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

  Signs include hepatomegaly, lymphadenopathy and splenomegaly, though these findings vary from individual to individual, depending on general health status and age group. [symptoma.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]

  Other less common findings include splenomegaly, cervical lymphadenopathy, arthritis, evanescent rash, and rarely a leukocytoclastic vasculitis. [clinicaladvisor.com]

  Mild hepatomegaly, splenomegaly, and cervical lymphadenopathy are found in 85%, 15%, and 14% of infected patients, respectively. [clevelandclinicmeded.com]

• Generalized Lymphadenopathy

  lymphadenopathy are the possible extrahepatic manifestations. [en.wikipedia.org]

• Fever

  The recurrence of the paratyphoid fever may be ascribed to the coexistence of hepatitis B, a course of ceftriaxone plus levofloxacin that was too short and the insensitivity of paratyphoid fever A to levofloxacin. [ncbi.nlm.nih.gov]

  The hepatitis A virus (HAV) causes fever, nausea, vomiting, and jaundice, and can lead to community-wide epidemics. Childcare centers are a common site of outbreaks. [kidshealth.org]

  Fever is relieved using fever medications and bed rest is advised. Medication to prevent nausea and vomiting is advised and the patient is asked to avoid alcohol and certain medications to allow the liver to heal and recover. [news-medical.net]

  Advice from a doctor should be obtained before using medication to relieve pain or fever. [immune.org.nz]

• Fatigue

  The highly contagious liver disease includes symptoms like fever, fatigue, nausea, dark urine, and yellowing skin. Most people who get hepatitis A recover completely and do not have lasting liver damage. [whcuradio.com]

  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]

  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 Hepatitis A is an acute viral illness characterized by the abrupt onset of fever, fatigue, jaundice (skin or eyes turning yellow/orange), loss of appetite, and nausea in older children and adults. [dshs.state.tx.us]

• Malaise

  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%. [msdmanuals.com]

  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]

• Falling

  The virus was first detected in Louisville last fall and can be spread through contact with surfaces, food or drinks contaminated by feces from an infected person. [wkyt.com]

  Clinics are scheduled for Saturday from 1 p.m. to 8 p.m. at Mynderse Academy in Seneca Falls. Additional clinic hours will be available there on Sunday from 10 a.m. to 4 p.m. [syracuse.com]

  […] been vaccinated for the illness to seek treatment if they ate at the restaurant on one of the following dates: People who ate at the McDonalds on October 31 were asked to attend a clinic at the Mynderse Academy Gymnasium at 105 Troy Street in Seneca Falls [cnycentral.com]

  Therefore, 2.5% of the normal population will have laboratory values that fall outside the upper and lower limits of normal. [doi.org]

• Weight Loss

  Physical exam was then notable for 70-lb weight loss from initial admission and diffuse peripheral weakness with global muscle atrophy. [ncbi.nlm.nih.gov]

  This illness is characterised by: Tiredness Loss of appetite Unexplained weight loss Darkened urine Stomach and/or lower back pains Pale faeces Yellowing of the eyes and skin Transmission Hepatitis C is present in blood and other body fluids. [goshh.ie]

  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]

  Symptoms may include: abdominal pain loss of appetite weight loss nausea (and sometimes vomiting) fever and chills mild headache tiredness dark urine and pale faeces yellow skin and eyes (jaundice) (see image). [sahealth.sa.gov.au]

• Nausea

  Symptoms may include fatigue, fever, nausea, myalgia, jaundice and pruritus. Recurrence and chronic hepatitis do not usually occur. [symptoma.com]

  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]

  Medication to prevent nausea and vomiting is advised and the patient is asked to avoid alcohol and certain medications to allow the liver to heal and recover. [news-medical.net]

  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]

• 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]

  Seek medical attention if you have any of the following symptoms: nausea and vomiting that does not improve within 1-2 days, yellow skin or eyes, dark-colored urine, or pain in the abdomen. [emedicinehealth.com]

  Medication to prevent nausea and vomiting is advised and the patient is asked to avoid alcohol and certain medications to allow the liver to heal and recover. [news-medical.net]

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

  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]

• Loss of Appetite

  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 E causes typical symptoms of viral hepatitis, including loss of appetite, a general feeling of illness, and jaundice. Doctors diagnose hepatitis E based on blood tests. [merckmanuals.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]

  The symptoms of Hepatitis A range from mild to severe and can include fever, malaise, loss of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a yellowing of the skin and whites of the eyes). [certest.es]

• Abdominal Pain

  She was admitted to our hospital with fever, jaundice and abdominal pain. Hepatic and pancreatic enzymes were elevated. Her serum alanine aminotransferase (ALT) level was high. [ncbi.nlm.nih.gov]

  Symptoms include fever, loss of appetite, nausea, abdominal pain and jaundice. Some people experience a fairly mild illness and recover within a couple of weeks. Other people develop more severe symptoms and may take months to fully recover. [hpsc.ie]

• Diarrhea

  A healthy 27-year-old female presented fever, palpitation, and diarrhea, and she was subsequently diagnosed as acute HAV infection. Concurrently, she showed hyperthyroidism, and the diagnosis was made as Graves' disease. [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]

  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]

• Jaundice

  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]

  jaundice) are generally attributed to Hippocrates. [about-hepatitis.com]

