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Hepatitis A

Hepatitides Infectious

Hepatitis A is a form of viral hepatitis, caused by the hepatitis A virus, a single-stranded, positive-sense, linear RNA enterovirus of the Picornaviridae family. The virus spreads by the fecal-oral route and infections often occur in conditions of poor sanitation. The incubation period usually lasts 2 to 6 weeks. Symptoms may include fatigue, fever, nausea, myalgia, jaundice and pruritus. Recurrence and chronic hepatitis do not usually occur.

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Presentation

The clinical symptoms vary from person to person, with some patients remaining asymptomatic or suffering from less severe symptoms. The subclinical cases are more common in children less than 5 years of age. The manifestation of HAV starts with a prodrome stage of fever with chills, anorexia, malaise, fatigue and abdominal pain. These symptoms last for a week. These are followed by diarrhea, nausea, vomiting, headache, and arthralgia[8].

Thereafter jaundice appears, with yellowing of skin and sclera, dark colored urine and pale stools. There is intense pruritis with skin rash. Signs include hepatomegaly, lymphadenopathy and splenomegaly, though these findings vary from individual to individual, depending on general health status and age group.

The individual remains infective from 15-20 days before the appearance of jaundice to 8 days after jaundice disappears. After the jaundice resolves, the other symptoms begins to diminish. The hepatomegaly continues for another 2-12 weeks and thereafter the liver regains its normal function [6].

