Epidemiological shift in hepatitis A causing diagnostic and treatment challenges in Ethiopia: A need for guideline and vaccine

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It is ranked first in terms of incidence rate among the four major acute forms of viral hepatitis (A, B, C, and E) and usually occurs in early childhood. However, the prevalence acute hepatitis A has recently increased among teenagers and young adults, and it is usually misdiagnosed. This study emphasizes the significance of awareness among healthcare workers about the increasing incidence of acute hepatitis A among this group to ensure accurate diagnosis and appropriate management. Methods A hospital-based retrospective cross-sectional study was employed. Fifty-eight confirmed acute HAV patients who visited Adera Medical and Surgical Center (AMSC) between August 2023 and January 2024 were enrolled. Sociodemographic, clinical, and laboratory parameters and documented management data, including hospitalization and any trial of antibiotic treatment before considering HAV or in the course of the illness, were collected. The data were entered and analyzed using SPSS (SPSS, Version 26.0). Results The sex ratio was similar, with a slight male predominance (M/F = 1.07). The mean age [± SD] of the patients was 19.3[± 8.8] years. Thirty-nine (67.2%) of the patients were students, and all of the patients were from Addis Ababa. Vomiting (82.8%), anorexia (70.7%) and yellowish discoloration of the eyes (62.1%) were the most common presenting symptoms, while icteric sclera 44 (75.9%) and epigastric tenderness 17 (29.3%) were the most common physical findings. More than half of the patients (55.2%) were initially misdiagnosed with typhoid fever (TF) (46.8%), peptic ulcer disease (PUD) (31.2%) or urinary tract infection (UTI) (15.6%). All patients recovered fully, and liver function tests (LFTs) normalized with supportive care within 2–4 weeks. Conclusion This study revealed a high incidence of HAV among adolescents and young adults (mean [± SD] age 19.31 [± 8.8] years), with more than half of the patients (55.2%) initially being misdiagnosed with TF, PUD or UTI, causing diagnostic and treatment challenges. This necessitates heightened awareness among healthcare workers and the public. Early HAV diagnosis through targeted laboratory investigations and avoiding unnecessary antibiotics are crucial for effective management and prevention via hygienic and immunization strategies. Acute hepatitis A shifting epidemiology diagnostic and treatment challenges Ethiopia Figures Figure 1 Background Hepatitis A is an acute inflammation of the liver caused by hepatitis A virus (HAV), a single-stranded RNA virus of the Picornaviridae family. It is a vaccine-preventable disease that mainly spreads through the feco-oral route either by direct close contact with an HAV-infected person or by ingestion of food or water contaminated by the feces of an infected person ( 1 , 2 , 3 ). HAV is endemic in low- to middle-income countries due to poor sanitary conditions, where most children are infected with hepatitis A before the age of 10. The World Health Organization estimates that approximately 1.5 million people are infected with HAV annually worldwide, resulting in 15,000–30,000 deaths per year. However, improving sanitary conditions in these countries has shifted the incidence of HAV to adolescents and young adults, the age at which the immune system strongly reacts to the infection and results in more severe disease symptoms ( 4 , 5 , 6 ). The clinical presentation of HAV can range from asymptomatic to fulminant liver failure. The manifestation and severity of symptoms after HAV infection directly correlate with age. It is usually asymptomatic in children, and older patients are at increased risk of severe disease ( 6 , 7 ). The incubation period of HAV lasts 15–45 days, followed by a nonspecific prodromal phase, with malaise, fever, and anorexia being the most common symptoms. Vomiting, diarrhea, and abdominal discomfort may also be present. The icteric phase manifests with jaundice and hepatic cytolysis with elevated LFTs. Hepatomegaly and gallbladder wall thickening can be found on sonography ( 1 , 6 , 8 ). HAV diagnosis is confirmed by the presence of anti-A IgM autoantibodies, which appear 5–10 days before the onset of symptoms and may persist for 4–6 months. Hepatitis A is a self-limiting illness that usually requires supportive management with IV fluid resuscitation, electrolyte correction, and anti-emetics. In most cases, HAV resolves completely on its own. Hospitalization is indicated if there is severe intractable vomiting, severe electrolyte and fluid imbalance, or altered mental status. The major cause of death in patients with HAV infection is fulminant hepatic failure, which occurs in < 1% of patients ( 2 , 6 ). Relapse of HAV can occur in 3–20% of patients, usually 3–12 weeks after initial presentation, but symptoms are less severe ( 6 ). Once primarily a childhood illness, hepatitis A, is exhibiting a concerning shift in demographics. Due to improved sanitation and hygiene practices, exposure to the virus is often delayed, leading to a surge in infections among teenagers and young adults with outdoor exposure in Ethiopia ( 9 ). The nonspecific nature of initial symptoms can mimic other conditions, leading to confusion and missed diagnoses. Moreover, healthcare providers may not be sufficiently aware of the increasing prevalence of hepatitis A in young adults, further contributing to the diagnostic dilemma. The objective of this study was to assess the pattern of clinical hepatitis A infection diagnostic and management practices in Addis Ababa, Ethiopia. Materials and methods This retrospective cross-sectional study was conducted to assess the clinical presentation, diagnostic practices and management trends of HAV patients from August 2023 to January 2024. The study took place at Adera Medical and Surgical Center (AMSC), a renowned dedicated gastrointestinal and hepatology center that offers specialized care to thousands of patients in Addis Ababa and regions of Ethiopia. All patients who came to AMSC gastrointestinal and hepatology unit with clinical symptoms and laboratory findings consistent with acute hepatitis A were included in