Hepatitis c

Learning objectives !! Describe the history of the hepatitis C virus. !! List the challenges that researchers have encountered that prevent them from eradicating the hepatitis C virus worldwide. !! Describe the prevalence of hepatitis C worldwide and domestically. !! Describe the normal function of the liver. !! List and describe the mechanisms that the hepatitis C virus uses to slowly and silently destroy the liver. !! Distinguish the difference between viral and non-viral forms of hepatitis. !! Identify and distinguish the difference between all of the viral forms of hepatitis. !! State the difference in symptoms that patients may exhibit in acute and chronic hepatitis C. !! Identify and discuss the three different diagnostic tests that are implemented to confirm hepatitis C. !! State the rationale for doing a liver biopsy on a patient with hepatitis C. !! List the risk factors that increase the likelihood of contracting the hepatitis C virus. !! Describe the treatment modalities to control the hepatitis C virus. !! Identify and discuss the education nurses can provide patients that are infected with the hepatitis C virus. !! Identify the expectations of the nurse who endures a needle-stick injury at work. !! Describe the future of the hepatitis C virus. Introduction Over the past few years, hepatitis C has received a vast array of media attention with the allegations that rock musician Tommy Lee and his ex-wife, Pamela Anderson, were infected and living with the hepatitis C virus after sharing a tattoo needle. Therefore, the hepatitis C virus had a new image with new faces correlated to the disease. At that time, many individuals realized that the hepatitis C virus could happen to anybody, regardless of one’s fame, fortune and/or socioeconomic status. Although hepatitis C has received significant media attention related to the rocker and Playboy model contracting the virus, individuals worldwide are still becoming infected with the hepatitis C virus. The hepatitis C virus has been recognized as a significant health concern worldwide since it is the most common chronic bloodborne infection. Unfortunately, the problem with hepatitis C is that many individuals may not realize they are infected because they are asymptomatic or have exhibited limited symptoms. In addition, many patients who have been infected with the virus have said that shortly after infection they thought they had been exposed to the flu because the symptoms are very similar in nature. Therefore, an individual may unknowingly spread the virus to others if participating in risky behaviors that involve the exchange of blood products, such as intravenous (IV) drug use, sharing needles or receiving a blood transfusion from an individual who was infected with the virus. As nurses, we care for patients from all walks of life; therefore, it is important to be attuned to the nature of the hepatitis C virus to prevent other patients and ourselves from unknowingly becoming infected with the virus. The hepatitis C virus is silent in nature. Therefore, it is imperative for patients to recognize their potential risk factors for contracting the virus, to ensure that they disclose their potential risky behaviors to their health care providers. Failure
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(3 Contact Hours)

HEPATITIS C

to properly recognize and treat hepatitis C in a timely manner may exacerbate the disease process. Patients who are not treated may potentially suffer from liver cancer, liver failure and/or cirrhosis of the liver. Of all the liver transplants performed worldwide, the majority of the transplants go to individuals infected with the hepatitis C virus [9]. The Centers for Disease Control and Prevention (CDC) has recognized that liver disease is the 10th leading cause of death among adults in the United States (U.S.). The CDC has estimated that 40-60 percent of chronic liver disease is related to the hepatitis C virus [9]. In addition, it is imperative for health care professionals responsible for caring for individuals who may inject IV drugs or participate in other risky behavior that involves the exchange of blood to properly screen and educate them about the potential risks associated with their behavior. Furthermore, before a person receives or donates blood, the blood must be properly analyzed to ensure that it does not contain the hepatitis C strain. Failure to adhere to the proper screening can only exacerbate the worldwide problem because hepatitis C is already