuscularly to children from 12 months to 15 years old, as well as adults from 16 years old, manufacturer: GlaxoSmithKline Biologicals SA, Belgium. Registration in the Russian Federation No. LS-001928.
Hep-A-in-Vac or Hep-A-in-Vac (50 U/ml hepatitis A antigen). Appointment for children over 3 years old, adolescents and adults, manufacturer: Vector-BiAlgam CJSC (Russia). A single intramuscular injection provides protection against hepatitis A for 12 months, a double injection is intended for long-term protection, the terms of protective immunity are not indicated in the instructions. Registration in the Russian Federation No. R No. 000461/01-2007. Two modifications of this vaccine are used. One of the modifications with polyoxidonium, the abbreviation (POL) is added to the indicated marking.
Details of use can be found in the instructions for the vaccine. All vaccines should be transported in compliance with the temperature chain and stored in compliance with the temperature regime in accordance with the instructions for the medicinal product.
Side effects are possible for any biological preparations, including hepatitis vaccines, in the form of:
general malaise;
headache;
slight increase in temperature;
flushes of blood;
edema at the injection site;
the appearance of proteins in the urine (in the form of cloudy urine, also determined by laboratory tests).
With the development of an allergy to the antigen or components of the vaccine, re-administration is not carried out, or it is administered after establishing the causes of the allergy not related to the vaccine.
Do not vaccinate during acute inflammation or exacerbation of a chronic course. Pregnant women are vaccinated in accordance with the instructions for the drug (vaccine).
For passive immunoprophylaxis, specific immunoglobulin against hepatitis A is used. Application is carried out in accordance with the instructions for the drug.
Hepatitis A treatment
Treatment of mild and moderate forms of hepatitis A is based on basic therapy. It includes: the use of diet, the maintenance of intestinal microflora and liver function, the careful use of drugs that affect the affected organ.
The therapeutic strategy and tactics should be based on the individuality of pathogenesis, taking into account the etiology of the pathogen, the characteristics of the patient’s body, his age, habitus, living conditions and work.
Treatment of mild hepatitis A
It is based on the preservation and maintenance of the functions of the affected organ with the help of a therapeutic diet. The patient needs to observe a semi-bed mode of life, to abandon physical exertion. Medicines are used with caution.
Treatment of the average form of hepatitis A
It is treated similarly (diet, regimen, limited use of pharmacological agents). In the event of a patient vomiting, which is a consequence of the accumulation of under-oxidized products (ammonia) in the blood. Vomiting causes dehydration. Therefore, the efforts of doctors are aimed at overcoming the violation of the antitoxic function of the organ.
Treatment of severe hepatitis A
The danger is the development of hepatic coma (impaired motor skills and consciousness).
Diet and bed rest are the basis for the prevention of precoma. In addition, conduct antitoxic therapy. In some cases, hormones (corticosteroids) are indicated.
In case of development of hepatic coma, therapeutic measures are carried out in the ward (department) of intensive care.
The basis of the treatment of severe patients is pathogenetic therapy:
Corticosteroids (hydrocortisone, prednisolone, dexamethasone) in an exceptionally short course. Without discussion, they are shown only in the case of the development of cerebral edema syndrome.
Detoxification solutions are prescribed intravenously, drip to replenish the energy of the brain tissue, with a decrease in blood glucose.
Hemorrhagic syndrome – a frequent companion of severe liver damage is manifested by profuse gastrointestinal bleeding. The patient is shown the introduction through a probe into the stomach of solutions of hemostatic agents (solution of 5% aminocaproic acid), parenteral administration of drugs that enhance blood clotting.
H-2 receptor blockers. To suppress excessive secretory activity of the stomach and intestines.
Deficiency of blood clotting factors. Shown transfusion of plasma, blood albumin.
Dehydration. A 10% solution of mannitol is indicated, drip intravenously. Lasix under the control of the level of potassium in the blood. With the development of metabolic acidosis, bicarbonate is indicated, with alkalosis, potassium preparations are indicated.
Only in case of bacterial complications, antibiotic therapy is prescribed.
The following indicators are the basis for the discharge of a convalescent person:
well-being equal to the indicators of healthy people of the corresponding age;
the absence of yellow staining of the integument and bilirubin in the blood.
restoration of liver size to normal.
absence of urine staining and absence of pigments in laboratory studies.
Diet for hepatitis A
At the heart of the treatment of hepatic pathologies, of any etiology and severity, is strict adherence to the diet. Its value is higher than pharmacological therapy. The fifth table is the name of the diet common in our country for this disease. Recommended cooking methods are steaming or boiling food.
The goal of the diet is to naturally reduce the load on the liver, which is the main biological filter of the body.
The diet is strictly observed at any stage of pathogenesis, including during the period of developed coma. The maximum allowable period of refusal to take food naturally (through the mouth) does not exceed five days.
In the state of precoma and coma, the energy needs of the body are replenished by intravenous administration of glucose solutions. After the specified terms, liquid nutrition in a volume of up to 50 g is injected into the stomach through a tube. The energy requirement (about 2400 kcal/day) is replenished with liquid meals (semolina porridge, mashed potatoes, jelly, etc.), as well as intravenous glucose.
Patients in a state of hepatic coma replace liquid food with nutrient mixtures. To prevent the absorption of toxins into the blood, primarily ammonia, patients are prescribed lactulose and similar drugs along with the diet.
Hepatitis A Prevention
Prevention of any infections is based on the interruption of the path of transmission of the pathogen by any available means.
The spread of the hepatitis A virus is ensured by the suppression of the fecal-oral mechanism of infection by:
creation of favorable living and working conditions for a person;
sanitary improvement of settlements, providing the population with high-quality drinking water and reliable sewerage;
safe food at the stages of procurement, processing, storage and sale;
improvement of sanitary culture