About this course:
The learner will understand the short-term and long-term impact of viral hepatitis, identify risk factors, and modes of transmission to assist the learner with the implementation of health promotion and health restoration activities to reduce the transmission of hepatitis and promote healing to infected persons.
At the completion of this activity, the participants should be able to:
- Compare and contrast the five major types of viral hepatitis.
- Describe the modes of transmission for the major types of hepatitis.
- List the symptoms commonly seen in the prodromal, icterus, and recovery stages of hepatitis.
- Discuss the vaccines that are currently available for the prevention of the various types of hepatitis.
- Explain the use of interferon and various types of antiviral medications in the treatment of hepatitis.
- Identify at least three nursing roles related to acute or chronic hepatitis either in prevention, promotion, or restoration.
Hepatitis usually results from a virus that causes inflammation and possible dysfunction of the liver resulting in a variety of health care concerns. The liver is anatomically positioned in the abdomen, mostly in the right upper quadrant. The liver is exceptionally vascular, with approximately 1500 ml of blood circulating through the liver every minute. There are three primary areas of function for the liver, which include storage, protection, and metabolism. Within these three areas, the liver is said to have more than 400 known functions. Vital functions include storing vitamins and minerals, phagocytosis abilities, detoxifying harmful or potentially harmful components, metabolism of nutrients, making some of the plasma proteins, and manufacturing and secreting bile. The many vital functions completed by the liver make having any disorder that impacts this organ a potentially unsafe situation for the patient and leaves the human body vulnerable (Ignatavicius, Workman & Rebar, 2018).
There are many types of hepatitis, but the most common types are acute or chronic viral hepatitis. Currently, the five major types of viral hepatitis include A, B, C, D and E. Hepatitis that does not fit the criteria of A, B, C, D or E but is viral is referred to as non-A-E hepatitis. Toxic or drug-induced hepatitis, as the name implies, is caused by a variety of toxins. Other possibilities include autoimmune hepatitis and secondary hepatitis, which results following another primary viral infection (Ignatavicius et al., 2018).
Etiology and Pathophysiology
As the liver is invaded by a viral infection or any other toxin, it produces an inflammatory response in the hepatocytes resulting in enlargement and congestion which may produce discomfort or right upper quadrant pain for the patient. The infection or toxin causes an immune response targeting the specific viral antigens. Increased inflammation can lead to necrosis and eventually, potential regeneration. The level of inflammatory damage, particularly the degree of necrosis, appears to be related to the person's immune response. If the immune response is appropriate, it will cause some cellular injury, but also leads to better elimination of the virus. Persons who have a weak or slow immune response and minimal symptoms are more likely to harbor the virus and eventually develop chronic hepatitis. Over time, these changes can begin to interfere with the blood flow into and out of the liver, causing a change in portal circulation and at some point, jaundice if obstruction occurs. This type of response can occur in the liver with any inflammatory response. Therefore, right upper quadrant pain or discomfort and jaundice are two possible symptoms seen in patients with hepatitis. Persons with viral hepatitis may be asymptomatic but will have positive serum results if screened and will be a carrier of the virus; be acutely ill; or develop chronic hepatitis. A person with chronic hepatitis may develop cirrhosis and what is known as fulminating disease, or rapid-onset liver failure. The level of illness, as described above, is thought to be dependent on the person's immune response (Grossman & Porth, 2014; Ignatavicius et al., 2018).
Statistics of Hepatitis
Vaccines have reduced the number of cases of hepatitis A and B. The Center for Disease Control and Prevention (CDC) has been instrumental in making recommendations for these vaccines. Despite the decline in cases, the CDC estimates 4,000 new cases of hepatitis A, 21,000 new cases of hepatitis B, and 41,000 new cases of hepatitis C in the US annually. Hepatitis D and E do occur in the US but are less common than hepatitis A, B, and C. Hepatitis C remains a national and global concern as this virus can lead to cirrhosis or cancer of the liver. It is difficult to determine exact numbers, but the World Health Organization (WHO, 2019c) estimates that there are approximately 71 million people infected with the hepatitis C virus worldwide. Hepatitis B can also cause similar long-term liver consequences (CDC, 2019b, 2019c; Ignatavicius et al., 2018; WHO, 2019b, 2019c).
Signs and symptoms
The presentation of viral hepatitis can range from asymptomatic to a viral illness, causing a variety of symptoms. The most common symptoms include: abdominal discomfort, a change in skin or sclera color to very light or dark yellow, arthralgia, myalgia, diarrhea, constipation, urine may become darker in color, stools may become lighter in color, nausea, vomiting, fever, fatigue, general malaise, and pruritis of the skin. The liver may not be able to produce or release appropriate levels of bile related to swelling. There is an inadequate release of bile into the intestinal tract that can cause clay-colored or lighter-colored stools from the lack of bile and bile salts. Some patients will report loss of appetite or lacking the energy to eat. Nurses may be challenged to find foods that the patient will eat to maintain adequate nutritional intake. The asymptomatic patient is a significant concern in the various types of hepatitis, and especially with hepatitis C, making diagnosis difficult without regular screening (Ignatavicius et al., 2018).
The symptoms of hepatitis can be categorized into three separate periods of illness: pre-icterus or prodromal, icterus, and recovery. In the prodromal period, the nurse should expect to see fatigue, anorexia, malaise, and other vague symptoms suggestive of a viral infection. The gastrointestinal symptoms present in this phase could include nausea, vomiting, diarrhea, or constipation. When assessing the serum blood levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT), there will be some degree of elevation that occurs before the rise in serum bilirubin. These two blood tests can be used to monitor the progression or regression of hepatitis as well as other liver disorders (Grossman & Porth, 2014; Van Leeuwen & Bladh, 2017).
