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.

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