recognized as the leading cause of death from liver disease in the U.S. History The history of hepatitis C is unique, as initially it was recognized as non-A, non-B hepatitis (NANBH) for patients exhibiting characteristics of the infection after receiving a blood transfusion. In the mid-1970s, the chief of the Infectious Disease Section in the Department of Transfusion Medicine at the National Institute of Health (NIH), Harvey Alter, reported that a patient who received a blood transfusion did not have hepatitis A or B, but researchers could not identify the causative organism. For the next decade, the unknown organism remained known as NANBH [13]. Researchers were puzzled by the nature of the virus, especially because there were 242,000 Americans infected every year in the 1980s [9]. In the late 1980s, scientists and researchers finally discovered the causative agent of the NANBH virus, and the name was officially changed to the hepatitis C virus [42]. Scientists discovered that the causative agent of the hepatitis C virus was an enveloped, singlestranded ribonucleic acid (RNA) virus [24]. The hepatitis C virus belongs to the flaviviriae family in which it is not integrated into the host genome [2]. There are a few challenging components of the hepatitis C virus. First of all, there is more than one genotype, a genetic structure, of the virus found worldwide. At this time, scientists have acknowledged that there are six known genotypes and more than 50 subtypes of hepatitis C [33]. The numerous genotypes and subtypes of the virus have impaired researchers trying to eradicate the disease process. In the U.S., the most common genotype form of hepatitis C is genotype one, which is composed of 1a and 1b, and accounts for 80 percent of the hepatitis C cases in the U.S. [18]. Therefore, in the U.S., the most common genotype for the hepatitis C virus is the first one. The second challenging component of hepatitis C is that only humans and chimpanzees have exhibited the various hepatitis C strains, which also limits the ability of scientists to properly elaborate on the research of the virus. In addition, according to Bennett, 2007: The primary immune response to hepatitis C is mounted by cytotoxic T lymphocytes. Unfortunately, this process fails to eradicate infection in most people; in fact, it may contribute to liver inflammation and, ultimately, tissue necrosis. The ability of

hepatitis C to escape immune surveillance is the subject of much speculation. One likely means of viral persistence relies on the presence of closely related but heterogeneous populations of viral genomes [2]. Third, the majority of patients, 85 percent initially infected with hepatitis C infections, will become chronically infected with the virus for decades. Unfortunately, the prolonged infection leads to severe liver damage because patients are usually unaware that they have the virus and that it is attacking their liver daily. The other 15 percent of individuals have an acute infection of the virus, which usually resolves spontaneously after a few weeks or months of exposure to the virus [18]. Due to the complexity of the structure and history of the virus, it perplexes the overall ability of scientists to eradicate it worldwide. Another problem with hepatitis C is that the virus replicates and mutates throughout the body at massive rates. Therefore, it prevents immunity as it develops resistant strains of the virus to the existing antibodies [14]. Unfortunately, this replication and mutation process can further exacerbate the complications of liver disease. Prevalence As implied, hepatitis C is an enormous concern for health care professionals nationwide who care for patients who engage in risky behaviors that involve the exchange of bodily fluids. At this time, according to the World Health Organization (WHO), an estimated 170 million (3 percent) people are chronically infected with hepatitis C, and 3 million to 4 million become infected every year [42]. Of the individuals affected, it is estimated that the hepatitis C virus causes 10,000 to 12,000 deaths annually in the United States [33]. Although the prevalence of the hepatitis C infection varies worldwide, the highest numbers of infections are reported in Africa at a rate of 5.3 percent [42]. Although the numbers appear alarming, the number of individuals infected in the U.S. has decreased over the past decade. The Centers for Disease and Prevention (CDC) has estimated the following data [9]: During the 1980s, 242,000 Americans were annually affected by the NANBH. Since the discovery of hepatitis C, the annual number of infections has declined by more than 80 percent to approximately 41,000 by 1998. In addition, according to a national survey, the National Health and Nutrition Examination (NHANES III) of the civilian, non-industrialized U.S population found that 1.8 percent of Americans (3.9 million) have been infected with HCV, of whom 2.7 million are chronically infected with the hepatitis C virus. See Table below: Prevalence of HCV infection by age and gender, United States 1988 – 1994