The icterus phase is characterized by a rise in the patient’s bilirubin level. This phase usually begins within seven to fourteen days after infection. During this phase, the patient may develop noticeable tenderness around the liver both by subjective data and on physical assessment. Weight loss, the development of spider angiomas, as well as jaundice, may start to appear in this phase (Grossman & Porth, 2014).
As the patient moves out of the icterus phase, most enter the recovery phase. During this phase, the patient should start to feel better; their appetite and any jaundice that may be present improves. The patient should continue to recover for approximately four months from the start of the infection depending on the severity of symptoms and the type of hepatitis (Grossman & Porth, 2014).
If a patient has been asymptomatic despite contracting hepatitis C, the virus can silently continue to destroy the liver without symptoms. If a patient contracts hepatitis B or C, they might become a carrier, indicating they are asymptomatic but can potentially infect someone else with the disease. If a patient becomes a carrier, they may be a healthy carrier that is not experiencing symptoms or have very few symptoms, or
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When a patient develops hepatitis A, their condition can vary from mild to severe illness. Hepatitis A virus (HAV) is a single-stranded RNA enterovirus that frequently spreads via food or water contaminated with the feces of an infected individual. When someone contracts HAV, it begins to mature and multiply in the liver and will eventually shed into the stool within the first two weeks of the infection. HAV may also spread secondary to poor sanitary conditions, compromised personal hygiene, and oral-anal sexual intercourse. HAV can survive outside of the human body, especially on the hands of humans, and is difficult to destroy and resistant to conventional detergents and other cleaning products. High temperatures and bleach can destroy the virus. Risk factors for hepatitis A include recreational drug use and travel to countries or areas that have an increased incidence of HAV (Grossman & Porth, 2014; Ignatavicius et al., 2018; WHO, 2019a).
The WHO (2019a) estimates the number of deaths from HAV in the year 2016 was approximately 7,134 world-wide. HAV can cause widespread disease in our communities secondary to the mode of transmission, but it rarely causes long-term effects such as chronic liver disease or fatality (Grossman & Porth, 2014; Ignatavicius et al., 2018).
Individual economic concerns for a patient diagnosed with HAV are related to being off work for an extended period. A business such as a restaurant may be forced to close for an extended period if the virus can be traced to that business. The infection rate can be high in developing nations and nations that experience unsanitary conditions, especially in children. It is common for children to be infected, but typically they do not experience symptoms. In countries that have a higher socioeconomic status statistically, there is a lower incidence of HAV. Hepatitis A is known to cause epidemics which seem to occur in cycles and can cause widespread illness and financial concerns. Because this virus is hardy and can withstand regular detergents and cleaning routines, it can take months to contain an epidemic or outbreak and for those infected to recover and return to their normal daily functions (WHO, 2019a).
The incubation period for HAV is between 14 and 28 days. During that time, a patient will develop symptoms that vary in intensity from person to person. Most HAV patients will experience a unique combination of a few prodromal and icterus symptoms but typically recover and develop lifelong immunity. Relapses of HAV are also possible. It is common for older children and adults to experience symptoms, especially jaundice, while children under the age of seven usually have mild symptoms and do not experience jaundice. The nurse should be aware that while most people with hepatitis A will recover, patients can develop life-threatening acute liver failure (WHO, 2019a).
HAV is diagnosed via a combination of serum testing and a physical assessment. The laboratory test screens for the presence of antibodies to HAV (anti-HAV). The patient’s serum will likely be positive for the presence of IgM antibodies as the patient begins to experience symptoms and will start to decline throughout the recovery period. IgG antibodies begin to peak approximately one month after the patient becomes ill and can be present for the rest of their life. Definite diagnosis is based on the presence of elevated IgM anti-HAV antibodies (Grossman & Porth, 2014; WHO, 2019a).
Treatment for HAV is individualized based on the patient's symptoms and lab values; there is not a specific recommended treatment. The patient will need supportive care which includes the promotion of general good health and reducing the risk of further trauma to the liver. The healthcare provider will need to review the list of medications the patient is prescribed and determine if any medications should be discontinued during the viral illness. The patient must have optimum nutrition to support immune function. Fluid and electrolyte status must be assessed and kept in balance, especially if the patient is experiencing excessive nausea, vomiting, and diarrhea. The patient should discuss any medications they are considering using with their healthcare provider as protection of the liver during this time is essential, and over-the-counter, herbals and supplements can cause further damage (Grossman & Porth, 2014; National Institutes of Health [NIH], 2019; WHO, 2019a).
Prevention of hepatitis A can be achieved by working to assure clean drinking water, safe handling and containment of sewage, health promotion activities to improve safe and effective handwashing, and promoting the utilization of the hepatitis A vaccine. According to the CDC’s Advisory Committee on Immunization Practices (ACIP), the current recommendations in the United States for hepatitis A immunization include: all children at the age of one year and older, persons who are homeless, persons who are at higher risk for infection or developing complications, and persons who are concerned about or want to avoid contracting hepatitis A (CDC, 2019a; WHO, 2019a).
High-risk individuals include those who travel to nations where there is a higher incidence of contaminated food and or water, men who engage in sexual intercourse with other men, people who use IV drugs, those that work in a lab setting where subjects are known to have hepatitis A, those that work with the organism, individuals with liver disease or symptoms of liver disease, anyone who is adopting or working closely with children who are from a country that has a high incidence of hepatitis A, and those that have been recently exposed and have not had the vaccine previously (CDC, 2019a).
