Hepatitis A and E

Hepatitis A and hepatitis E are two different viruses that inflame the liver in much the same way. Both are swallowed: they pass out in the stool of an infected person and reach the next person through water, ice or food.

Neither becomes a long-term infection in people with normal immunity, and most recover fully and are then protected against that virus. Hepatitis A is commonest in children, hepatitis E in young adults, and hepatitis E is the more dangerous of the two in pregnancy.

Symptoms begin two to four weeks after catching hepatitis A, and anywhere from two to ten weeks after hepatitis E. They usually start with:

• Fever, and feeling generally unwell
• Loss of appetite, nausea and vomiting
• Discomfort or pain over the liver, on the upper right of the tummy
• Loose motions, and sometimes joint pains or a rash

After a few days the urine turns dark, the stools may go pale, the skin itches and the eyes and skin turn yellow. Hepatitis E symptoms usually last from one to six weeks, while hepatitis A can take a few months to clear completely, although most people feel much better long before that. Children under six often have no symptoms and only a few turn yellow, which is why an outbreak can spread quietly.

See a doctor within a few days for yellow eyes or dark urine, for fever with nausea and loss of appetite that is not settling, after close contact with someone who has hepatitis A, and sooner if the person is over 60 or already has liver disease.

Both viruses spread by what doctors call the faecal-oral route, which means they leave the body in stool and are swallowed by someone else. In practice that happens through:

• Drinking water, or ice, that has been contaminated by sewage
• Food washed in unsafe water, or handled by someone who did not wash their hands
• Raw or lightly cooked shellfish from contaminated water
• Undercooked pork, other meat and offal, which can carry hepatitis E
• Close contact in a household with someone who has hepatitis A, including sexual contact

• Drinking water from an unsafe or damaged supply, and water that mixes with sewage in the rains
• Poor sanitation, or no easy way to wash hands with soap
• Living with, or caring for, someone who has hepatitis A
• Travel to places where these infections are common, without vaccination against hepatitis A
• Pregnancy, which does not raise the chance of catching hepatitis E but makes it far more serious
• Existing liver disease, or older age, which make a severe illness more likely
• A weakened immune system, in which hepatitis E can become long-lasting

Most people recover completely. Rarely the inflammation is severe enough to cause acute liver failure, which can be fatal and needs hospital care. This is more likely in older people and in anyone whose liver was already damaged.

Hepatitis E in the second half of pregnancy is the most serious situation of all, with a real risk of liver failure, of losing the baby, and of death of the mother. In people with a weakened immune system, such as those who have had an organ transplant, hepatitis E can settle into a long-lasting infection.

• Drinking water that has been boiled, filtered properly or sealed in a bottle, and avoiding ice of unknown origin
• Washing hands with soap after using the toilet, after changing a nappy and before cooking or eating
• Eating food that is freshly cooked and served hot, and peeling fruit yourself
• Cooking meat, offal and shellfish thoroughly
• Safe disposal of sewage, and keeping drinking water away from drains
• The hepatitis A vaccine, which a doctor may advise for children, travellers, people with liver disease and household contacts
• Not preparing food for others, and avoiding close contact, for about a week after jaundice starts

Jaundice has many causes, so the diagnosis is made on blood tests. One set of tests measures how inflamed the liver is and how well it is working. Another looks for antibodies made against hepatitis A or hepatitis E, which shows which virus is responsible.

A test that finds the genetic material of the virus in blood or stool can be used early in the illness, or where the antibody test is unclear. A scan may be done if another cause of jaundice, such as a blocked bile duct, needs to be ruled out.

There is no medicine that kills either virus in an otherwise healthy person, and none is needed. Treatment is rest, fluids and eating what can be managed, in small amounts through the day, while the liver repairs itself.

Alcohol should be stopped completely. Every medicine, tonic and herbal or traditional preparation should be checked with the doctor first, because several, including paracetamol taken without advice, are hard on a liver that is already inflamed.

Anyone who cannot keep fluids down, who becomes drowsy or confused, or who is pregnant may need hospital care and close monitoring. People with a weakened immune system and long-lasting hepatitis E are looked after by a specialist, who may reduce the medicines that suppress immunity or use antiviral treatment.