Splenomegaly
  • Tender hepatomegaly, splenomegaly, and lymphadenopathy may occur. Young children are usually asymptomatic and the likelihood of symptoms tends to increase with age [ 4 ]. 70% of infections in children aged under 6 months are asymptomatic.[patient.info]
  • Signs include hepatomegaly, lymphadenopathy and splenomegaly, though these findings vary from individual to individual, depending on general health status and age group.[symptoma.com]
  • Less common symptoms include chills, myalgias, arthralgias, cough, diarrhea, constipation, pruritus, and urticaria. 4 Physical signs include tender hepatomegaly, splenomegaly, bradycardia, and posterior cervical lymphadenopathy. 4, 6 The icteric phase[web.archive.org]
Generalized Lymphadenopathy
Fever
  • Abstract A 25-year-old Japanese man was admitted with general malaise and fever, which had developed 12 days after coming back to Japan from Indonesia.[ncbi.nlm.nih.gov]
  • CASE: A 38-year-old HIV-positive patient presented with right upper abdominal pain, fever and jaundice.[ncbi.nlm.nih.gov]
  • We report a 3-year-old boy presenting with 3 days of fever, vomiting, abdominal distention and scleral icterus. On examination, he had tachypnea, hepatosplenomegaly, ascites and right-sided pleural effusion.[ncbi.nlm.nih.gov]
  • Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a severe, drug-induced hypersensitivity reaction characterized by skin rash, fever, lymph-node enlargement, and internal organ involvement.[ncbi.nlm.nih.gov]
  • A 58-year-old Japanese woman who presented with fever and general malaise was diagnosed as having jaundice and liver dysfunction by a positive serum test for anti-hepatitis A virus IgM, which ultimately led to a diagnosis of acute hepatitis A virus associated[ncbi.nlm.nih.gov]
Fatigue
  • The most common symptoms are as follows: Nausea Vomiting Diarrhea, especially in children Low-grade fever Loss of appetite Rash Tiredness, fatigue Jaundice - A yellow discoloration of the skin and the whites of the eyes Urine is dark brownish in color[web.archive.org]
  • Most adults with hepatitis A have symptoms, including fatigue, low appetite, stomach pain, nausea, and jaundice, that usually resolve within 2 months of infection; most children less than 6 years of age do not have symptoms or have an unrecognized infection[cdc.gov]
  • Top of Page Beliefs & Concerns Additives in Vaccines Multiple Vaccinations and the Immune System Top of Page Vaccine Safety As with all vaccines, there can be minor reactions, including pain and redness at the injection site, headache, fatigue or a vague[cdc.gov]
  • Symptoms may include fatigue, fever, nausea, myalgia, jaundice and pruritus. Recurrence and chronic hepatitis do not usually occur.[symptoma.com]
  • Symptoms include fever, nausea or vomiting, fatigue, and jaundice (as the virus specifically infects the liver), and they last less than two months.[refinery29.com]
Malaise
  • Abstract A 25-year-old Japanese man was admitted with general malaise and fever, which had developed 12 days after coming back to Japan from Indonesia.[ncbi.nlm.nih.gov]
  • A 58-year-old Japanese woman who presented with fever and general malaise was diagnosed as having jaundice and liver dysfunction by a positive serum test for anti-hepatitis A virus IgM, which ultimately led to a diagnosis of acute hepatitis A virus associated[ncbi.nlm.nih.gov]
  • Although infrequent, extra-hepatic manifestations related to HAV have been described, affecting the heart, bone marrow, blood vessels, and other tissues.A 10-year-old boy from a rural area presented with a 15-day history of malaise, fever, and jaundice[ncbi.nlm.nih.gov]
  • In contrast, most older children and adults have typical manifestations of viral hepatitis , including anorexia, malaise, fever, nausea, and vomiting; jaundice occurs in over 70%.[merckmanuals.com]
  • Anorexia, malaise and weakness may persist for some weeks after biochemical recovery. The average age at infection has increased in developing countries, resulting in more severe hepatitis occurring [ 5 ].[patient.info]
Weight Loss
  • Symptoms of Hep A can include: a short, mild, flu-like illness nausea and vomiting diarrhoea loss of appetite weight loss jaundice (yellow skin and whites of eyes, darker yellow urine and pale faeces) itchy skin[gov.uk]
  • Signs and symptoms Symptoms include: abdominal pain loss of appetite weight loss nausea (and sometimes vomiting) fever and chills mild headache tiredness yellow skin and eyes (jaundice) (see image) dark urine and pale faeces.[sahealth.sa.gov.au]
  • Common symptoms are: Feeling sick to your stomach Feeling very tired No appetite and weight loss Pain on the right side of the abdomen, under the rib cage (where your liver is) Fever and sore muscles Rashes or pain in the joints Jaundice – yellowing of[smartsexresource.com]
  • Features may include severe pruritus, diarrhoea, weight loss and malabsorption. However, they usually fully recover. Fulminant liver failure. This occurs in less than 0.4% of people and usually manifests during the first four weeks of illness.[patient.info]
Dentist