the study, and patients considered to have acute hepatitis but not confirmed with laboratory investigations were excluded. Fifty-eight (58) patients were recruited for the study using a convenient sampling technique. Data were collected by reviewing the patients’ medical records. The acquired data were examined for accuracy, cleaned, and validated before analysis using SPSS 26.0. For categorical variables, descriptive statistics were utilized as a statistical data analysis technique and are expressed as frequencies and numbers (percentages). Tables and figures were used to summarize the results. Categorical data are represented as frequencies, whereas continuous variables are represented as the means, standard deviations, and minimum and maximum values. Results The mean (± SD) age of the patients was 19.31 [± 8.8] years. Approximately two-thirds (63.7%) of the patients were older than 15 years, with ages ranging between 4 and 37 years. Thirty (51.7%) of them were males, while 28 (48.3%) were females. All of the patients were urban dwellers residing in Addis Ababa, 39 (67.2%) of whom were students. (Table 1 ) Table 1 Sociodemographic characteristics of HAV patients visiting AMSC, August 2023 to January 2024. Total (n = 58) Characteristics Frequency Percent (%) Gender Male 30 51.7 Female 28 48.3 Age groups 0 to 5 years 2 3.4 6 to 10 years 11 19.0 11 to 15 years 8 13.8 16 to 20 years 10 17.2 21 to 25 years 10 17.2 Above 25 years 17 29.3 Address Addis Ababa 58 100 Occupation Student 39 67.2 Health care worker 1 1.7 Teacher 1 1.7 Businessman 6 10.3 Accountant 7 12.0 Government officer 1 1.7 Unemployed 3 5.2 The median duration of illness before presentation to AMSC was seven days (range 2–30 days). Vomiting (82.8%), anorexia (70.7%) and yellowish discoloration of the eyes (62.1%) were the most common presenting symptoms. Dark urine, epigastric/abdominal pain, fatigue, diarrhea, fever, pruritus, and clay-colored stool were also reported by 58.6%, 53.4%, 44.8%, 20.6%, 15.5%, 10.3% and 6.9% of the patients, respectively. Only 1 patient reported arthralgia. Icteric sclera was the most common physical finding in 44 patients (75.9%), followed by epigastric tenderness in 17 patients (29.3%). (Fig. 1 ) Two patients presented with extrahepatic manifestations (acute cholecystitis), and only 6 (10.5%) of the patients had a history of contact with a jaundiced person, while risk was not identified or documented in 44 (75.9%) and 8 (13.8%) of the patients, respectively. All patients did not have history of vaccination for HAV. Laboratory investigation revealed significant increases in AST, ALT, and total and direct bilirubin, while ALP was less than two and a half times greater than the upper normal limit in the majority of the patients. Leukocytosis was detected in four patients. Hemoglobin and platelet results were normal in 87.9% of the patients. All of the patients tested positive for anti-HAV IgM but were negative for HBsAg, HCVab and HIV tests. Sixty-two percent of the patients had hepatomegaly on ultrasonographic abdominal examination, while thickened gallbladder wall and splenomegaly were observed in 29.3% and 3.4% of the patients, respectively. Fatty liver, hepatic hemangioma and bright liver were reported in 8.6% of the patients. (Table 2 ) Table 2 Laboratory and imaging findings of HAV patients visiting AMSC, August 2023 to January 2024. Total, n = 58 Variables Frequency Percent (%) Laboratory investigations WBC count ( in /L) ≤ 4000 16 27.6 4000–11,000 38 65.5 > 11,000 4 6.9 Hemoglobin level (in g/dl) Severe Anemia (≤ 7) 0 0 Moderate Anemia (> 7.0–10.0) 2 3.4 Mild Anemia (> 10-12.5) 4 8.6 Normal (≥ 12.5) 51 87.9 Platelet count (in /L) Thrombocytopenia ( 450 x 10 3 ) 1 1.7 ALT value (in IU/L) Normal (≤ 40) 0 - below 2.5 times elevated 5 8.6 2.5 to 5 times elevated 2 3.4 More than 5 times elevated 51 87.9 AST value (in IU/L) Normal (≤ 40) 1 1.7 below 2.5 times elevated 4 6.9 2.5 to 5 times elevated 14 24.1 More than 5 times elevated 39 67.2 ALP value (in IU/L) Normal (≤ 147) 2 3.4 below 2.5 times elevated 31 53.4 2.5 to 5 times elevated 19 32.8 More than 5 times elevated 6 10.3 GGT value (in IU/L), n = 47 Normal (≤ 30) 2 4.3 below 2.5 times elevated 5 10.6 2.5 to 5 times elevated 17 36.2 More than 5 times elevated 23 48.9 Direct Bilirubin (in mg/dl), n = 57 Normal (< 0.3) 2 3.5 below 2.5 times elevated 6 10.5 2.5 to 5 times elevated 10 17.5 More than 5 times elevated 39 68.4 Total Bilirubin, in mg/dl Normal (≤ 1.2) 6 10.3 below 2.5 times elevated 7 12.1 2.5 to 5 times elevated 23 39.5 More than 5 times elevated 22 37.9 Imaging Abdominal ultrasound exam findings, n = 58 Hepatomegaly 36 62.1 Thickened gall bladder wall 17 29.3 Splenomegaly 2 3.4 Fatty liver 3 5.1 Hepatic hemangioma 1 1.7 Bright Liver 1 1.7 More than half of the patients (55.2%) visited other medical centers before presenting to AMSC, and TF (46.8%), PUD (31.2%) and UTI (15.6%) were considered as initial diagnoses. Autoimmune hepatitis and gallstone disease were also diagnosed in four of the patients. Ciprofloxacillin (43.3%), PPIs (33%) and doxycycline (9.9%) were the most commonly prescribed drugs for the patients. Antibiotics such as cotrimoxazole, ceftriaxone, and cefixime were also given to 6 (20%) patients, while one patient received unspecified medication before presenting to our center. (Table 3 ) Table 3 Laboratory and imaging findings of HAV patients visiting AMSC, August 2023 to January 2024. Variables Total, n = 58 Frequency Percent (%) Previous visit to another hospital/clinic Yes 32 55.2 No 22 37.9 Unknown 4 6.9 Diagnosis during previous visit to hospital/clinic, n = 32 TF 14 43.8 UTI 5 15.6 PUD 10 31.3 Autoimmune hepatitis 2 6.25 Gall stone disease 2 6.25 Unspecified 2 6.25 Was medication prescribed during previous visit to another hospital/clinic, n = 32 Yes 30 93.75 No 2 6.25 Prescribed medications during the previous hospital/clinic visit, n = 30 Ciprofloxacillin 13 43.3 Doxycycline 3 9.9 Cotrimoxazole 2 6.6 PPI 10 33.3 Others(ceftriaxone,cefixim) 4 13.3 Unspecified 1 3.3 Eleven (19%) of the patients required hospitalization at our center during their management. The patients who were diagnosed with acute HAV in our center were treated with intravenous fluid (for admitted patients), multivitamin, Livolin (phosphatidylcholine 