numbers could be potentially skewed. That is because the majority of the data that has been retrieved is from patients who have not been incarcerated or homeless on the streets. Therefore, it is likely that there are more individuals undiagnosed with the hepatitis C who may currently be incarcerated and/or homeless because the majority of them do not seek health care. Unfortunately, individuals who are incarcerated then released into society or who are homeless may unknowingly spread the virus with the exchange of risky behavior. Pathophysiology of the liver and impact on the hepatitis C virus The definition of hepatitis is an inflammation of the liver. Therefore, when cells within the liver are inflamed, a patient is diagnosed with hepatitis. Under normal circumstances, the liver is the largest and most massive internal organ in the body, weighing approximately 1.2-1.5 kilograms (2.4-3.0 pounds) [13]. In the grand scheme of things, the liver’s mass comprises 1/40th to 1/50th of a total adult body’s weight and 1/18th of the body’s weight during infancy [41]. The liver plays an important role in producing and secreting bile, receiving nutrients and synthesizing the nutrients into forms that can be absorbed into the body’s cells [31]. To maintain the demands of its many roles within the human body, the liver requires a large amount of blood. The liver receives blood from the arterial and venous systems. The hepatic artery branches from the abdominal aorta and provides oxygenated blood at the rate of 400 to 500 milliliters a minute, which is about 25 percent of the cardiac output. The hepatic portal vein receives deoxygenated blood from the inferior and superior mesenteric veins and the splenic vein at a rate of 1,000 to 1,200 milliliters a minute. The portal venous blood constitutes 70 percent of the blood supply to the liver [31]. It is astonishing to understand the important role of the liver on a daily basis. In essence, the liver plays an important role in metabolism and sustaining life within the body. For the liver to continue to function normally to sustain life, individuals must take care of their liver by avoiding toxins and other culprits, such as the hepatitis C virus that induces an inflammatory state within the liver. Once the hepatitis C virus enters the body, the virus induces hepatocyte injury and death either by directly killing the cells or by activating the inflammatory and immune reaction [27]. Over time, if the liver becomes inflamed it can obstruct and damage the bile, leading to cholestasis and obstructive jaundice [31]. Cholestasis, reduced bile flow, occurs because the gallbladder is located on the inferior surface of the liver and it stores and concentrates the bile from the liver between meals. If the liver becomes inflamed, the flow of bile is altered or ceased. If the bile is stopped, the pigment bilirubin, a waste product that is formed when old or damaged red blood cells are broken down and escape into the bloodstream, then accumulate in massive numbers [10]. In addition, if the inflammatory process is not reversed or treated, liver failure will occur, leading to the following devastating problems [31]:  Intestinal bleeding because the vast amount of blood circulating causes the liver to become obstructed and swollen. Capillaries can eventually collapse, decreasing the blood flow to the liver, and hypoxia of the tissue and scarring will develop [26].  Cardiorespiratory insufficiency.  Renal failure, such as glomerulonephritis [33].

http://www.cdc.gov/ncidod/diseases/hepatitis/c/plan/HCV_infection.htm

In the literature of the CDC, it has been noted and speculated that although the WHO and CDC have provided estimated figures correlating the patients infected with the hepatitis C infection, the
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The cardiorespiratory and renal failure typically occur together as they are the result of decreased blood flow and organ failure.