  • Also, tell your doctor, dentist, and other health care professionals that you have hepatitis A. Talk with a blood donation center before you donate blood. If you had hepatitis A when you were younger than 11, you may be able to donate blood.[niddk.nih.gov]
  • […] hands with warm, soapy water after using the toilet or changing diapers and before fixing food or eating use bottled water for drinking, making ice cubes, and washing fruits and vegetables when you are in a developing country tell your doctor and your dentist[medicinenet.com]
Aspiration
  • A diagnostic pleural tap yielded a milky, lymphocyte-predominant exudative aspirate, with pleural fluid triglycerides of 175 mg/dl, suggestive of chylothorax. Serology for anti-HAV IgM was positive in both blood and pleural fluid.[ncbi.nlm.nih.gov]
Nausea
  • Abstract Hepatitis A virus causes acute viral hepatitis, presenting with jaundice, nausea, and vomiting. Symptoms are self-limited and treated symptomatically. Routine vaccination of infants has greatly reduced the incidence in the United States.[ncbi.nlm.nih.gov]
  • Symptoms may include fatigue, fever, nausea, myalgia, jaundice and pruritus. Recurrence and chronic hepatitis do not usually occur.[symptoma.com]
  • The agency says Hepatitis A can cause inflammation of the liver, and sufferers can experience a wide range of symptoms including fever, low appetite, nausea, vomiting, diarrhea, muscle aches, and jaundice.[thestar.com]
  • The most common symptoms are as follows: Nausea Vomiting Diarrhea, especially in children Low-grade fever Loss of appetite Rash Tiredness, fatigue Jaundice - A yellow discoloration of the skin and the whites of the eyes Urine is dark brownish in color[web.archive.org]
  • Anyone in South Wales epidemiologically linked to a serological and/or RNA positive confirmed case of hepatitis A during the 15-50 d before onset of symptoms (diarrhea, vomiting, fever, nausea, AND jaundice, or jaundice-associated symptom) was defined[ncbi.nlm.nih.gov]
Vomiting
  • Pain in area of liver - On the right side of the abdomen, just under the rib cage If the vomiting is severe, dehydration may occur.[web.archive.org]
  • One week later patient's condition worsened, she was jaundiced, with persistent vomiting and looked acutely ill and uncomfortable with severe steady abdominal pain mainly in the epigastrium and upper quadrants.[ncbi.nlm.nih.gov]
  • We report a 3-year-old boy presenting with 3 days of fever, vomiting, abdominal distention and scleral icterus. On examination, he had tachypnea, hepatosplenomegaly, ascites and right-sided pleural effusion.[ncbi.nlm.nih.gov]
  • Abstract Hepatitis A virus causes acute viral hepatitis, presenting with jaundice, nausea, and vomiting. Symptoms are self-limited and treated symptomatically. Routine vaccination of infants has greatly reduced the incidence in the United States.[ncbi.nlm.nih.gov]
  • The agency says Hepatitis A can cause inflammation of the liver, and sufferers can experience a wide range of symptoms including fever, low appetite, nausea, vomiting, diarrhea, muscle aches, and jaundice.[thestar.com]
Loss of Appetite
  • The most common symptoms are as follows: Nausea Vomiting Diarrhea, especially in children Low-grade fever Loss of appetite Rash Tiredness, fatigue Jaundice - A yellow discoloration of the skin and the whites of the eyes Urine is dark brownish in color[web.archive.org]
  • Symptoms include: Fever Tiredness Nausea Loss of appetite Abdominal pains Dark urine Pale coloured faeces Jaundice (yellow colour of the skin and eyes), rare in young children Symptoms usually last for several weeks but less than two months.[immune.org.nz]
  • Hepatitis A symptoms usually appear within 28 days of exposure and may include an abrupt onset of fever, malaise, loss of appetite, nausea, stomach pain, dark-colored urine, light colored stool and jaundice.[syracuse.com]
Abdominal Pain
  • CASE: A 38-year-old HIV-positive patient presented with right upper abdominal pain, fever and jaundice.[ncbi.nlm.nih.gov]
  • One week later patient's condition worsened, she was jaundiced, with persistent vomiting and looked acutely ill and uncomfortable with severe steady abdominal pain mainly in the epigastrium and upper quadrants.[ncbi.nlm.nih.gov]
  • While it can be asymptomatic, HAV typically presents with a prodrome of fever, nausea/vomiting, and abdominal pain followed by jaundice.[ncbi.nlm.nih.gov]
  • When clinical manifestations appear, these include choluria, jaundice, and abdominal pain.[ncbi.nlm.nih.gov]
  • The child who carried sub-genotype IIIA travelled to Afghanistan and presented with abdominal pain, icterus and vomitus. He was positive for anti-HAV IgM and IgG but negative for hepatitis B and C.[ncbi.nlm.nih.gov]
Diarrhea
  • The agency says Hepatitis A can cause inflammation of the liver, and sufferers can experience a wide range of symptoms including fever, low appetite, nausea, vomiting, diarrhea, muscle aches, and jaundice.[thestar.com]
  • The most common symptoms are as follows: Nausea Vomiting Diarrhea, especially in children Low-grade fever Loss of appetite Rash Tiredness, fatigue Jaundice - A yellow discoloration of the skin and the whites of the eyes Urine is dark brownish in color[web.archive.org]