300 mg + B vitamins + vitamin E) and dietary advice and recovered fully within 2–4 weeks with normalized LFTs. No complications or deaths occurred in our HAV cohort. Discussion Hepatitis A is an enteric virus infection that is closely associated with socioeconomic status, poor sanitary conditions, and hygiene practices, leading to infection during early childhood, at which age the immune system is immature and the immune reaction to the infection is weak, resulting in no or mild symptoms and lasting acquired immunity ( 2 , 4 , 9 ). With socioeconomic status growth and improvements in hygiene and access to clean water, the acquisition of hepatitis A has shifted to children, adolescents and young adults with more outdoor exposure to contaminated water and food. At this age, the disease will be severe and complicated as damage to hepatocytes is caused by the reaction of the mature strong immune system more than the virus itself. ( 2 , 9 , 10 ). Children, adolescents, and young adults from high-income families acquire Hepatitis A when they are exposed to the virus for the first time through food or drink contaminated with HAV at schools, restaurants, or colleges after being brought up in a relatively clean environment. The host immune reaction to HAV at this age is aggressive, resulting in severe hepatitis and manifestations, in contrast to HAV infection during early infancy in poor economic lifestyles ( 9 , 11 ). A study done in Brazil and Mexico revealed that the mean age of symptomatic HAV patients has shifted from childhood to early adulthood as safe water access has improved ( 12 ). A similar pattern of a shift in the endemicity of hepatitis A was also shown in a study conducted in India in 2019; as the majority of the population is no longer exposed to HAV in childhood, the disease remains highly endemic, resulting in more severe disease and outbreaks in older and susceptible individuals ( 13 ). Studies from other developing countries in Africa, Asia, and Latin America have also shown similar patterns (13,14,15). An age-specific seroprevalence study conducted in Ethiopia revealed a 50% HAV antibody seroprevalence among children, while almost all individuals were positive for anti-HAV antibody by the age of 15 ( 16 ). In contrast, our study showed that clinical acute hepatitis A is becoming common among adolescents and young adults from urban settings, as approximately two-thirds (63.7%) of the patients were above the age of 15 years, and all of the patients lived in the capital city, Addis Ababa. This is more than what was reported by a study calling for the inclusion of HAV vaccine in the National Expanded Program on Immunization (EPI) program, which was conducted at the same center, AMSC, in Addis Ababa, Ethiopia, in 2021, and showed 48% of patients with Hepatitis A to be above the age of 15 years and 89% of patients were from high-income and middle-income families ( 9 ). The shifting epidemiology of HAV in Ethiopia presents new challenges for diagnosis and treatment. The nonspecific nature of initial symptoms and health care providers having a low index of suspicion for hepatitis A in young adults with acute hepatitis has led to misdiagnosis and treatment. Misdiagnosis can have significant implications for public health, including delayed diagnosis, increased risk for transmission in the community and outbreaks. Moreover, unnecessary tests, interventions, and treatments drain financial resources and burden patients and the healthcare system. Antibiotics such as ciprofloxacin, doxycycline, and cotrimoxazole, which were prescribed for almost one-third of the patients (31%), can also cause drug-induced liver injury, further confounding the hepatitis and resulting in acute liver failure, which is associated with significant morbidity and mortality. Conclusion This study revealed an epidemiological shift in acute HAV from childhood to adolescence and young adulthood in an urban setting. More than half of the patients were initially misdiagnosed with TF, PUD or UTI. Clinicians need to be especially aware of this shift in hepatitis A among adolescent and young adult patients who initially present with prodromal acute hepatitis. This will help avoid empirical hepatotoxic antibiotics, effective treatment, prevention of local outbreaks, and health cost savings. We recommend that current national HAV seroprevalence studies and assessment of the existing hepatitis A control strategies be conducted to prevent future disease outbreaks via public health education and immunization. Declarations Ethics approval and informed consent statement The ethical approval for the present study was obtained from the institutional review board of Adera Medical and Surgical Center. Because the study was retrospective, consent was not required and was waived. All the information obtained was held confidential and used only for the intended purpose. The research was conducted in accordance with the Declaration of Helsinki. Availability of data and materials The datasets used and/or analyzed during the current study are available from the principal investigator up on reasonable request. Author contributions Abate Bane Shewaye - study conceptualization and design, manuscript development, review and editing. Kaleb Assefa Berhane - data collection, analysis and manuscript development. Amsalework Daniel - data collection and manuscript development. All the authors have read and agreed to publish the manuscript. Conflicts of interest statement The authors report no conflicts of interest related to this work. Funding No funding was obtained. Acknowledgments We are grateful to the patients and colleagues who were involved in the care of the patients. 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Franco E, Meleleo C, Serino L, Sorbara D, Zaratti L. Hepatitis A: Epidemiology and prevention in developing countries. World J Hepatol. 2012 Mar 27;4(3):68-73. doi: 10.4254/wjh.v4.i3.68. Van Effelterre T, Guignard A, Marano C, Rojas R, Jacobsen KH. Modeling the hepatitis A epidemiological transition in Brazil and Mexico. Hum Vaccin Immunother. 