Several types of vaccines are available but vary from country to country. In the United States, several products are available. Havrix and is a single-antigen vaccine approved for use in 1995 and manufactured by GlaxoSmithKline. Children that are from 12 months to 18 years of age should have two doses administered six to twelve months apart. The injections should be given IM but not in the gluteal area. It is also vital for the nurse to assess for latex allergies as a portion of the prefilled device contains latex and could produce an allergic reaction. This vaccine should not be given if the patient has ever reacted to any hepatitis A vaccine component, to Havrix, or neomycin. The most common reactions noted with this vaccine have been pain and redness at the injection site, headache, drowsiness, and loss of appetite. Its safety and effectiveness in patients that are pregnant or lactating are unknown. If requesting the vaccine for possible exposure during travel to an area with a high incidence of HAV, the patient should receive the first dose at least two weeks before traveling (CDC, 2019a).
The other single-antigen vaccine that is currently available is known as Vaqta and was approved for use in 1996 and manufactured by Merck Sharpe & Dohme Corporation. The recommendations for use and contraindications are the same as Havrix. The first dose should be given intramuscularly between the ages of twelve months and eighteen years and the second dose six to eighteen months later. In someone older than 19 years, both doses are doubled. The side effects or reactions are similar to Havrix. As with Havrix, there is a risk of an allergic reaction to latex when using the prefilled syringes so the nurse must assess for latex allergy. The risks to pregnant and or lactating women are not known (CDC, 2019a).
The final vaccine available is a combination vaccine known as Twinrix, which is a combination of the hepatitis A and hepatitis B vaccine. This combination vaccine was approved for use in 2001 and must be given IM. This vaccine is recommended for those persons over 18 years of age and safety for pregnant and lactating women is unknown. This vaccine can be given as a three-dose or four-dose series with the four doses being an accelerated process. After the first dose in the three-dose series, the same dose is repeated one month and then six months later. The four-dose series is intended for persons who have a known potential exposure within short notice. The first dose is given (day 0), followed by repeat injections on days 7, 21-30, and then again at 12 months. Similar contraindications and side effects are found with Twinrix as the other two vaccines (CDC, 2019a; GlaxoSmithKline, 2010).
With all three vaccines, the exact amount of time that immunity remains effective is unknown. Studies have shown that anti-HAV is persistent for at least 20 years in both adult and pediatric patients (CDC, 2019a).
Hepatitis B is caused by the hepatitis B virus (HBV). In comparison to HAV, HBV is more problematic and more likely to cause chronic disease, liver cancer, or cirrhosis. According to the CDC (2019b), there are approximately 850,000 persons or more living with HBV, many of which are infected and unaware. Hepatitis B is preventable by vaccines that are available, safe, and effective. Most insurance companies will pay for or assist with the cost of the vaccine (CDC, 2019b; WHO, 2019b).
HBV is a double-stranded virus that can cause acute as well as chronic hepatitis and the ensuing complications. If a woman with HBV is pregnant, the infection can be passed to her unborn child. Hepatitis B is also transmitted by blood and body fluids which can include needlesticks or other sharp objects used for tattoos, piercings, or IV drug use. It is also transmitted sexually in a variety of situations, including men that have intercourse with other men and persons who have multiple sexual partners. Hepatitis B has a more extended incubation period than HAV, with an average being 75 days, but it can vary from 30 to 180 days (Grossman & Porth, 2014; WHO, 2019b). Some persons infected with HBV may not have any signs of infection, while others will present with acute symptoms that may last several weeks. The most prevalent symptoms would include the previously listed prodromal and icterus symptoms. Jaundice is common in HBV.
Some patients have an immune system that can fight the virus, and they will recover, while others will develop chronic hepatitis B. The complications of chronic HBV include cirrhosis, liver failure, and liver cancer. Patients are more likely to develop chronic hepatitis B if they contract the virus as an infant (80-90%) or child (30-50%) and less likely if an adult (less than 5%). In those adults who develop chronic hepatitis, the risk of developing a liver complication is 20-30% (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], 2019b; WHO, 2019b).
As in HAV, to diagnose HBV serum lab studies must be completed along with a physical assessment. In HBV, there will be the positive presence of hepatitis B surface antigen (HBsAg), and IgM antibodies to the hepatitis B core antigen (HBcAg) will be present in acute hepatitis infections. When the patient first develops the infection, their blood may also be positive for the hepatitis B e antigen (HBeAg), indicating that they are highly infectious. The presence of HBsAg for six months or longer or a negative IgM titer are the primary determinants in diagnosing chronic disease. If the HBsAg remains elevated, this is indicative of increased risk for chronic liver disease and liver cancer. The HBsAg is essential in the diagnosis and continued observation of the patient. This antigen will appear in the serum before the onset of symptoms, will peak during the disease, and will decline during the recovery phase. Antibodies to HBsAg (anti-HBs) will develop after an infection has resolved, or if the patient has been previously vaccinated. This should be the only elevated marker seen in a vaccinated individual. If the patient is diagnosed with HBV, the provider will likely order other tests to determine the extent of injury to the liver. A patient with chronic HBV will need to have routine physical exams and lab work to follow their condition. These routine tests will be done to establish a baseline and to track the extent and progress of liver damage. The tests may include liver function tests, liver ultrasound, and liver biopsy (CDC, 2019b; Grossman & Porth, 2014; NIDDK, 2019b).
In acute hepatitis B, there is no specific treatment. The goal is to treat the symptoms and to promote general overall good health. The patient will need adequate nutrition to promote healing and maintenance of fluid and electrolyte balance. The patient must discuss with their provider any medications they are currently taking or may want to start in the future, including vitamins, herbals, supplements, and any prescribed medications to assess for potential liver damage. As in most viral conditions, the patient will recover with proper nutrition, rest, and an adequate immune response (NIDDK, 2019b; WHO, 2019b).