  • Anyone in South Wales epidemiologically linked to a serological and/or RNA positive confirmed case of hepatitis A during the 15-50 d before onset of symptoms (diarrhea, vomiting, fever, nausea, AND jaundice, or jaundice-associated symptom) was defined[ncbi.nlm.nih.gov]
  • Symptoms may include fever, feeling tired, poor appetite, dark yellow urine, stomach pain, diarrhea, vomiting, yellow skin or eyes. There is no specific medication to treat hepatitis A and most people recover on their own.[state.nj.us]
Jaundice
  • Under these measures, pruritus and jaundice, as well as serum bilirubin levels improved gradually and after four plasmapheresis sessions we were able to discharge the patient.[ncbi.nlm.nih.gov]
  • The individual remains infective from 15-20 days before the appearance of jaundice to 8 days after jaundice disappears. After the jaundice resolves, the other symptoms begins to diminish.[symptoma.com]
  • Older persons infected by the virus usually develop a symptomatic infection with abrupt onset, fever, and jaundice lasting two months. Children usually have an asymptomatic infection and rarely develop jaundice.[ncbi.nlm.nih.gov]
  • Anyone in South Wales epidemiologically linked to a serological and/or RNA positive confirmed case of hepatitis A during the 15-50 d before onset of symptoms (diarrhea, vomiting, fever, nausea, AND jaundice, or jaundice-associated symptom) was defined[ncbi.nlm.nih.gov]
  • ) 782.4 Jaundice (yellow) 782.4[icd9data.com]
Hepatomegaly
  • The hepatomegaly continues for another 2-12 weeks and thereafter the liver regains its normal function. Hepatitis A is best diagnosed serologically.[symptoma.com]
  • Common examination findings are hepatomegaly and clinical jaundice with marked elevation of serum transaminases (usually 1000 units/L). No specific therapy is available and treatment is supportive.[bestpractice.bmj.com]
  • Tender hepatomegaly, splenomegaly, and lymphadenopathy may occur. Young children are usually asymptomatic and the likelihood of symptoms tends to increase with age [ 4 ]. 70% of infections in children aged under 6 months are asymptomatic.[patient.info]
  • Less common symptoms include chills, myalgias, arthralgias, cough, diarrhea, constipation, pruritus, and urticaria. 4 Physical signs include tender hepatomegaly, splenomegaly, bradycardia, and posterior cervical lymphadenopathy. 4, 6 The icteric phase[web.archive.org]
Hepatosplenomegaly
  • On examination, he had tachypnea, hepatosplenomegaly, ascites and right-sided pleural effusion.[ncbi.nlm.nih.gov]
  • […] is a common cause of morbidity; it is the mildest of viral hepatitis; 30% of the US population has been exposed Epidemiology Contaminated food–eg, shellfish, and other foods prepared by HAV carriers Clinical Fever, nonspecific GI malaise–eg, nausea, hepatosplenomegaly[medical-dictionary.thefreedictionary.com]
Scleral Icterus
  • We report a 3-year-old boy presenting with 3 days of fever, vomiting, abdominal distention and scleral icterus. On examination, he had tachypnea, hepatosplenomegaly, ascites and right-sided pleural effusion.[ncbi.nlm.nih.gov]
Myalgia
  • Symptoms may include fatigue, fever, nausea, myalgia, jaundice and pruritus. Recurrence and chronic hepatitis do not usually occur.[symptoma.com]
  • Less common symptoms include chills, myalgias, arthralgias, cough, diarrhea, constipation, pruritus, and urticaria. 4 Physical signs include tender hepatomegaly, splenomegaly, bradycardia, and posterior cervical lymphadenopathy. 4, 6 The icteric phase[web.archive.org]
Dark Urine
  • Symptoms of the disease include mild fever, loss of appetite, nausea, fatigue, vomiting, diarrhea, abdominal pain and dark urine and jaundice.[nj.com]
  • Symptoms of Hepatitis A include fever, fatigue, loss of appetite, abdominal discomfort, dark urine, diarrhea, and yellow skin and eyes. They typically last several weeks to as long as two months.[hawaiinewsnow.com]
  • Clinical presentation Symptoms Incubation period 15-50 days, mean of 28 days Acute hepatitis: lethargy, nausea, fever, anorexia for a few days then jaundice, pale stools and dark urine Usually asymptomatic in children, more severe illness in elderly and[sti.guidelines.org.au]
Headache
  • The symptoms of dehydration include the following: Feeling weak, tired, or "blah" Feeling confused or unable to concentrate Rapid heartbeat Headache Urinating less frequently than usual Irritability Symptoms usually last less than 2 months, although they[web.archive.org]
  • Top of Page Beliefs & Concerns Additives in Vaccines Multiple Vaccinations and the Immune System Top of Page Vaccine Safety As with all vaccines, there can be minor reactions, including pain and redness at the injection site, headache, fatigue or a vague[cdc.gov]
  • […] raw produce, contaminated drinking water, uncooked foods and cooked foods that are not reheated after contact with an infected food handler Incubation Period 28 days average (ranges from 15 to 50 days) Symptoms Diarrhea, dark urine, jaundice, fever, headache[foodsafety.gov]
  • Possible side effects of the hepatitis A vaccine may include redness and soreness where the injection was given, headache, fatigue and tiredness. More serious side effects are extremely rare and can include severe allergic reactions.[conditions.health.qld.gov.au]