2017 Aug 3;13(8):1942-1951. Patterson J, Abdullahi L, Hussey GD, Muloiwa R, Kagina BM. A systematic review of the epidemiology of hepatitis A in Africa. BMC Infect Dis. 2019 Jul 22;19(1):651. doi: 10.1186/s12879-019-4235-5 Agrawal A, Singh S, Kolhapure S, Hoet B, Arankalle V, Mitra M. Increasing Burden of Hepatitis A in Adolescents and Adults and the Need for Long-Term Protection: A Review from the Indian Subcontinent. Infect Dis Ther . 2019 Dec;8(4):483-497. doi: 10.1007/s40121- 019-00270-9. Tapia-Conyer R, Santos JI, Cavalcanti AM, Urdaneta E, Rivera L, Manterola A, Potin M, Ruttiman R, Tanaka Kido J. Hepatitis A in Latin America: a changing epidemiologic pattern. Am J Trop Med Hyg. 1999 Nov;61(5):825-9. doi: 10.4269/ajtmh.1999.61.825. Edemariam Tsega, Nordenfelt E, Biru Mengesha, Hansson BG, Molla Tsega, Lindberg J. Age-specific prevalence of hepatitis A virus antibody in Ethiopian children. Scand J Infect Dis. 1990;22(2):145- 8. doi: 10.3109/00365549009037894. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4241965","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":289889150,"identity":"85aec129-cf44-4616-ad54-0052f849b659","order_by":0,"name":"Abate Bane Shewaye","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYDACCSBmbACxmA+AuDLEaGFsgGhhSwBxeUjRwmMAJgnq4J/d/PzBxx12efz8Zz6/ulFjwcPAfvjoBryW3Dlm2DjzTHKx5IzcbdY5x4AO40lLu4HXmhsJhs28bcyJG27wbjPOYQNqkeAxw6tF/kb6x+a/bfWJ+8+feWac848ILQY3cgybGdsOJ25gyGF+nNtGhBbDO2cKZ/aeOZ4440aaGXNunwQPGyG/yN1u3/Dh547qxP7+w48/53yrk+NnP3wMv/eRAJsEmCRWOQgwfyBF9SgYBaNgFIwcAAD39U4h2vb5mgAAAABJRU5ErkJggg==","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"prefix":"","firstName":"Abate","middleName":"Bane","lastName":"Shewaye","suffix":""},{"id":289889151,"identity":"a9044b1b-62a6-4712-a643-533d948ae3c6","order_by":1,"name":"Kaleb Assefa Berhane","email":"","orcid":"","institution":"Adera Medical and Surgical Center","correspondingAuthor":false,"prefix":"","firstName":"Kaleb","middleName":"Assefa","lastName":"Berhane","suffix":""},{"id":289889152,"identity":"2b76f1c5-b8d4-46b9-9268-6ce4fa26a532","order_by":2,"name":"Amsalework Daniel","email":"","orcid":"","institution":"Adera Medical and Surgical Center","correspondingAuthor":false,"prefix":"","firstName":"Amsalework","middleName":"","lastName":"Daniel","suffix":""}],"badges":[],"createdAt":"2024-04-09 12:42:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4241965/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4241965/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54785188,"identity":"9fd01326-8121-48bd-84f4-ce1b47f0b39d","added_by":"auto","created_at":"2024-04-16 18:04:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":60306,"visible":true,"origin":"","legend":"\u003cp\u003eClinical Presentation of HAV patients visiting AMSC,August 2023 to January 2024.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4241965/v1/2a6135f0db7a8bd362fa3ed9.png"},{"id":54829963,"identity":"f7897dc4-c69d-49c6-be3c-3cf41a695fad","added_by":"auto","created_at":"2024-04-17 10:51:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":431462,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4241965/v1/8abdd092-7153-400c-abbb-770fd91b5447.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Epidemiological shift in hepatitis A causing diagnostic and treatment challenges in Ethiopia: A need for guideline and vaccine","fulltext":[{"header":"Background","content":"\u003cp\u003eHepatitis A is an acute inflammation of the liver caused by hepatitis A virus (HAV), a single-stranded RNA virus of the Picornaviridae family. It is a vaccine-preventable disease that mainly spreads through the feco-oral route either by direct close contact with an HAV-infected person or by ingestion of food or water contaminated by the feces of an infected person (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHAV is endemic in low- to middle-income countries due to poor sanitary conditions, where most children are infected with hepatitis A before the age of 10. The World Health Organization estimates that approximately 1.5\u0026nbsp;million people are infected with HAV annually worldwide, resulting in 15,000\u0026ndash;30,000 deaths per year. However, improving sanitary conditions in these countries has shifted the incidence of HAV to adolescents and young adults, the age at which the immune system strongly reacts to the infection and results in more severe disease symptoms (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe clinical presentation of HAV can range from asymptomatic to fulminant liver failure. The manifestation and severity of symptoms after HAV infection directly correlate with age. It is usually asymptomatic in children, and older patients are at increased risk of severe disease (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The incubation period of HAV lasts 15\u0026ndash;45 days, followed by a nonspecific prodromal phase, with malaise, fever, and anorexia being the most common symptoms. Vomiting, diarrhea, and abdominal discomfort may also be present. The icteric phase manifests with jaundice and hepatic cytolysis with elevated LFTs. Hepatomegaly and gallbladder wall thickening can be found on sonography (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). HAV diagnosis is confirmed by the presence of anti-A IgM autoantibodies, which appear 5\u0026ndash;10 days before the onset of symptoms and may persist for 4\u0026ndash;6 months.\u003c/p\u003e \u003cp\u003eHepatitis A is a self-limiting illness that usually requires supportive management with IV fluid resuscitation, electrolyte correction, and anti-emetics. In most cases, HAV resolves completely on its own. Hospitalization is indicated if there is severe intractable vomiting, severe electrolyte and fluid imbalance, or altered mental status. The major cause of death in patients with HAV infection is fulminant hepatic failure, which occurs in \u0026lt;\u0026thinsp;1% of patients (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Relapse of HAV can occur in 3\u0026ndash;20% of patients, usually 3\u0026ndash;12 weeks after initial presentation, but symptoms are less severe (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOnce primarily a childhood illness, hepatitis A, is exhibiting a concerning shift in demographics. Due to improved sanitation and hygiene practices, exposure to the virus is often delayed, leading to a surge in infections among teenagers and young adults with outdoor exposure in Ethiopia (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The nonspecific nature of initial symptoms can mimic other conditions, leading to confusion and missed diagnoses. Moreover, healthcare providers may not be sufficiently aware of the increasing prevalence of hepatitis A in young adults, further contributing to the diagnostic dilemma. The objective of this study was to assess the pattern of clinical hepatitis A infection diagnostic and management practices in Addis Ababa, Ethiopia.