HEALTHWISE: When A and E Meet Hepatitis C
—Lucinda K. Porter, RN
Living with chronic hepatitis C
virus infection (HCV) is problematic enough, but if the liver has to
contend with an additional virus, this presents an enormous burden.
This month, I discuss two types of viral hepatitis—A and E. Both are
global problems, considerably bigger health issues outside of the U.S.
However, history has taught us that global diseases can become local
This summer, nearly 145 people in eight states were
stricken with hepatitis A virus (HAV) linked to “Townsend Farms Organic
Antioxidant Blend” frozen berry and pomegranate mix purchased at
Costco. No deaths were reported, but at least 63 people were
Here is the good news: there was
only one report of an HAV infection in a child. Since smoothies are
popular among children, why weren’t more children infected?
Vaccination. The HAV vaccine has been protecting children since 2006.
The one reported child in this recent HAV outbreak was not immunized.
Prior to the vaccine, about
one-third of the HAV cases in the U.S. occurred in children 5 to 14
years of age. According to the Centers for Disease Control and
Prevention (CDC), in the U.S. there were 31,582 HAV cases in 1995. In
2010, there were 1,670.
HAV is a highly contagious virus
that infects the liver, and although it is rarely life threatening, it
needs to be taken seriously. HAV may be more severe for those with
other liver diseases, such as HCV, and for those with compromised
immunity, such as with HIV. The virus is most often transmitted when an
infected food handler passes the disease to people who eat or handle
infected food. Although some people have no symptoms, many have fever,
fatigue, nausea, vomiting, and abdominal and joint pain. In severe
cases, it can cause liver failure and require a transplant.
HAV vaccination is recommended for:
Travelers to countries that have high prevalence of HAV
Men who have sex with men
Those who use injection and non-injection recreational drugs
People with chronic liver diseases, such as hepatitis B or C
People who are treated with clotting-factor concentrates
People who work with HAV, such as in research
Others who are at higher risk for HAV, and for whom vaccination should be considered are:
Employees of child day care centers
People who care for or live in facilities such as nursing homes, prisons, etc.
Two doses of HAV vaccine are
needed for lasting protection. For adults also needing hepatitis B
(HBV) immunization, the HAV vaccine is available in a formulation that
protects against both. It is called Twinrix, and is given in a
series of three injections over a six-month period. Those with HIV may
be safely vaccinated against HAV and HBV.
The HAV vaccine has been used in
millions of cases worldwide, with no reports of serious adverse
events. In very rare cases, a person may be allergic to some component
of the vaccine, such as a preservative. Roughly half of those who
receive the vaccine will have mild side effects, such as soreness at
the injection site (56%), headache (14%), or temporary weakness (7%).
When these problems occur, they usually happen 3-5 days after
vaccination and last for 1 or 2 days.
Those who have had HAV are
immune to getting it again. Those who aren’t immune naturally or through
vaccination, and who are exposed to HAV might benefit from a shot of
either immune globulin or HAV vaccine, if given within the first 2
weeks after exposure. Immune globulin is made from plasma that contains
antibodies that protect against infection.
Healthy travelers who are not
immune to HAV may benefit from even a single dose of HAV, given at any
time before departure. This provides some protection, and they can have
the other HAV dose when they return. Unprotected travelers can minimize
their HAV risk by avoiding potentially contaminated water or food,
undercooked shellfish, and uncooked fruits or vegetables not peeled or
prepared by the traveler.
Hepatitis E virus (HEV) infection is uncommon in
the U.S. Worldwide, HEV is probably the most common cause of acute
hepatitis, perhaps infecting up to one third of the world’s population.
HEV transmission is related to
poor sanitation in large areas of the world. HEV is a waterborne
disease, and contaminated water or food supplies have been implicated
in major outbreaks. It may be spread via raw or uncooked shellfish and
pork, from animals to humans, transfusion of infected blood products,
and vertically from a pregnant woman to her fetus. Preliminary research
suggests that men who have sex with men may be at risk for HEV.
HEV risk reduction is similar to
that of HAV. When traveling internationally in high-risk areas, avoid
potentially contaminated water or food, such as undercooked pork. China
has produced an HEV vaccine, but it isn’t available in the U.S.
HEV infection is fatal about 4%
of the time. Liver transplant recipients may be at a greater risk for
HEV infection. Fatality increases to 20% among pregnant women. Liver
failure in infected pregnant women is high. Treatment for HEV is
largely supportive—rest, alcohol avoidance, fluids, and a nutritious
Although HEV prevention is not
as straightforward as HAV prevention is, the fact that HEV prevalence
remains low in the U.S., suggests that precautions generally work to
protect travelers. If you plan to travel to an area with a high
prevalence of HEV, or other potentially infectious diseases, begin your
travel with a stop at the CDC’s Travelers’ Health website: wwwnc.cdc.gov/travel
Centers for Disease Control and Prevention:
Lucinda K. Porter, RN, is a long-time contributor to the HCV Advocate and author of Free from Hepatitis C and Hepatitis C One Step at a Time (September 2013) Her blog is http://lucindaporterrn.com