If chronic hepatitis B develops, the provider may choose to use antiviral agents. Not all persons who have chronic hepatitis B will need treatment, but it is estimated that approximately 10-40% will need treatment. Treatment focuses on slowing the damage to the liver and reducing the risk of liver complications. Some oral medications that may be indicated include entecavir (Baraclude), telbivudine (Tyzeka), tenofovir alafenamide (Vemlidy) and tenofovir disoproxil (Viread). They require approximately 48 weeks of therapy with studies showing positive outcomes. 70-75% of patients who use these medications show an excellent response to treatment. Common side effects include asthenia, headaches, nausea, dizziness, and fatigue, although specific side effects vary slightly with each medication (Adams, Holland & Urban, 2017; NIDDK, 2019b).
In addition to antiviral agents, interferons might be indicated to protect cells that have not become infected. When a virus attempts to attack a healthy cell, the interferon acts as a repellent of sorts and renders the virus inactive. These injectable medications include interferon alfa-2b (Intron A) or peginterferon alfa-2a (Pegasys). The interferons require approximately four months of treatment and are less successful than the oral antivirals with a success rate of 30-40%. Some side effects associated with the interferons are flu-like symptoms, muscle and joint pain, headaches, loss of appetite, and diarrhea. More serious adverse effects include decreased platelet count, increased risk of suicidal ideation, and hepatotoxicity (Adams et al., 2017; NIDDK, 2019b).
Prevention is a far better option rather than treatment. The current recommendation for health care workers and other individuals who are at risk is to be immunized with either Engerix-B or Recombivax HB. The vaccine is safe for pregnant women, and all persons receiving the vaccine should be given a series of three injections over six months. It is also recommended that all children be vaccinated starting at birth with three doses through 18 months of age. The first injection should be given at birth and is monovalent, followed by two additional doses that can be combination vaccines or monovalent. If monovalent, they should still be given at the same time as the first and third doses of diphtheria, tetanus, and acellular pertussis (DTaP). Four doses are permitted with one monovalent at birth and three additional doses when combined with other infant vaccines. A combination vaccine that is available for the pediatric patient is Pediarix which is hepatitis B, DTaP, and inactivated polio. Twinrix, which is hepatitis A and B, is approved as a three-dose series for those 18 and older. The WHO estimates that this vaccination schedule provides at least 20 years or more of immunity (Adams et al., 2017; NIDDK, 2019b; WHO, 2019b).
In addition to vaccines, screening of all blood and blood products to be used for transfusions as well as public health campaigns to decrease unsafe injections, sharing of needles, and safer sexual intercourse practices should all be the focus of public health promotions to reduce the rate of hepatitis B (WHO, 2019b).
Hepatitis C virus (HCV) can cause both acute and chronic hepatitis. A patient with HCV can be asymptomatic or develop lifelong illness and serious complications. HCV is known to cause most cases of liver cancer, cirrhosis, and chronic hepatitis. HCV is transmitted via blood, and in the past, it was most commonly transmitted by contaminated blood transfusions. With improvements in the testing done on blood supplies in the United States, the risk of transmission in this manner is dramatically reduced. Current transmission is more likely to occur from injectable recreational drugs and sexual intercourse with an infected individual. There is a risk of transmission from pregnant women to the baby during delivery as well as a risk in procedures that involve the use of needles such as tattoos, body piercings, and acupuncture. There are an estimated 71 million people living with chronic HCV worldwide (CDC, 2019c; Grossman & Porth, 2014; WHO, 2019c).
HCV is a single-stranded and genetically unstable virus. This instability has allowed it to develop at least six different genotypes and approximately 70 subtypes. The ability of HCV to change has made trying to find treatments and vaccines difficult. The incubation period ranges from two to twenty-six weeks, with an average of six to twelve weeks (CDC, 2019c; Grossman & Porth, 2014).
Up to 80% of infected patients remain asymptomatic. If symptoms develop, they will be the typical symptoms experienced during the prodromal and icterus phase of hepatitis. Approximately 10-15% of HCV patients will recover from the virus, while the rest will develop chronic hepatitis. Those with a higher risk of developing chronic hepatitis and complications include male gender, older patients, persons who are immunocompromised, and those that use alcohol or medications that are toxic to the liver (Grossman & Porth, 2014).
Diagnosis is difficult as most persons who become infected with HCV do not experience symptoms. Asymptomatic patients may not have long-term consequences. Alternately, a patient may present years later with symptoms suggestive of liver disease and discover during the diagnostic workup that they are HCV positive. During routine healthcare, providers may suggest screening for HCV based on risk factors as described above using a serum titer for anti-HCV antibodies. If the anti-HCV test is positive, it indicates the person is infected. The next step is to screen for HCV ribonucleic acid (RNA) to confirm that the HCV is chronic. After a final determination has been made to verify chronic hepatitis C, the patient is evaluated for the degree of liver involvement and possible damage with liver function tests. These results will help guide the healthcare team in developing the treatment plan. For those that have risk factors, early detection will allow for treatment and possible resolution of the HCV (NIDDK 2019c; WHO, 2019c).