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003eThis retrospective cross-sectional study was conducted to assess the clinical presentation, diagnostic practices and management trends of HAV patients from August 2023 to January 2024. The study took place at Adera Medical and Surgical Center (AMSC), a renowned dedicated gastrointestinal and hepatology center that offers specialized care to thousands of patients in Addis Ababa and regions of Ethiopia.\u003c/p\u003e \u003cp\u003eAll patients who came to AMSC gastrointestinal and hepatology unit with clinical symptoms and laboratory findings consistent with acute hepatitis A were included in the study, and patients considered to have acute hepatitis but not confirmed with laboratory investigations were excluded.\u003c/p\u003e \u003cp\u003eFifty-eight (58) patients were recruited for the study using a convenient sampling technique. Data were collected by reviewing the patients\u0026rsquo; medical records. The acquired data were examined for accuracy, cleaned, and validated before analysis using SPSS 26.0. For categorical variables, descriptive statistics were utilized as a statistical data analysis technique and are expressed as frequencies and numbers (percentages). Tables and figures were used to summarize the results. Categorical data are represented as frequencies, whereas continuous variables are represented as the means, standard deviations, and minimum and maximum values.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe mean (\u0026plusmn;\u0026thinsp;SD) age of the patients was 19.31 [\u0026plusmn;\u0026thinsp;8.8] years. Approximately two-thirds (63.7%) of the patients were older than 15 years, with ages ranging between 4 and 37 years. Thirty (51.7%) of them were males, while 28 (48.3%) were females. All of the patients were urban dwellers residing in Addis Ababa, 39 (67.2%) of whom were students. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of HAV patients visiting AMSC, August 2023 to January 2024.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eAge groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 to 5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 to 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 to 15 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 to 20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 to 25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove 25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAddress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAddis Ababa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth care worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBusinessman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAccountant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment officer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe median duration of illness before presentation to AMSC was seven days (range 2\u0026ndash;30 days). Vomiting (82.8%), anorexia (70.7%) and yellowish discoloration of the eyes (62.1%) were the most common presenting symptoms. Dark urine, epigastric/abdominal pain, fatigue, diarrhea, fever, pruritus, and clay-colored stool were also reported by 58.6%, 53.4%, 44.8%, 20.6%, 15.5%, 10.3% and 6.9% of the patients, respectively. Only 1 patient reported arthralgia. Icteric sclera was the most common physical finding in 44 patients (75.9%), followed by epigastric tenderness in 17 patients (29.3%). (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTwo patients presented with extrahepatic manifestations (acute cholecystitis), and only 6 (10.5%) of the patients had a history of contact with a jaundiced person, while risk was not identified or documented in 44 (75.9%) and 8 (13.8%) of the patients, respectively. All patients did not have history of vaccination for HAV.\u003c/p\u003e \u003cp\u003eLaboratory investigation revealed significant increases in AST, ALT, and total and direct bilirubin, while ALP was less than two and a half times greater than the upper normal limit in the majority of the patients. Leukocytosis was detected in four patients. Hemoglobin and platelet results were normal in 87.9% of the patients. All of the patients tested positive for anti-HAV IgM but were negative for HBsAg, HCVab and HIV tests.\u003c/p\u003e \u003cp\u003eSixty-two percent of the patients had hepatomegaly on ultrasonographic abdominal examination, while thickened gallbladder wall and splenomegaly were observed in 29.3% and 3.4% of the patients, respectively. Fatty liver, hepatic hemangioma and bright liver were reported in 8.6% of the patients. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory and imaging findings of HAV patients visiting AMSC, August 2023 to January 2024.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eTotal, n\u0026thinsp;=\u0026thinsp;58\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVariables\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLaboratory investigations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eWBC count ( in /L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4000\u0026ndash;11,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e65.