Types of hepatitis It is important to understand that there are other types of hepatitis. In addition, in order to properly understand the disease process of the hepatitis C virus, one must understand that the symptoms of all forms of hepatitis may be similar. As health care professionals caring for a patient with hepatitis, if we understand the differences of hepatitis, we can properly screen for hepatitis based on the potential causes and risk factors people engage in. The two major categories and origin of hepatitis are related to a viral or non-viral processes: 1. Non-viral Non-viral hepatitis causes an inflammatory process in the liver, typically as a result from an exposure to certain chemicals and drugs. The major culprits contributing to non-viral hepatitis are consumption of an abundance of alcohol or medications such as acetaminophen (Tylenol); both can damage the liver. In addition, there are chemicals in the fumes of paints and bug sprays that may potentiate a non-viral hepatitis. Other sources of non-viral hepatitis include bacterial abscesses, Lyme disease and syphilis [14]. The majority of patients usually recover from non-viral hepatitis; however, a small percentage do go on to develop fulminating hepatitis, hepatic failure or cirrhosis of the liver. Fulminating hepatitis is a syndrome that results from necrosis of the liver cells and liver failure [31]. 2. Viral Viral hepatitis is the common systemic infection or disease process that results in the hepatic cell destruction, autolysis and necrosis. In the majority of patients, the hepatic cells will eventually regenerate with very little to no residual damage at all. Nonetheless, if old age and a serious underlying disorder are factors, complications from viral hepatitis therefore become almost certain. The prognosis for viral hepatitis then becomes poor if edema and hepatic encephalopathy occur [26]. According to the majority of data, there are five major types of viral hepatitis. It is imperative for health care professionals to recognize the different types of viral types of hepatitis as they may coincide with particular behaviors and lifestyles that may put an individual at risk for contracting a particular virus. The five major types of hepatitis are as follows: [26].  Type A, hepatitis A (HAV) is infectious or short-incubation hepatitis. It is contracted through the fecal, oral route in contaminated water, food or undercooked shellfish. The virus can also be transmitted by infected blood. The majority of patients, 45 percent in urban areas, have the hepatitis A antibodies in their bloodstream [31]. In order to prevent the spread of hepatitis A, patients need to avoid unsanitary conditions within the food and water chain systems. Another potential method of transmission occurs at day care centers for children where workers fail to wash their hands appropriately between each diaper change. The incubation period for hepatitis A is four to six weeks; however, a person is most contagious during the fecal shedding, which is at its peak for 10 to 14 days before the onset of symptoms [31]. Fortunately, a vaccination for hepatitis A is available. The CDC (2008) recommends all children obtain the hepatitis A vaccination at a minimum of 12 months, followed by a second six months later [4]. The CDC recommends adults with chronic liver disease, those who travel to high-risk countries, and men who have sex with men receive the vaccination in a two-shot series, with the second administration six to 12 months after the first. [4].  Type B, hepatitis B (HBV) is a serum or long-incubation hepatitis. Hepatitis B is contracted with infected blood, bodily
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fluids and/or contaminated needles. Hepatitis B is considered a sexually transmitted infection (STI) because it is transmitted in blood and bodily fluids. Unfortunately, the virus is usually found among people who are also positive for the human immunodeficiency virus (HIV). Mandatory screening of blood donors has greatly reduced the incidence of post-transfusion hepatitis B cases. However, transmission continues to be a major problem among drug abusers who share needles. Another potential risk of transmission is mother to infant transmission. However, over the past few years, women who seek prenatal care are properly screened prior to delivery. In addition, if a woman who did not receive prenatal care or was not screened enters a facility to deliver, she is screened prior to the delivery. If a woman tests positive and/or is in the threemonth window of potential infection, the infant will receive the hepatitis B vaccination and intravenous immunoglobulin (IVIG) to prevent the child from contracting the hepatitis B virus. In addition, all individuals, especially those who have risky occupations – such as nurses – are required to obtain the threeshot hepatitis B series. It is imperative for infants to be treated appropriately, because the CDC has estimated that approximately 90 percent of babies who contract the hepatitis B virus infection will become chronic carriers, and of those, 25 percent will die of liver cancer or cirrhosis [8]. Therefore, if the infant has no risk factors he or she will receive the hepatitis B vaccination at birth or 1 month, then the second in two months, and the third dose no earlier than 24 weeks, with an average administration at 6 months [4]. The CDC recommends that adults receive the first vaccination at any time, then the second one to two months later and the third vaccination six months after the first [4].  