World Hepatitis Day: Taking Action to Prevent, Test for and Treat

The below was written by  Shawana S. Moore, DNP, MSN, CRNP, WHNP-BC. Dr. Moore is Assistant Professor and WHNP Program Director at Jefferson University. She is also on the NPWH Board of Directors. 

July 28th is World Hepatitis Day – the optimal time to refresh our knowledge on Hepatitis to better care for communities. Hepatitis is defined as the inflammation of the liver, most often caused by a virus. Millions of people throughout the world are affected by viral Hepatitis and it accounts for more than one million deaths per year.1The five types of viral Hepatitis are A, B, C, D and E with the most common types being A, B and C. Let’s review the most current evidence regarding screening, risk factors, treatment and prevention recommendation for the three most common viral Hepatitis.

Symptoms

The symptoms for all three types of hepatitis are the same, but may vary in severity and duration.

  • Fatigue
  • Decreasedappetite
  • Stomach pain
  • Nausea
  • Jaundice
  • Joint pain
  • Dark urine
  • Diarrhea

Hepatitis A

Method of Transmission

  • Person to person through fecal-oral route
  • Consumption of contaminated food or water

Individuals at Risk

  • Men who have sex with men
  • Persons with clotting factors disorders
  • Injection drug users
  • Travelers to countries with high to intermediate incidences of Hepatitis A
  • Persons in close contact with someone who has Hepatitis A
  • Persons working with primates

Acute Versus Chronic

Hepatitis A is self-limiting and does not result in chronic infection.1

Diagnosis

Diagnosis of Hepatitis A is based ona positive serum test for antibodies to HAV (anti-HAV) IgM and can be made 2 weeks before the onset of symptoms to about 6 months afterwards. A positive total anti-HAV result and a negative IgM anti-HAV result indicate past infection or vaccination and immunity. The presence of serum IgM anti-HAV usually indicates current or recent infection and does not distinguish between immunity from infection and vaccination.3

Treatment

Supportive care

Prevention

Hepatitis A is preventable. Prevention measures include the following:

  • Vaccinations
  • Immunoglobulin (IG)
  • Food and water precautions
  • Good hygiene and sanitation

There are two monovalent Hepatitis A vaccines available in the United States given in 2-doses, approved for individuals 12 months of age and older. These vaccinations are safe to provide during pregnancy. 3

Hepatitis B

Method of Transmission

  • Person to person through bodily fluids
  • Percutaneous puncture from instrument with infected blood

Individuals at Risk

  • Men who have sex with men
  • Babies born to infected mothers
  • Sex partners of infected persons
  • Men who have sex with men
  • Injection drug users
  • Household contacts or sexual partners of known persons with chronic HBV infection
  • Health care and public safety workers at risk for occupational exposure to blood or blood-contaminated body fluids
  • Patients receiving hemodialysis

Acute Versus Chronic

Hepatitis B can be acute or chronic.  Approximately, 95% of adults recover completely from HBV infection and do not become chronically infected.5

Diagnosis

Diagnosis of Hepatitis B is based onserology test for HepatitisB surface antigen (HBsAg), Hepatitis B surface antibody (anti-HBs), IgM antibody to Hepatitis B core antigen (IgM anti-HBc) and total Hepatitis B core antibody (anti-HBc). A positive HBsAg, positive total anti-HBc, positive IgM anti-HBc and negative total anti-HBc indicate an acute HBV infection. Chronic HBV infection is determined by a positive HBsAg, positive total anti-HBc, and negative total anti-HBc.4

Treatment

The treatment for an acute HBV infection is supportive care. Antiviral medications are available to treat chronic HBV. The American Association for the Study of Liver Diseases (AASLD) Practice guidelines  provide guidance for proper treatment of chronic HBV infection. It is important to note that individuals with chronic HBV infection will require regular monitoring to prevent liver damage and or hepatocellular carcinoma.4

Prevention

Hepatitis B is preventable through a 3 dose vaccination given over 6 months. These vaccinations are safe to provide during pregnancy and lactation.4

Hepatitis C

Method of Transmission

  • Person to person through blood
  • Percutaneous puncture from instrument with infected blood

Individuals at Risk

  • Injection drug users (current and former)
  • Recipients of blood transfusions or solid organ transplants prior to July 1992 or clotting factor concentrates before 1987
  • Patients receiving chronic hemodialysis
    • Health care workers after needle sticks involving HCV-positive blood
  • Recipients of blood or organs from a donor who tested HCV-positive
  • People with HIV infection
  • Infants born to HCV-positive mothers

Statistics

It is estimated that 2.4 million individuals are living with HCV.