The WHO recommends treatment for persons over twelve years of age, diagnosed with chronic HCV, has an overall goal of eradicating the infection. The recommendation is to treat with direct-acting antivirals (DAAs). Some examples of DAAs are daclatasvir (Daklinza), elbasvir (Zepatier), and ledipasvir (Harvoni) as well as others. There are also a couple of newer medications: ribavirin (Copegus) and peginterferon alfa-2a (Pegasys). Most of these medications will need to be taken for twelve to twenty-four weeks to cure the hepatitis C. The healthcare provider will need some additional information to determine the appropriate medication, dose, and duration of treatment including the genotype of the virus, the presence of any liver damage, and prior history of treatment for hepatitis C. Ribavirin (Copegus) is an oral medication while peginterferon alfa-2a (Pegasys) is given by subcutaneous injection at home. Patients on peginterferon alfa-2a (Pegasys) need to be screened for coexisting conditions such as alcohol use, illicit drug use, and mental illness as these can cause significant risks. The healthcare team, in collaboration with the patient, will need to make a well-informed decision based on personal history, risks, and benefits before starting the medication (Adams et al., 2017; MedlinePlus, 2019; NIDDK, 2019c;).
In a recent clinical update published in JAMA, Marks and Naggie (2019) found support for continued use of these medications. The WHO’s goal is to achieve total elimination of viral hepatitis in the world by 2030. To this end, Marks and Naggie (2019) support treating all persons infected with HCV with DAAs unless life expectancy is minimal. They recommend that treatment should be initiated and continued for eight to twelve weeks, and follow-up serum diagnostics should be completed in about twelve weeks to evaluate for the presence of HCV RNA. Once RNA levels are not detectable, the patient is considered cured. These medications and continued follow-up care are decreasing the level of chronic HCV and the associated long-term consequences (Marks & Naggie, 2019).
Currently, there is not a vaccine available for HCV. Finding an effective vaccine has proven to be challenging, but science continues to work on this. Prevention and screening continue to be recommended. All healthcare workers involved in parenteral therapy need to strive for the administration of safe injections and the handling of sharps. Community health promotion activities should encourage people to use sterile needles, discourage sharing needles, and promote safer intercourse practices. The medical community must continue to be vigilant in the testing of all blood and blood products and encourage routine screening (WHO, 2019c).
The hepatitis D virus can cause both acute and chronic hepatitis D and is sometimes referred to as delta hepatitis. Hepatitis D is unique; it is an incomplete virus that must co-exist with the hepatitis B virus to replicate. This hepatitis B/D combination is the most severe form of chronic hepatitis. HDV is spread by blood and body fluids in the same way as HBV. Because of the number of persons receiving the hepatitis B vaccine, a decrease in the incidence of HDV has been recognized. A positive HBsAg titer, indicating chronic hepatitis B, superimposed with acute or chronic hepatitis D can cause what is known as superinfection. This superinfection, HDV, in addition to chronic HBV, can accelerate the disease. It also can impact an asymptomatic carrier converting them to acute hepatitis as well as increasing progression to cirrhosis of the liver. Throughout the world, there is approximately 5% of the population that have chronic HBV and are infected with HDV. It is challenging to know the exact number of persons infected because not all countries track and report these types of disorders, but an approximate number is between 15-20 million people worldwide are impacted (CDC, 2019d; Grossman & Porth, 2014; NIDDK, 2019d; WHO, 2019d).
If the infection results in acute hepatitis, the symptoms can range from mild to severe and can resolve spontaneously or lead to chronic hepatitis which is quite rare. If superinfection occurs, the results can be extensive symptoms leading to acute liver failure and ultimately be fatal. Superinfection may progress more quickly to liver cirrhosis. Symptoms may include most of the standard prodromal and icterus symptoms. Older adults with chronic HBV are most at risk. Others at risk include IV drug users, those with multiple sexual partners, and those traveling from or to an area or country with a high prevalence of HDV (WHO, 2019d).
To make a diagnosis of HDV, the patient will need a history and physical assessment, as well as laboratory diagnostics. In acute hepatitis D, the patient will have elevated levels of anti-HDV IgM and the presence of Anti-HDV. The serum specimen should also be positive for HDV RNA. In many areas and countries, diagnostics tests that can confirm the presence of HDV are limited or not available (Grossman & Porth, 2014; NIDDK, 2019d; WHO, 2019d).
The best treatment for HDV is prevention, including the prevention of HBV by vaccination. Treatment is limited, but the current recommendation is to treat with pegylated interferons for approximately 48 weeks. The patient may also need treatment for HBV infection and liver damage, which could include a liver transplant. There are some studies and clinical trials that are showing some promise with medications, including HBV entry inhibitors and prenylation inhibitors. These medications are still in trials and not available currently for general use (CDC; 2019d; Grossman & Porth, 2014; NIDDK, 2019d; WHO, 2019d).
Hepatitis E is caused by the hepatitis E virus (HEV). This virus is similar in transmission to HAV, being shed in the fecal material of infected persons. Infection is likely related to drinking contaminated water. Most of the time, the patient has an acute episode and recovers with the effects lasting between two and six weeks. While this is usually acute and self-limiting, hepatitis E can lead to acute liver failure, which can be terminal in some patients. The WHO estimates that approximately 20 million persons will be infected with HEV and develop acute symptoms in their lifetime. In 2015 there were about 44,000 deaths associated with HEV. Hepatitis E can be divided into four different genotypes: 1, 2, 3, and 4. Genotypes 1 and 2 have been isolated in humans, while 3 and 4 have only been identified in animals. Infected animals are not ill but can potentially infect humans (CDC, 2019e; NIDDK, 2019e; WHO, 2019e).