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;11,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHemoglobin level (in g/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSevere Anemia (\u0026le;\u0026thinsp;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eModerate Anemia (\u0026gt;\u0026thinsp;7.0\u0026ndash;10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMild Anemia (\u0026gt;\u0026thinsp;10-12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (\u0026ge;\u0026thinsp;12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePlatelet count (in /L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThrombocytopenia (\u0026lt;\u0026thinsp;150 x 10\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (150 x 10\u003csup\u003e3\u003c/sup\u003e \u0026ndash; 450 x 10\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThrombocytosis (\u0026gt;\u0026thinsp;450 x 10\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eALT value (in IU/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (\u0026le;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ebelow 2.5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 to 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAST value (in IU/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (\u0026le;\u0026thinsp;40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ebelow 2.5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 to 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eALP value (in IU/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (\u0026le;\u0026thinsp;147)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ebelow 2.5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 to 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eGGT value (in IU/L), n\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (\u0026le;\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ebelow 2.5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 to 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eDirect Bilirubin (in mg/dl), n\u0026thinsp;=\u0026thinsp;57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (\u0026lt;\u0026thinsp;0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ebelow 2.5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 to 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal Bilirubin, in mg/dl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (\u0026le;\u0026thinsp;1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ebelow 2.5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5 to 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e39.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than 5 times elevated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImaging\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eAbdominal ultrasound exam findings, n\u0026thinsp;=\u0026thinsp;58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHepatomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThickened gall bladder wall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSplenomegaly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFatty liver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHepatic hemangioma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBright Liver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMore than half of the patients (55.2%) visited other medical centers before presenting to AMSC, and TF (46.8%), PUD (31.2%) and UTI (15.6%) were considered as initial diagnoses. Autoimmune hepatitis and gallstone disease were also diagnosed in four of the patients. Ciprofloxacillin (43.3%), PPIs (33%) and doxycycline (9.9%) were the most commonly prescribed drugs for the patients. Antibiotics such as cotrimoxazole, ceftriaxone, and cefixime were also given to 6 (20%) patients, while one patient received unspecified medication before presenting to our center. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory and imaging findings of HAV patients visiting AMSC, August 2023 to January 2024.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eTotal, n\u0026thinsp;=\u0026thinsp;58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercent (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003ePrevious visit to another hospital/clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eDiagnosis during previous visit to hospital/clinic, n\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUTI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePUD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAutoimmune hepatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGall stone disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWas medication prescribed during previous visit to another hospital/clinic, n\u0026thinsp;=\u0026thinsp;32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e93.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003ePrescribed medications during the previous hospital/clinic visit, n\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCiprofloxacillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDoxycycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCotrimoxazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePPI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOthers(ceftriaxone,cefixim)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEleven (19%) of the patients required hospitalization at our center during their management. The patients who were diagnosed with acute HAV in our center were treated with intravenous fluid (for admitted patients), multivitamin, Livolin (phosphatidylcholine 300 mg\u0026thinsp;+\u0026thinsp;B vitamins\u0026thinsp;+\u0026thinsp;vitamin E) and dietary advice and recovered fully within 2\u0026ndash;4 weeks with normalized LFTs. No complications or deaths occurred in our HAV cohort.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHepatitis A is an enteric virus infection that is closely associated with socioeconomic status, poor sanitary conditions, and hygiene practices, leading to infection during early childhood, at which age the immune system is immature and the immune reaction to the infection is weak, resulting in no or mild symptoms and lasting acquired immunity (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith socioeconomic status growth and improvements in hygiene and access to clean water, the acquisition of hepatitis A has shifted to children, adolescents and young adults with more outdoor exposure to contaminated water and food. At this age, the disease will be severe and complicated as damage to hepatocytes is caused by the reaction of the mature strong immune system more than the virus itself. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChildren, adolescents, and young adults from high-income families acquire Hepatitis A when they are exposed to the virus for the first time through food or drink contaminated with HAV at schools, restaurants, or colleges after being brought up in a relatively clean environment. The host immune reaction to HAV at this age is aggressive, resulting in severe hepatitis and manifestations, in contrast to HAV infection during early infancy in poor economic lifestyles (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA study done in Brazil and Mexico revealed that the mean age of symptomatic HAV patients has shifted from childhood to early adulthood as safe water access has improved (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). A similar pattern of a shift in the endemicity of hepatitis A was also shown in a study conducted in India in 2019; as the majority of the population is no longer exposed to HAV in childhood, the disease remains highly endemic, resulting in more severe disease and outbreaks in older and susceptible individuals (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Studies from other developing countries in Africa, Asia, and Latin America have also shown similar patterns (13,14,15).\u003c/p\u003e \u003cp\u003eAn age-specific seroprevalence study conducted in Ethiopia revealed a 50% HAV antibody seroprevalence among children, while almost all individuals were positive for anti-HAV antibody by the age of 15 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In contrast, our study showed that clinical acute hepatitis A is becoming common among adolescents and young adults from urban settings, as approximately two-thirds (63.7%) of the patients were above the age of 15 years, and all of the patients lived in the capital city, Addis Ababa. This is more than what was reported by a study calling for the inclusion of HAV vaccine in the National Expanded Program on Immunization (EPI) program, which was conducted at the same center, AMSC, in Addis Ababa, Ethiopia, in 2021, and showed 48% of patients with Hepatitis A to be above the age of 15 years and 89% of patients were from high-income and middle-income families (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe shifting epidemiology of HAV in Ethiopia presents new challenges for diagnosis and treatment. The nonspecific nature of initial symptoms and health care providers having a low index of suspicion for hepatitis A in young adults with acute hepatitis has led to misdiagnosis and treatment.\u003c/p\u003e \u003cp\u003eMisdiagnosis can have significant implications for public health, including delayed diagnosis, increased risk for transmission in the community and outbreaks. Moreover, unnecessary tests, interventions, and treatments drain financial resources and burden patients and the healthcare system.\u003c/p\u003e \u003cp\u003eAntibiotics such as ciprofloxacin, doxycycline, and cotrimoxazole, which were prescribed for almost one-third of the patients (31%), can also cause drug-induced liver injury, further confounding the hepatitis and resulting in acute liver failure, which is associated with significant morbidity and mortality.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study revealed an epidemiological shift in acute HAV from childhood to adolescence and young adulthood in an urban setting. More than half of the patients were initially misdiagnosed with TF, PUD or UTI. Clinicians need to be especially aware of this shift in hepatitis A among adolescent and young adult patients who initially present with prodromal acute hepatitis. This will help avoid empirical hepatotoxic antibiotics, effective treatment, prevention of local outbreaks, and health cost savings. We recommend that current national HAV seroprevalence studies and assessment of the existing hepatitis A control strategies be conducted to prevent future disease outbreaks via public health education and immunization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and informed consent statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethical\u0026nbsp;approval for\u0026nbsp;the present study was obtained from the\u0026nbsp;institutional review board of Adera Medical and Surgical Center.\u0026nbsp;Because the study was retrospective, consent was not required and was waived.\u0026nbsp;All the information obtained was held\u0026nbsp;confidential\u0026nbsp;and used only for the intended purpose.\u0026nbsp;The research was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the principal investigator up on\u0026nbsp;reasonable\u0026nbsp;request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbate Bane Shewaye - study conceptualization and design, manuscript development, review and editing.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKaleb Assefa Berhane - data collection, analysis and manuscript development.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAmsalework Daniel - data collection and manuscript development.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAll the authors have read and agreed to publish the manuscript.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest related to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the patients and colleagues who were involved in the care of the patients.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFoster A, Hernandez S. Hepatitis A: A Case Report Example of a Growing Epidemiological Threat. Spartan Med Res J. 2019 Mar 4;3(3):7436. doi: 10.51894/001c.7436.\u003c/li\u003e\n \u003cli\u003eHerzog C, Van Herck K, Van Damme P. Hepatitis A vaccination and its immunological and epidemiological long-term effects - a review of the evidence. Hum Vaccin Immunother. 2021 May 4;17(5):1496-1519. doi: 10.1080/21645515.2020.1819742.\u003c/li\u003e\n \u003cli\u003eWang M, Feng Z. Mechanisms of Hepatocellular Injury in Hepatitis A. Viruses. 2021 May 8;13(5):861. doi: 10.3390/v13050861.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. \u003cem\u003eWHO Immunological Basis for Immunization Series, Module 18: Hepatitis A Update.\u003c/em\u003e WHO; Geneva, Switzerland: 2019.\u003c/li\u003e\n \u003cli\u003eIorio N, John S. Hepatitis A. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.\u0026nbsp;Available from: https://www.ncbi.nlm.nih.gov/books/NBK459290/\u003c/li\u003e\n \u003cli\u003eMigueres M, Lhomme S, Izopet J. Hepatitis A: Epidemiology, High-Risk Groups, Prevention and Research on Antiviral Treatment. Viruses. 2021 Sep 22;13(10):1900. doi: 10.3390/v13101900.