Acute Versus Chronic

Hepatitis C can be acute or chronic with approximately 75-85% of those infected developing chronic HCV.Chronic HCV infection places individuals at risk for developing cirrhosis. 6

Diagnosis

The following are blood tests performed to test for HCV infection:

  • Screening tests for antibody to HCV (anti-HCV)
  • Qualitative tests to detect presence or absence of virus (HCV RNA polymerase chain reaction [PCR])
  • Quantitative tests to detect amount (titer) of virus (HCV RNA PCR)

The CDC created a quick Reference Card for HCV Resultsto assist with interpretation of results.

Treatment

New guidelines advise against treatment for acute HCV infection. However,it is recommended that individuals are followed and monitor closely. There are several FDA Approved Treatments for HCVavailable.6WIth 8-12 weeks of oral therapy, over 90% of HCV infected persons can be cured of HCV infection regardless of HCV genotype.7 A huge barrier to achieving this outcome is cost. A 12 week course of drug therapy for HCV can range from $55,000-95,000. The following companies and organization may provide assistance with paying the cost for treatment:

Additionally the following pharmaceutical companies may provide support for drug coverage:

Prevention

There is no vaccination for HCV infection.

Additional Resources and Tools

The CDC Guidelines and Recommendations  provides update to date resources for healthcare providers related to viral Hepatitis.

Additionally, the CDC created The ABCs of Hepatitis Fact Sheetas a quick reference for information related to statistics, transmission, risk factors, clinical features, screening, testing and vaccination recommendations for HAV, HBV and HCV.

Guidelines for management of HCV

References

  1. Center for Disease Control and Prevention. Vital Hepatitis. Available at https://www.cdc.gov/Hepatitis/index.htm <https://www.cdc.gov/Hepatitis/index.htm&gt; . Accessed July 21, 2019.
  2. Center for Disease Control and Prevention. Viral Hepatitis A. Available at https://www.cdc.gov/Hepatitis/hav/index.htm <https://www.cdc.gov/Hepatitis/hav/index.htm&gt; . Accessed July 21, 2019.
  3. Center for Disease Contro and Prevention. Travels Health Hepatitis A. Available at https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/Hepatitis-a <https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/Hepatitis-a&gt; . Accessed July 21, 2019
  4. Center for Disease Control and Prevention. Hepatitis B. Available at https://www.cdc.gov/Hepatitis/hbv/hbvfaq.htm#b1 <https://www.cdc.gov/Hepatitis/hbv/hbvfaq.htm%23b1&gt; . Accessed July 23, 2019.
  5. Fattovich G, Bortolotti F, Donato F. Natural history of chronic Hepatitis B: special emphasis on disease progression and prognostic factors. J Hepatol. 2008;48(2):335-52.
  6. Center for Disease Control and Prevention Viral Hepatitis C. Available at https://www.cdc.gov/Hepatitis/hbv/hbvfaq.htm#overview <https://www.cdc.gov/Hepatitis/hbv/hbvfaq.htm%23overview&gt; . Accessed July 22, 2019.
  7. American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA). Recommendations for testing, management, and treating Hepatitis C. HCV testing and linkage to care. Available at https://www.hcvguidelines.orgexternalicon. Accessed July 23, 2019.

Partnerships in Women’s Health – NPWH and PCORI

As a professional membership organization for women’s health nurse practitioners (WHNPs), the National Association of Nurse Practitioners in Women’s Health (NPWH) is a leading voice for courageous conversations about women’s health. NPWH champions state-of-the-science health care that holistically addresses the unique needs of women across their lifetimes. We elevate the health issues others overlook and compel attention to women’s health from providers, policymakers, and researchers.

The Patient-Centered Outcomes Research Institute (PCORI) is a nonprofit organization authorized by Congress to fund comparative clinical effectiveness research (CER). The studies PCORI funds are designed to produce reliable, useful information that will help patients, family caregivers, clinicians, employers, insurers, policy makers, and others make better-informed health and healthcare decisions.

CER compares two or more available healthcare options to determine what works best for which patients, under what circumstances. PCORI supports patient-centered outcomes research, which is CER that focuses not only on traditional clinical outcomes but also on the needs, preferences, and outcomes most important to patients and those who care for them.

NPWH is pleased to have ongoing opportunities to partner with PCORI as we work toward meeting shared goals regarding women’s health. NPWH and PCORI recognize that women have unique and sometimes complex healthcare needs that have not been fully addressed in the clinical and research arenas. PCORI has funded 61 comparative effectiveness research (CER) studies targeting conditions that specifically or more often affect women. A few examples illustrate the wide array of topics addressed in these studies: personalizing breast cancer screening, improving outcomes for low-income mothers with depression, treatment options for fibroids. The findings of these CER studies provide clinicians and patients with reliable information for shared decision making about treatment options.