The risk for hepatitis E is highest in areas that have contaminated water, refugee camps, or areas that have experienced war or a natural disaster that may have contaminated their water supply. Less commonly, it can be contracted by ingesting meat from an infected animal that was not fully cooked, by receiving a transfusion of contaminated blood products, or during delivery from a contagious mother to her baby. Consistently, the highest rate of transmission is via the oral-fecal route from contaminated water (CDC, 2019e; WHO, 2019e).
Following exposure to HEV, the incubation period is two to ten weeks, but the average is six weeks. During the incubation period, the infected person will start to shed the virus in their fecal matter as early as three days before the onset of symptoms and as late as three to four weeks after the patient has experienced symptoms. Those most likely to experience symptoms are younger adults, from mid-teens to '40s. Younger children frequently have very minimal symptoms or none at all. HEV causes a variety of symptoms consistent with the prodromal and icterus phase lasting from one to six weeks. As with most hepatitis, the illness can be quite severe and can cause acute liver failure in some, but this is rare. Acquiring HEV during pregnancy, especially in the second or third trimester, increases the risk of acute liver failure as well as the possibility of both fetal and maternal loss. If the virus is contracted during the third trimester, it is estimated that 20-25% will result in death. In areas that have a higher incidence of HEV, the mortality rate in pregnant women has been documented as high as 51%. In rare cases, persons who contract HEV from genotype 3 or 4 and are immunocompromised may develop chronic HEV (CDC, 2019e; Grossman & Porth, 2014; WHO, 2019e).
The treatment for HEV consists of supportive care for the patient as the virus is usually self-limiting, such as appropriate nutrition, fluid, and electrolyte support, rest, and avoiding alcohol until recovery is complete. The patient should also consult with their provider regarding current medications or potential new medications to prevent further injury to the liver. The healthcare team should consider hospital admission for pregnant patients and those who have symptoms suggestive of acute liver failure, or what is often referred to as fulminant hepatitis. If the patient has a comorbid condition that has resulted in immunosuppression, the healthcare provider may consider treating with ribavirin (Copegus) and interferon (CDC, 2019e; WHO, 2019e).
This type of hepatitis has also been referred to as hepatitis X. Patients experience symptoms that are suggestive of viral hepatitis such as general malaise, fever, and tenderness of the abdomen surrounding the liver, nausea, and vomiting. Their physical assessment will reveal swelling of the liver as well as the other symptoms. Despite this, their diagnostic tests are negative for any specific type of hepatitis, which makes the diagnosis presumptive versus confirmative. Currently, it remains idiopathic and self-limiting. There are documented cases of chronic hepatitis X in approximately 12% of persons diagnosed. Cases of non-A-E hepatitis have been diagnosed worldwide, but no particular risk factors or modes of transmission have been identified. There is some speculation amongst researchers that there may be several other unknown viruses that may be a factor. There is not a set treatment regiment, but supportive care similar to the other forms of hepatitis would be most appropriate (Ignatavicius et al., 2018; NIDDK, 2019f).
Chronic Viral Hepatitis
As discussed earlier, each of the types of viral hepatitis can become chronic. The three types that are more commonly associated with chronic disease are hepatitis B, C, and D, with HCV being the most concerning. Chronic hepatitis is characterized by the persistence of inflammation within the liver that continues for more than three to six months. The patient's AST level continues to be elevated, and if a liver biopsy is done, which is typical, there would also be changes within the histology of the tissue extracted. AST is an indicator of damage to the cells of the liver, which is often elevated in cirrhosis and hepatitis. The values vary with age and gender and by various resources, but an adult male standard value would be 20-40 units/L and an adult female normal range 15-30 units/L. This level will be elevated in an individual with chronic viral hepatitis depending on the degree of inflammation and liver damage (Grossman & Porth, 2014; Van Leeuwen & Bladh, 2019).
Chronic hepatitis symptoms vary but generally will include fatigue, malaise, anorexia, and episodic periods of jaundice. The primary concern for these patients is preventing the inflammation from leading to further damage and destruction of the liver resulting in chronic liver disease (Grossman & Porth, 2014).
Treatment options for those with chronic hepatitis are not identified and are not always as effective as desired. Treatment may cause adverse effects as well as being costly. The recommended treatment for people who have chronic hepatitis B includes the use of interferons and antiretroviral agents similar to those used in patients with AIDS. As patients use these medications, approximately 40% will experience improvement in their serum diagnostic studies resulting in longer survival times. In persons who have chronic hepatitis C, the recommendation is to treat with some of the newer pegylated interferons as previously discussed. Patients may also require a liver transplant, with more positive outcomes seen with chronic hepatitis C (Grossman & Porth, 2014).
An autoimmune disorder is one in which the immune system is attacking itself rather than initiating an immune response against a foreign invader. In autoimmune hepatitis, the body is attacking the hepatocytes of the liver. A viral illness often precipitates it a few weeks before the onset of the autoimmune dysfunction. The result of the autoimmune dysfunction is an inflammatory response in the liver, which can cause swelling and liver dysfunction resulting in liver cirrhosis, liver cancer, or liver failure. At this time, there appear to be two different types of autoimmune hepatitis: Type I and Type 2. Autoimmune hepatitis is found worldwide and can happen to any age group and either gender, but the highest rates are found in women. Approximately 40% of persons with autoimmune hepatitis also have another type of autoimmune disease. The population subgroup with the highest rate of autoimmune hepatitis appears to be Alaska Natives. Type 2 is more common in children, but Type 1 is more commonly diagnosed (Grossman & Porth, 2014; NIDDK, 2019a).