Type C, hepatitis C (HCV) encompasses 20 percent of viral hepatitis cases, including the majority of post-transfusion cases. This virus is elaborated on throughout this course.  Type D or delta hepatitis (HDV) can be responsible for up to 50 percent of all fulminant hepatitis cases, which have a very high mortality rate. In addition, delta hepatitis is found in up to 1 percent of viral cases. The unique component about hepatitis D is that it occurs in individuals infected with hepatitis B. Therefore, a patient cannot become infected with hepatitis D unless he/she has hepatitis B. The rationale is that the delta virus depends upon the hepatitis B virus to replicate [31]. In essence, a person is at risk of contracting HDV if he/she is exposed to blood, bodily fluids and/or contaminated needles, similar to HBV. Within the U.S., type D typically occurs in people who frequently are exposed to blood along with blood products, such as hemophilia patients and IV drug users.  Type E was formerly grouped with the hepatitis types C and D under the name non-A. Non-B hepatitis is mostly common in young adults and is more severe in pregnant women. Hepatitis E is not prevalent in the U.S. and is more common in developing, endemic countries as it is transmitted via the fecal-oral route. It clinically resembles hepatitis A because they are both transmitted via the fecal-oral route. According to the Clinical Guidelines in Family Practice, there is another form of viral hepatitis: hepatitis G. Hepatitis G is found in 1.5 percent of all blood donors among children and adults [38]. The infection has been reported in up to 20 percent of adults with chronic

hepatitis B and/or hepatitis C; therefore, a co-infection can exist as both of the viruses can be transmitted by blood and bodily products [6]. The unique component of hepatitis G is that the symptoms are extremely mild and there is no treatment for the viral infection. In addition, there is no serological testing available to assist in the diagnosis process [38]. At this time, only hepatitis A and B have a vaccination to prevent and/or reduce the risk of infection. Fortunately, all children who have well-baby physicals will receive the vaccinations to prevent the transmission if their parents comply. Risk factors for contracting the hepatitis C virus The primary mode of transmission for hepatitis C is through injection drug use or a blood transfusion. However, in some cases, there appears to be no known exposure to risk factors for patients who have tested positive for the hepatitis C virus. There is speculation that these may be individuals who have not disclosed their lifestyle and risky behaviors. The National Digestive Diseases Information Clearinghouse (NDDIC) in 2006 recognized that the following individuals are at the highest risk of contracting the virus [33].  Men.  Alcoholics.  Patients with cirrhosis.  People over the age of 40 years old. Until 1990, individuals who received blood transfusions were the main risk-factor group who acquired the hepatitis C infection. At that time, there were inadequate and unreliable screening methods to properly recognize and diagnose the hepatitis C virus, and many people unknowingly became infected with the virus. It was not until the mid- to late 1980s that the CDC implemented blood donor screening to assess for HIV and hepatitis C (NANBH) antibodies before any blood transfusion. At that time, the CDC speculated that the risk for becoming infected with hepatitis C was about 1 in 200 units of blood. In May 1990, the Food and Drug Administration (FDA) approved and licensed an enzyme immunoassay (EIA) test for hepatitis C. The EIA test identifies the presence of the hepatitis C antibodies in the blood. Unfortunately, the EIA had a very high incidence of false positives, forcing an adjustment to a more sensitive and reliable test two years later. The adjustment in the testing proved to be worthwhile as the incidence of contracting the hepatitis C virus fell to a 1 in 100,000 units of a chance [17]. Today, the testing has become so accurate that the risk of infection has decreased to about 1 incident per 2 million units. [32]. In addition, before individuals donate blood at any banking center, they are asked a series of questions to rule out the risk that their blood is contaminated. Donors who are found to be any of the following are prohibited from donating blood and will be entered into the blood bank registry as a “deferral registry” that is viewed nationwide at any blood center [1]:  Anyone who has ever used illegal intravenous drugs (illegal IV drugs).  Men who have had sexual contact with other men since 1977.  Anyone who has ever received clotting factor concentrates.  Anyone with a positive test for the HIV/AIDS virus.  Men and women who have engaged in sex for money or drugs since 1977.  Anyone who has had hepatitis since his or her 11th birthday.  Anyone who has had babesiosis or Chagas disease.  Anyone who has taken Tegison for psoriasis.  Anyone who has risk factors for Crueutzfeldt-Jakob disease (CJD) or who has an immediate family member with CJD.  Anyone who has risk factors for variant CJD.
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 Anyone who spent three months or more in the United Kingdom from 1980 through 1996.  Anyone who has spent five years in Europe from 1980 to the present. All of the research and data is congruent on the most common risk factors for contracting the hepatitis C virus. In addition, see table for a diagram eliciting the most common risk factors for contracting the hepatitis C virus.