A study recently funded by PCORI, Moms in Recovery (MORE): Defining Optimal Care for Pregnant Women and Infants, will be closely followed by NPWH as it focuses on the comparison of outcomes for women receiving prenatal care in practices providing medication-assisted treatment (MAT) with those receiving care in practices that refer MAT to specialty care. NPWH recognizes the immense significance of opioid use disorder (OUD) for pregnant and postpartum women and their infants. WHNPs are on the forefront to identify, support, and provide appropriate referrals and collaborative care for pregnant and postpartum women with OUD. At our 22nd Annual NPWH Premier Women’s Healthcare Conference in October, we are partnering with the American College of Obstetricians and Gynecologists to provide the American Society of Addiction Medicine’s Treatment of OUDs Course as a four-hour workshop, along with a four-hour online education component specifically designed for women’s healthcare providers. As well, previous NPWH conferences, journal articles and our 2016 position statement: Prevention and Management of Opioid Misuse and Opioid Use Disorder Among Women Across the Lifespan demonstrate our dedication to preparing WHNPs to meet the challenges of the opioid epidemic.

This June we represented NPWH at the PCORI-AHRQ Stakeholder Workshop on Improving Care for Women with Urinary Incontinence (UI) held in Washington DC. This one-day workshop brought together healthcare providers and organizations to explore the feasibility of developing a dissemination and implementation project aimed at improving the diagnosis and treatment of UI among women. The key findings from the systematic review on nonsurgical interventions for UI for women published by PCORI and AHRQ provided an evidence-based focus.

PCORI is a valued member of the NPWH-led BOlder Women’s Health Coalition (see below) with a goal to bring together leaders in policy, research, healthcare, and public and clinical education to promote healthy aging for women.

NPWH, through its broad educational strategies and ability to engage nurse practitioners providing women’s healthcare, disseminates and promotes implementation in practice of best evidence. NPWH has significant potential as a membership organization of nurse practitioners providing women’s healthcare to participate with PCORI and other partners in the study of outcomes from dissemination and implementation strategies as relates to improving women’s health.

To learn more about the NPWH activities and initiatives, visit our website at www.npwh.org,where you will find information on upcoming meetings, collaborative initiatives, educational opportunities, and a Well Woman Visit App.

ADDITIONAL INFORMATION: BOlder Women’s Health Coalition

NPWH believes this generation of aging women deserves our most innovative vision and actions to address their healthcare needs, advance their quality of life, and support their ongoing contributions to a better society. NPWH is the lead organization for the BOlder Women’s Health Coalition bringing together cross-sector leaders in health, aging, and clinical arenas to identify opportunities for collaboration and synergy. The goal is to work with healthcare, public policy, research, business, and nonprofit service to secure high-quality health for older women. We are focusing on the needs and unique challenges of aging women and innovating solutions to promote healthy aging.

The coalition’s four supporting pillars are:  

  • Policy:Advocating for legislative and regulatory policies that benefit older women
  • Clinical Education:Strengthening the knowledge of health care providers on prevention, diagnostics, and holistic treatments of older women
  • Public Education:Providing aging women and their families with the information they need to be healthy as they age and to remove the undermining stigma and stereotypes of aging
  • Research:Promoting approaches to research that will improve older women’s health and wellness

More than 25 coalition partners, including PCORI, are working to unite diverse sectors, share resources, and create strategies that advance the health and well-being of older American women for decades to come.

About the Authors
Beth Kelsey, EdD, APRN, WHNP-BC, FAANP

Beth Kelsey is a certified WHNP. She teaches the women’s health course for family nurse practitioner students at Ball State University in Muncie, Indiana. Kelsey is the director of publications for NPWH and the editor-in-chief of Women’s Healthcare: A Clinical Journal for NPs, the official journal of NPWH. She is the co-editor of Midwifery & Women’s Health Nurse Practitioner Certification Review Guide, 4th ed.

Susan Rawlins, MS, APRN, WHNP-BC

A women’s health nurse practitioner, Rawlins received her bachelor’s and master’s degrees in nursing from Texas Women’s University and her certificate as a women’s health nurse practitioner from the University of Texas, Southwestern Medical Center at Dallas. She is currently the director of professional development at the National Association of Nurse Practitioners in Women’s Health; serves on the editorial advisory board of Women’s Healthcare: A Clinical Journal for NPs, the official journal of NPWH; and is the co-director of the 2018 WHNP Certification Exam Review Course & Women’s Health Update. During her career, Rawlins has had the opportunity to combine the roles of educator, researcher, and clinician.