Autoimmune hepatitis may or may not cause symptoms and may be found incidentally on routine lab screening as part of an annual physical exam. If symptomatic, they would be similar to viral hepatitis symptoms such as fatigue, muscle and or joint pain, change in the color of stools or urine, possible jaundice, and others. Autoimmune hepatitis may cause unique integument changes such as acne, rash, psoriasis, or vitiligo. It is also possible that the patient presents with symptoms suggestive of chronic liver disease (Grossman & Porth, 2014; NIDDK, 2019a).
A diagnosis is made based on a comprehensive history and physical assessment. The history portion of the exam is vital to establish the use of potential toxins such as alcohol or other medications, previous acute or chronic illnesses, and any other autoimmune disorders. Potential subjective complaints will guide the physical assessment the patient has, as well as a full examination of the liver for tenderness and enlargement by inspection, palpation, and percussion (Grossman & Porth, 2014; NIDDK, 2019a).
Laboratory tests for the presence of HCV and HBV will help to rule these out as potential causes. ALT and AST will help assess liver function, and an antinuclear antibody (ANA) test will check for autoantibodies. Patients with autoimmune hepatitis will often have very elevated liver enzymes, as well as an elevation of serum gamma globulins. Upon completion of the physical assessment coupled with the diagnostic test results, the provider may order an ultrasound or other radiographic studies as well as a liver biopsy. During the pathology examination of the tissue taken during the biopsy the pathologist will evaluate for the presence of indicators of autoimmune hepatitis, the degree of damage to the liver tissue, as well as the presence and level of scarring which indicates cirrhosis (Grossman & Porth, 2014; NIDDK, 2019a).
After the confirmation of autoimmune hepatitis, treatment typically consists of immunosuppressant medications such as corticosteroids. If the disorder was found incidentally, and the patient does not have symptoms or indications of damage, they may be monitored and not started on medications initially. Patients requiring treatment will be prescribed a corticosteroid such as prednisone (Deltasone) with or without azathioprine (Imuran). The use of monotherapy or combination therapy will depend on the degree of symptoms, diagnostic studies, and the degree of tissue damage that is evident. Both medications will suppress the immune response, but the combination increases the risk of adverse effects such as significant types of infection. The nurse should review with the patient the common adverse effects associated with corticosteroids including weight gain, increased puffiness of the face, acne, hyperglycemia, fluid retention, change in moods, change in bone density, and others. The use of azathioprine (Imuran) is more likely to cause effects such as leukopenia, rash, gastrointestinal upset, and increased inflammation of the liver and pancreas. Initially, the patient will likely be started on a higher dose of medication which is then tapered down based on physical assessment and lab results as the patient stabilizes, dropping the dose as low as possible while still controlling symptoms (Grossman & Porth, 2014; NIDDK, 2019a).
The goal is to control the disease and work towards remission to prevent or reverse liver damage. As the patient's lab values and assessment findings stabilize, the patient will likely undergo another liver biopsy to have a more definitive evaluation of the liver status. If the patient achieves remission, the patient and the healthcare provider will need to make decisions regarding continuing with a very low dose of medication to maintain the remission or to discontinuing the medications, which increases the risk of relapse. Multiple factors will be considered before discontinuing the medications. If medications are stopped and the patient has a relapse, the medications will need to be restarted. A liver transplant may be indicated or considered as a treatment option. Autoimmune hepatitis is likely to be long-term if not a lifelong disease. The patient will need to be evaluated regularly for the onset or progression of liver damage and cirrhosis. The nurse should educate the patient regarding the importance of increased rest, proper nutrition, and overall healthy lifestyle choices. With remission and appropriate medical care, patients with autoimmune hepatitis will likely have a good quality of life (Grossman & Porth, 2014; NIDDK, 2019a).
Evidence-based Nursing Care
Nursing care for patients with any hepatitis diagnosis may range from patient education to caring for a patient that has severe life-threatening liver damage secondary to either acute or chronic hepatitis. Patient education is essential in a variety of settings and would include educating patients or groups of people about the known risk factors and modes of transmission. As healthcare workers, a common goal is to reduce the risk and incidence of hepatitis, and education is paramount to that endeavor. Education should include promoting vaccines that are available for HAV and HBV, discussing and demonstrating appropriate hand hygiene as well as hygiene practices in general, avoiding contaminated water and food, explaining the risks of travel in certain areas, and what to do if there is potential exposure.
Public health campaigns should include the risk of IV drug use, safer sexual practices, and other ways to decrease transmission via blood and body fluids. All healthcare professionals must collaborate on education and risk reduction together. Not only to educate patients, but to work towards an improved standard of care involving needlesticks, sharps incidents, and other possible sources of contamination for caregivers. As patients are diagnosed with hepatitis and will be cared for by their family, education should also be directed at safety precautions to prevent transmission to family members and friends (Ignatavicius et al., 2018).
Nursing will be involved in completing assessments in collaboration with the provider. Within the scope of practice for the nurse, this would include gathering health history information and completing the physical assessment for both subjective and objective data. Vigilant detail must be utilized when assessing the patient’s current and historical medications, as well as over-the-counter medications, supplements, and alternative and complementary therapies as some of these can be toxic to the liver and increase the risk of further damage. The nurse may also likely be involved in collecting specimens from the patient as ordered and assisting with some diagnostic testing such as liver biopsy and other invasive studies. The nurse may be asked to assist the provider directly, but they also provide a source of emotional support for the patient during the procedure. Patients may also need emotional support if their diagnosis includes evidence of significant damage to the liver and long-term complications (Ignatavicius et al., 2018).