Workup

Hepatitis A is best diagnosed serologically. Various types of serologic tests are available, like electron microscopy [EM], complement fixation, immune adherence haemagglutination, radioimmunoassay and enzyme immunoassay. Of these, immune adherence haemagglutination is the one most frequently used. In serologic tests, serum IgM for HAV is detected. This appears within the first week of infection and is positive till 6 months of the illness. Thus, it represents the active or current infection in an individual. This is followed by the detection of IgG antibodies. These antibodies persist lifelong and represent an old infection.

Blood tests include a complete liver function test. It shows an abnormal elevation of ALT, AST, serum bilirubin and alkaline phosphatase which represents acute hepatitis A. Elevated ALT is the sole indicator of liver damage.

Treatment

As HAV infection is a self limiting illness; there is no specific treatment. Supportive care is done by adequate fluid rehydration and nutritional support. Continuous monitoring is done and rest is recommended [9].

Antiemetics are administered for nausea and vomiting. Intravenous fluid therapy is initiated to prevent dehydration. Family members of the infected person are vaccinated to prevent the risk of gaining infection. Patients are advised to stop fatty, oily food and alcohol.

Prognosis

There is no chronic infection or recurrent infection of hepatitis A. Once infected, the individual gets life time immunity. The prognosis is good. Rarely does the infection prove fatal. This is determined through the age of the individual; elderly have a high risk of bad prognosis and the underlying liver disease, that may lead to acute fulminant hepatitis.

On an average, 100 people die every year in the United States with acute liver failure due to hepatitis A infection. It was also found that most deaths occurred in people older than 50 years, thus age is the prime factor in determining the severity of the illness [7].

Etiology

It is caused by hepatitis A virus [HAV]. HAV is a single stranded RNA virus belonging to the picornavirus family. This virus is non-enveloped and though there are multiple genotypes, only one serotype exists. This virus was first isolated in the year 1979. The virus is capable of surviving in low pH levels and in moderate temperatures. Also, it can be stable for months together in environment. HAV is transmitted through faeco-oral route, person to person contact and is rampant in places with overcrowding and poor hygienic conditions. Common sources for outbreaks are contaminated food and water with HAV virus. This is seen with people handling food or processing food that is infected with the virus [1] [2].

Epidemiology

There are millions of people getting infected by this virus throughout the year. In the year 1988, about 27,000 cases were recorded in the United States and in the year 1995, about 32,000 cases were noted. From 1995-2006, there was a reduction in the hepatitis A infection, as large number of children were vaccinated for HAV. Thus, only 1.2 cases per 100,000 populations were recorded.

Children in the age group 5-14 years are more likely to be infected [3]. Over 40 years record reveals that average age of infection increases gradually. Its geographical distribution differs with the socio economic conditions, thus developing countries with poor hygienic conditions are largely infected by this virus. Individuals at risk include male homosexuals, childcare workers, foreign travelers and those with low socio-economic conditions [4].

Sex distribution
Age distribution

Pathophysiology

After reaching the liver, the virus enters the liver cells. The ribosome in the host binds together and forms polysomes. They synthesize the viral proteins. These then assemble together and are shed in the biliary tree and excreted in the faeces.

An inflammatory process begins throughout the liver. The hepatocytes are invaded by the virus and are destroyed. During the incubation period, large numbers of virus are detected in the faeces of the infected person. Other changes occurring in the liver comprise of focal activation of sinusoidal lining cells; accumulation of histiocytes and lymphocytes in the parenchyma of the liver. These replace the destroyed hepatocytes of the liver that have undergone necrosis. These changes mainly occur in the periportal areas. Occasionally, focal degeneration along with coagulative necrosis in the form of acidophilic bodies is seen [5].

During the incubation period, host defenses develop antibody against the hepatitis virus. Specific HAV IgM antibody is found in the serum within a week of infection. Its maximum levels are reached after the first week and the levels slowly decline during 40-60 days of the infection. After this, IgG specific antibody appears, and persists for many years. This antibody is protective and is a marker for a past infection in the host [6].

Prevention

Hepatitis A infection can be transmitted from person to person; hence, individuals must take precautions in order to check its spread. They must wash hands thoroughly using a disinfectant, especially before food preparation, before and after eating food, before and after using toilets and after changing nappies of children. Strict sanitation and proper waste disposal especially of faeces should be done. Travelers should use boiled or cooked food. They should avoid dairy products and raw vegetables. Vaccination is advised before travelling to countries where the outbreaks are known to occur. Preferably use bottled water and if unavailable, then boil water before consuming.