 People are at greater risk of contracting hepatitis C if they had a blood transfusion prior to 1991. Although one potentially could be infected with the hepatitis C virus after a blood transfusion today, the risk has declined significantly. If an individual contracts the hepatitis C virus after a blood transfusion today, the infected patient will have detectable antibodies within 12 weeks after the blood transfusion [38].  Any individual who has a past or current history of experimenting with IV drugs or intranasal cocaine can become infected with the virus. At this time, individuals who inject drugs are the largest source of patients who are becoming infected with the hepatitis C virus, at an estimated 60 percent. There has been no correlation to the time frame in participating in this risky behavior because it only takes one time to inject infected blood into a vein, which can have a deadly consequence. It has been speculated that over 50 percent of cases are transmitted by IV drug use [32].  Any individual who has received any organ in which the donor had hepatitis C infection. Although this may have occurred more frequently prior to the 1990s, the risk has reduced dramatically with the knowledge and appropriate screening prior to a transplant. However, there is always a window of opportunity, an average of three months, in which an individual may have become unknowingly infected.  In hospitals an outpatient facilities, it is possible for patients to contract a nosocomial infection. Various facilities nationwide have documented patient-to-patient conversion of hepatitis C by colonoscopy, hemodialysis and in surgery [38].  Any health care professional who has been exposed to unsterile equipment or pricked with a needle that has infected blood may become infected with hepatitis C. This can occur during an injection or while performing a procedure on a patient who has the virus. Therefore, as nurses we need to utilize universal precautions at all times to reduce the risk of transmission. It has been estimated that with needle stick injuries, a nurse’s risk is [38]: ŠŠ Hepatitis B is transmitted in 30 percent of exposures. ŠŠ Hepatitis C is transmitted in 3 percent of exposures. ŠŠ HIV is transmitted in 0.3 percent of exposures.  Any individual who has used unsterile equipment or attended a site that is not adhering to FDA guidelines for body piercing, tattooing, manicures/pedicures and/or acupuncture.

 Any individual who uses an infected person’s toothbrush, razor or anything else that may have blood on it. Therefore, patients should be discouraged from sharing any supplies that could have a droplet of blood on them.  Any individual who received a clotting factor concentrate (such as anti-hemophilic factor), a blood plasma derived product, before 1987 when effective means to screen for hepatitis C were not available may be at risk for contracting the hepatitis C virus. The CDC has noted that except for one outbreak of the hepatitis C virus from a single type of contaminated intravenous immunoglobulin, other plasma-derived products, including immune globulin for intramuscular (IM) injection, have not been associated with the transmission of hepatitis C in the U.S. [9].  An infant born to a woman infected with the hepatitis C infection. Researchers have speculated that maternal-fetal transmission is rare, and is usually associated with a co-infection of HIV [38]. However, it is important to recognize that the potential risk is apparent. There has been no conclusive evidence whatsoever that hepatitis C can be spread via breast-feeding [4].  At one time, it was speculated that hepatitis C might be transmitted during sexual activity, but there have been numerous studies conducted on this potential risk factor, and even spouses of patients with hepatitis C have a less than 5 percent chance of being infected with the virus. In addition, researchers have noted that the majority of time when hepatitis C does occur between intimate partners, it is more common in countries where hepatitis C is common in the general population. In contrast, the CDC (2006) has contributed sexual exposures with an alarming 15 percent of all of the hepatitis C cases. However, the CDC reiterates that the risk is low for transmitting the hepatitis C virus through sexual intercourse, but it is exacerbated in adults who have unprotected sex with multiple partners [9].  Some researchers have speculated that individuals with HIV infection appear to be at a higher risk of co-infection with the hepatitis C [38]. The CDC has contributed hemodialysis, employment in the health care field and birth to a hepatitis C-infected mother in combination for 5 percent of the total cases [9]. In addition, the source of infection typically cannot be positively identified in 10 percent of acute hepatitis C cases and about 30 percent of chronic cases. The National Institute of Diabetes and Digestive and Kidney Diseases (NDDIC) states that these random infections are most likely caused as the result of someone coming in contact with blood or body fluids from an infected person through an open sore, cut or medical injection. Another variable for health care providers to contemplate is the notion that a few individuals who have become infected with the virus are reluctant to seek care, as they may have to acknowledge that they have a past drug abuse and addiction cycle. The consensus among the majority of experts is that acquiring hepatitis C from an infected individual through casual contact such as shaking hands, kissing, hugging or sharing eating utensils is not feasible [17]. Clinical presentation of hepatitis Unfortunately, over 80 percent of people with hepatitis C do not exhibit any symptoms initially in the infectious process. Symptoms that do appear may be so mild and vague that the infected individual may not notice them or may attribute to other causative factors. Unfortunately, the individual who self-diagnoses may not seek medical care because he/she does not perceive the symptoms to be severe. Another alarming factor is that a person may not exhibit symptoms until 10-20 years after the initial infection. Unfortunately, after this prolonged time, there will have been a vast array of chronic and usually irreversible damage to the liver and body.