In collaboration with dietary staff and nutrition experts, the nurse will need to assess the nutritional needs of the patient and discuss with the patient what types of foods they like, dislike, and what they are interested in eating at this time. Many patients with hepatitis have anorexia and food aversion; it can be challenging to find food items that sound appealing to them. The nurse can suggest smaller portions to be eaten more frequently to decrease the risk of nausea and vomiting. Initially, the nurse should encourage a diet that is high in carbohydrates and calories and lower in fat and protein until the patient regains their appetite. Appropriate levels of fat and protein are then essential to a full recovery. Dietary staff may help find snacks that are nutritionally dense but also appealing to the patient. The provider will collaborate with both nursing and dietary staff regarding any vitamins and supplements based on nutritional needs and the status of the liver, as some vitamins could be a potential problem until the liver has healed (Ignatavicius et al., 2018).
Patients with hepatitis are vulnerable to fatigue and need adequate rest in the hospital or while recovering at home. To heal and restore liver tissue, rest is required to decrease metabolic demands and promote stronger blood flow to the hepatic system. The provider may limit the level of activity based on liver enzyme testing results. The amount of activity can be increased if lab results are improving, but the activity level should be decreased again if liver function tests worsen. The nurse should encourage the patient to rest when they feel tired, pace themselves, and to learn to prioritize activities to accomplish their most vital tasks first (Ignatavicius et al., 2018).
Nursing will need to administer medications if the patient is an inpatient, educate all patients regarding their medications, and monitor for adverse effects of the medications. If the patient is on corticosteroids and or other immunosuppressive medication(s), the nurse must assess for any signs of infection and use standard precautions at all times. Protective environment precautions may need to be implemented if leukopenia is persistent in reducing the risk of infection based on individual hospital policy. Education to the patient and family regarding infection prevention is essential as well. The nurse may be involved in making referrals to other agencies or case management to assist the patient with medication costs, home health/public health for support at home, and others that might benefit the patient. Indeed, the role of the nurse in caring for patients with hepatitis can be minimal or extensive but should include providing health promotion activities to protect the community from acquiring hepatitis (Ignatavicius et al., 2018).
The WHO, in collaboration with governments and other partners worldwide, started a campaign in 2011 for World Hepatitis Day. In 2019 the campaign was entitled "Invest in Eliminating Hepatitis" to promote the elimination of viral hepatitis by 2030. The goal for 2019 was to bring attention to the need for increased funding worldwide for hepatitis prevention, improved testing, and treatment options, all leading to the 2030 goal. As part of this initiative, ongoing research on hepatitis continues in both narrow and broad perspectives (WHO, 2019a).
Some of the current research being conducted by the NIH’s (2019) National Institute of Allergies and Infectious Disease (NIAID) concerns HBV. While the current vaccine has decreased the incidence of HBV worldwide, there are still more than 620,000 deaths per year. The NIAID is actively working with pharmaceutical companies and other agencies to improve treatments that could be monotherapy or work with current medications in combination therapy to decrease the incidence of chronic hepatitis. The NIAID, along with other researchers, recently completed a clinical trial for an HCV vaccine. The vaccine in this clinical trial did not appear to be useful, but the NIAID continues to work with others to find a vaccine for HCV as well as conducting research on finding biomarkers. These biomarkers could potentially help predict the progression of hepatitis C to liver cancer. While most people who develop HEV recover without significant consequences, pregnant women have more risk of complications and infants born to infected mothers tend to have more health issues. A vaccine has been approved in China, but has not in the United States, so the NIAID has recently launched a clinical trial on a possible vaccine for HEV. This clinical trial is scheduled to be completed in the spring of 2020 (NIH, 2019).
A recent study was conducted on patients newly diagnosed with cancer. This study was conducted to evaluate the need for screening for HBV, HCV, and HIV at the initial time of cancer diagnosis related to the possibility of reactivating the virus and creating adverse clinical outcomes as the cancer is being treated. Based on 3,051 persons who were newly diagnosed with cancer, the study found that 31-42% of these patients had unknown viral hepatitis. The prevalence of unknown HIV infection was not remarkable. Based on this study, the authors recommend testing for the presence of viral hepatitis infection at the time of cancer diagnosis to alleviate possible adverse outcomes with the oncology treatment and existing hepatitis (Ramsey et al., 2019).
In 2009 the United States Preventive Services Task Force recommended that all pregnant women in the US be tested for HBV during their first prenatal visit. This recommendation was based on the number of HBV-positive pregnant women and the risk of perinatal transmission. Not only is the baby at risk for contracting HBV during delivery, but the long-term health impacts on the child can be significant. Identifying those at risk can assist providers in recommending treatment to decrease the risk of perinatal transmission. Thus, a new study was conducted in 2019 to evaluate the need for a continued recommendation of screening for HBV in pregnant women in the US. Based on this study, the United States Preventive Services Task Force (2019) reaffirmed its recommendation. This is a Grade A Recommendation that prenatal screening for HBV continues during the first prenatal visit in an attempt to decrease perinatal transmission of HBV. The task force uses a grading system from A to D to establish guidelines for their recommendations. Grade A recommendations indicate the task force believes there is a significant benefit and would recommend that providers offer this service. Not only does this recommendation assist in identifying pregnant women that have HBV, but it attempts to decrease perinatal transmission and reduce the risk of significant health concerns for their children (NIH, 2019).
In conclusion, hepatitis is found worldwide and not only causes physical human suffering but is a financial concern to patients, industry and society in general. Vaccines have decreased the incidence of several types of hepatitis, but often people don’t realize they have hepatitis until it is too late; this leads to chronic disease and complications that can be life-threatening. The WHO is working to eliminate viral hepatitis by the year 2030. Members of the healthcare community should be working towards that goal by promoting hepatitis prevention, and education about modes of transmission and caring for individuals diagnosed with hepatitis. Together we can make this goal a reality.
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