Passive prevention of hepatitis A is done by administration of pooled normal human immunoglobulin. This should contain more than 100IU/ml anti HAV. It is administered intramuscularly at a dose of 2 IU/kg body weight. Hepatitis A vaccines are safe and provide fare immunity against the infection. The centre for disease control and prevention [CDC] has regulated a vaccine programme for children and adults. After the first dose, a booster is administered after 6- 12 months. These vaccines are especially advised to the individuals having an occupational risk, such as, laboratory workers; these are at a risk of acquiring infections during their course of work in microbiological laboratories. Other high risk persons include sewage workers as they are continuously exposed to raw sewage, food handlers and healthcare workers [10].

Summary

The word hepatitis refers to an inflammation of the liver. Hepatitis A is one of the commonest and oldest diseases known till date. It’s a viral infection which results in inflammation of liver caused by hepatitis A virus. Hepatitis A is a self limiting disease lasting from 2 weeks to several months which might culminate into severe disability. Once infected, HAV produces life time immunity and there is a no carrier state. Hepatitis A can prove fatal to an individual who already has an underlying chronic liver disease [1].

Patient Information

Hepatitis A infection is a common liver infection that causes liver inflammation resulting in jaundice. This disease is transmitted through transmission of the Hepatitis A virus from infected faeces to food. This is frequently seen in countries with poor sanitation facilities.

This infection can be prevented by observing proper hygiene, like, washing hands before eating food and before cooking or handling food. Also to wash hands after using toilets. Vaccination can also provide immunity to individuals at risk.

The common symptoms are jaundice, fever, nausea, abdominal pain, vomiting and loss of appetite. Treatment is supportive.

References

Article

  1. Wasley A, Feinstone SM, and Bell BP. 2009. Hepatitis A Virus. In: Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. (pp-2367-2387) 7th ed. Philadelphia. PA: Churchill Livingstone Elsevier.
  2. Klevens RM, Kruszon-Moran D, Wasley A, Gallagher K, et al. Seroprevalence of Hepatitis A Virus Antibodies in the United States: Results from the national Health and Nutrition Examination Survey. Public Health Rep.2011 Jul-Aug; 126(4): 522–532.
  3. Payne L, Coulombier D. Hepatitis A in the European Union: responding to challenges related to new epidemiological patterns. Euro Surveill. 2009;14(3):pii=19101.
  4. Klevens RM, Miller J, Iqbal K, Thomas A, Rizzo EM, Hanson H, et al. The Evolving Epidemiology of Hepatitis A in the United States: Incidence and Molecular Epidemiology from Population-Based Surveillance. Arch Intern Med. 2010 Nov 8;170(20):1811–8.
  5. Wedemeyer H, Pawlotsky JM. 2011. Acute viral hepatitis. In: Goldman L, Schafer AI, (Eds.) Cecil Medicine. (chp 150)- 24th ed. Philadelphia, Pa: Saunders Elsevier.
  6. Sjogren MH, Cheatham JG. 2010. Hepatitis A. In: Feldman M, Friedman LS, Brandt LJ, (Eds.) Sleisenger and Fordtran's Gastrointestinal and Liver Disease.(chp 77) 9th ed. Philadelphia, Pa: Saunders Elsevier.
  7. Akriviadis EA, Redeker AG. Fulminant hepatitis A in intravenous drug users with chronic liver disease. Ann Intern Med. 1989 May 15;110(10):838-9.
  8. Active immunization. In: Pickering LK [Ed.] Red Book: 2003 Report of the Committee on Infectious Diseases, 26th edition. Elk Grove Village, IL: American Academy of Pediatrics;2003.
  9. Lachish T, Tandlich M, Schwartz E. Acute hepatitis in israeli travelers. J Travel Med. 2013 Jul-Aug;20(4):232-6. doi: 10.1111/jtm.12039
  10. Prevention [CDC] Update: Prevention of hepatitis A after exposure to hepatitis A virus and in international travelers. Updated recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR Morb Mortal Wkly Rep. 2007;56:1080-1084.

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Last updated: 2017-08-09 17:39