\u003c/li\u003e\n \u003cli\u003eLemon SM, Ott JJ, Van Damme P, Shouval D. Type A viral hepatitis: A summary and update on the molecular virology, epidemiology, pathogenesis and prevention. J Hepatol. 2017 Sep 5:S0168-8278(17)32278-X. doi: 10.1016/j.jhep.2017.08.034.\u003c/li\u003e\n \u003cli\u003eShin EC, Jeong SH. Natural History, Clinical Manifestations, and Pathogenesis of Hepatitis A. Cold Spring Harb Perspect Med. 2018 Sep 4;8(9):a031708. doi: 10.1101/cshperspect.a031708.\u003c/li\u003e\n \u003cli\u003eBane A, Sultan A, Ahmed R. Increasing Burden of Acute Hepatitis A among Ethiopian Children, Adolescents, and Young adults: A Change in Epidemiological Pattern and Need for Hepatitis A Vaccine. Ethiop J Health Sci. 2022 Mar;32(2):255-260. doi: 10.4314/ejhs.v32i2.5.\u003c/li\u003e\n \u003cli\u003eCao G, Jing W, Liu J, Liu M. The global trends and regional differences in incidence and mortality of hepatitis A from 1990 to 2019 and implications for its prevention. Hepatol Int. 2021 Oct;15(5):1068-1082. doi: 10.1007/s12072-021-10232-4.\u003c/li\u003e\n \u003cli\u003eFranco E, Meleleo C, Serino L, Sorbara D, Zaratti L. Hepatitis A: Epidemiology and prevention in developing countries. World J Hepatol. 2012 Mar 27;4(3):68-73. doi: 10.4254/wjh.v4.i3.68.\u003c/li\u003e\n \u003cli\u003eVan Effelterre T, Guignard A, Marano C, Rojas R, Jacobsen KH. Modeling the hepatitis A epidemiological transition in Brazil and Mexico. Hum Vaccin Immunother. 2017 Aug 3;13(8):1942-1951.\u003c/li\u003e\n \u003cli\u003ePatterson J, Abdullahi L, Hussey GD, Muloiwa R, Kagina BM. A systematic review of the epidemiology of hepatitis A in Africa. \u003cem\u003eBMC Infect Dis.\u0026nbsp;\u003c/em\u003e2019 Jul 22;19(1):651. doi:\u0026nbsp;10.1186/s12879-019-4235-5\u003c/li\u003e\n \u003cli\u003eAgrawal A, Singh S, Kolhapure S, Hoet B, Arankalle V, Mitra M. Increasing Burden of\u003cbr\u003eHepatitis A in Adolescents and Adults and the Need for Long-Term Protection: A Review from the Indian Subcontinent. \u003cem\u003eInfect Dis Ther\u003c/em\u003e. 2019 Dec;8(4):483-497. doi: 10.1007/s40121- 019-00270-9.\u003c/li\u003e\n \u003cli\u003eTapia-Conyer R, Santos JI, Cavalcanti AM, Urdaneta E, Rivera L, Manterola A, Potin M, Ruttiman R, Tanaka Kido J. Hepatitis A in Latin America: a changing epidemiologic pattern. Am J Trop Med Hyg. 1999 Nov;61(5):825-9. doi: 10.4269/ajtmh.1999.61.825.\u003c/li\u003e\n \u003cli\u003eEdemariam Tsega, Nordenfelt E, Biru Mengesha, Hansson BG, Molla Tsega, Lindberg J. Age-specific prevalence of hepatitis A virus antibody in Ethiopian children. Scand J Infect Dis. 1990;22(2):145- 8. doi: 10.3109/00365549009037894.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Acute hepatitis A, shifting epidemiology, diagnostic and treatment challenges, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-4241965/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4241965/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHepatitis A is an acute viral infection of the liver caused by hepatitis A virus (HAV) that is acquired through the feco-oral route. It is ranked first in terms of incidence rate among the four major acute forms of viral hepatitis (A, B, C, and E) and usually occurs in early childhood. However, the prevalence acute hepatitis A has recently increased among teenagers and young adults, and it is usually misdiagnosed. This study emphasizes the significance of awareness among healthcare workers about the increasing incidence of acute hepatitis A among this group to ensure accurate diagnosis and appropriate management.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA hospital-based retrospective cross-sectional study was employed. Fifty-eight confirmed acute HAV patients who visited Adera Medical and Surgical Center (AMSC) between August 2023 and January 2024 were enrolled. Sociodemographic, clinical, and laboratory parameters and documented management data, including hospitalization and any trial of antibiotic treatment before considering HAV or in the course of the illness, were collected. The data were entered and analyzed using SPSS (SPSS, Version 26.0).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe sex ratio was similar, with a slight male predominance (M/F\u0026thinsp;=\u0026thinsp;1.07). The mean age [\u0026plusmn;\u0026thinsp;SD] of the patients was 19.3[\u0026plusmn;\u0026thinsp;8.8] years. Thirty-nine (67.2%) of the patients were students, and all of the patients were from Addis Ababa. Vomiting (82.8%), anorexia (70.7%) and yellowish discoloration of the eyes (62.1%) were the most common presenting symptoms, while icteric sclera 44 (75.9%) and epigastric tenderness 17 (29.3%) were the most common physical findings. More than half of the patients (55.2%) were initially misdiagnosed with typhoid fever (TF) (46.8%), peptic ulcer disease (PUD) (31.2%) or urinary tract infection (UTI) (15.6%). All patients recovered fully, and liver function tests (LFTs) normalized with supportive care within 2\u0026ndash;4 weeks.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study revealed a high incidence of HAV among adolescents and young adults (mean [\u0026plusmn;\u0026thinsp;SD] age 19.31 [\u0026plusmn;\u0026thinsp;8.8] years), with more than half of the patients (55.2%) initially being misdiagnosed with TF, PUD or UTI, causing diagnostic and treatment challenges. This necessitates heightened awareness among healthcare workers and the public. Early HAV diagnosis through targeted laboratory investigations and avoiding unnecessary antibiotics are crucial for effective management and prevention via hygienic and immunization strategies.\u003c/p\u003e","manuscriptTitle":"Epidemiological shift in hepatitis A causing diagnostic and treatment challenges in Ethiopia: A need for guideline and vaccine","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-16 18:04:24","doi":"10.21203/rs.3.rs-4241965/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7a5376ea-5443-4d4d-be42-561880158b93","owner":[],"postedDate":"April 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-17T10:43:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-16 18:04:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4241965","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4241965","identity":"rs-4241965","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}