  When clinical manifestations appear, these include choluria, jaundice, and abdominal pain. [ncbi.nlm.nih.gov]

• Hepatomegaly

  The child was deeply icteric and had hepatomegaly. IgM antibodies for hepatitis A virus were positive. However this child had prolonged cholestasis and cholestyramine was started. The child responded only after prednisolone was started. [ncbi.nlm.nih.gov]

  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]

• Hepatosplenomegaly

  On examination, he had tachypnea, hepatosplenomegaly, ascites and right-sided pleural effusion. [ncbi.nlm.nih.gov]

  Homepage Rare diseases Search Search for a rare disease Ichthyosis-hepatosplenomegaly-cerebellar degeneration syndrome Disease definition Ichthyosis-hepatosplenomegaly-cerebellar degeneration syndrome is characterised by ichthyosis, hepatosplenomegaly [orpha.net]

  The initial symptoms of HAV include fever (about 39°C), malaise, fatigue, headache, anorexia, nausea and vomiting, pain in the right upper quadrant, and hepatosplenomegaly. [atsu.edu]

  […] 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]

  Differential Diagnosis of Acute Hepatitis Possible diagnoses Distinguishing features Viral infections Cytomegalovirus Mild to moderate ALT, AST, alkaline phosphatase elevations, can accompany human immunodeficiency virus, with or without hepatosplenomegaly [web.archive.org]

• 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]

• Yellow Discoloration of the Skin

  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]

  The general symptoms of hepatitis E can be: Fatigue Abdominal pain and tenderness Nausea, vomiting Loss of appetite Diarrhea Dark coloured urine Pale feces Jaundice in some cases (yellow discoloration of the skin and sclera of the eyes) People who have [bccdc.ca]

  A hepatitis infection is also associated with jaundice, a yellow discoloration of the skin and a yellowish color to the whites of the eyes. [healthychildren.org]

  This illness is characterised by: Tiredness Loss of appetite Unexplained weight loss Darkened urine Stomach pains Pale faeces Yellowing of the eyes and skin The most well-known symptom of hepatitis B is a yellow discoloration of the skin (jaundice) which [goshh.ie]

  The most common hepatitis A symptoms are as follows: Nausea Vomiting Diarrhea, especially in children Pale or gray-colored stools Low-grade fever Loss of appetite Rash Tiredness, fatigue Jaundice (a yellow discoloration of the skin and the whites of the [emedicinehealth.com]

• Skin Rash

  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]

  They may include: Mild fever Feeling very tired Less hunger Feeling sick to your stomach Throwing up Belly pain Dark pee Light-colored poop Skin rash or itching Joint pain Yellowish skin or eyes Diagnosis Your doctor will ask for your medical history [webmd.com]

  Thereafter jaundice appears, with yellowing of skin and sclera, dark colored urine and pale stools. There is intense pruritis with skin rash. [symptoma.com]

  Arthralgias and skin rash. These occur less often (lower limbs and with a vasculitic appearance). Tender hepatomegaly, splenomegaly, and lymphadenopathy may occur. [patient.info]

• Myalgia

  Early in the disease, called the prodromal phase, symptoms may include: Fever Joint pain or arthritis Rash Edema (swelling) Symptoms of the next phase, the preicteric phase, include: Fatigue Myalgia (muscle pain) Anorexia Nausea and/or vomiting Fever [hopkinsmedicine.org]

  Symptoms may include fatigue, fever, nausea, myalgia, jaundice and pruritus. Recurrence and chronic hepatitis do not usually occur. [symptoma.com]

  Headache, arthralgias, myalgias, rash, or diarrhea can follow. Jaundice begins within 1-2 weeks from the onset of the prodrome. It occurs in 70% of adults infected with HAV, with or without pruritus, and in a far smaller proportion of children. [clevelandclinicmeded.com]

  AST less than 300 U per L (5.01 μkat per L; Figure 2 ) Carbon tetrachloride History of exposure Bacterial infections Leptospirosis History of exposure to water contaminated by animal urine or direct contact with animal urine Q fever Relapsing fever, myalgia [web.archive.org]

• Dark Urine

  The highly contagious liver disease includes symptoms like fever, fatigue, nausea, dark urine, and yellowing skin. Most people who get hepatitis A recover completely and do not have lasting liver damage. [whcuradio.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]

  Symptoms of the disease include mild fever, loss of appetite, nausea, fatigue, vomiting, diarrhea, abdominal pain and dark urine and jaundice. [nj.com]

  If you have noticed lately you feel weak and itch, have a loss of appetite, dark urine, and a low-grade fever, you may be suffering from symptoms of hepatitis A. [mountsinai.org]

  Symptoms often occur suddenly and include fatigue, abdominal and/or joint pain, loss of appetite, fever, nausea, jaundice, dark urine, clay-colored bowel movements, and diarrhea. [nvic.org]

• 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]

  […] 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]

  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]

  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]

• Rabies

  Hepatitis B, diphtheria, poliovirus (oral and inactivated), tetanus, typhoid (oral and intramuscular), cholera, Japanese encephalitis, rabies, and yellow fever vaccines can be given at the same time that hepatitis A vaccine is given, but at a different [cdc.gov]

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.

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.

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].

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].

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].

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].

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].

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].

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.

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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.
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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.
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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.