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On a positive note, the small percentage of individuals who experience some form of symptoms in the early acute phase will notice symptoms approximately 5-12 weeks after the initial exposure. The majority of infected individuals who have exhibited symptoms have described the symptoms as a “flu-like” illness with durations that last approximately a few weeks to several months. There are numerous symptoms that are associated with hepatitis C virus and a few that tend to be more common than others [15]. In addition, the majority of practitioners distinguish hepatitis as either acute or chronic.  Symptoms of acute viral hepatitis In general, the symptoms for acute viral hepatitis may begin abruptly or could very well develop over a long period of time. As previously mentioned, individuals may mistake the infection of hepatitis C for the flu, as more often than not the symptoms are mild. An individual who is experiencing flu-like symptoms most often complain of fever, chills, headache, fatigue and muscle aches. In addition to flu-like symptoms, some patients experience gastrointestinal problems that may be exacerbated with symptoms of nausea and vomiting. In addition, there usually is a general feeling of discomfort, which radiates from the upper right portion of the abdomen and feels like a sharp pain that intensifies with rough, purposeful movements. The uncomfortable pain may lead someone to lose his or her appetite, lose weight, or even develop dehydration due to the nausea and vomiting. A few patients may develop jaundice, which is yellowing of the skin and the whites of the eyes, and dark urine. Children however, typically do not develop jaundice. Fifty percent of all patients will experience mild itching, irritability, muscle pain, drowsiness and light colored stools. In a quarter of patients, joint aches accompanied by diarrhea are experienced, while 10 percent experience an enlarged spleen [19]. The most common symptoms associated with the acute phase of the hepatitis C virus are: ŠŠ Nausea. ŠŠ Vomiting. ŠŠ Diarrhea. ŠŠ Loss of appetite. ŠŠ Fatigue. ŠŠ Pain over the liver (on the right side of the abdomen, just under the rib cage). ŠŠ Jaundice – A condition in which the skin and the whites of the eyes turn yellow. ŠŠ Dark-colored urine (may look like cola or tea). ŠŠ Stools become pale in color (grayish or clay colored) [15]. Although the initial symptoms may be mild with nausea and vomiting and/or the flu, important ones are pain in the liver, jaundice and change in the urine and/or stool. As a practitioner, it is important to recognize these symptoms in combination with the lifestyle and/or risk factors that may put the patient at risk for becoming infected with the hepatitis C virus. Because of the vague symptoms, many patients do not seek the care of their primary health care provider. But if a patient presents with symptoms related to acute hepatitis C or for another reason, his or her health care provider could notice during a normal exam a mild enlargement of the liver or tenderness. In a few cases, patients may have spider veins or palmar erythema noted during the physical exam [33]. If the individual has prolonged nausea and vomiting, dehydration may be a serious risk, depending on age and other medical

conditions. In order to assess the patient for dehydration, the following symptoms may be noted: ŠŠ Fatigue or weakness. ŠŠ Confusion or difficulty concentrating. ŠŠ Headache. ŠŠ Anuria (not urinating). ŠŠ Irritability [15].  Symptoms of chronic hepatitis It is imperative to ideally screen and diagnose a patient in the acute phase of hepatitis to prevent chronic infection. Seventy to 90 percent of individuals who have been infected with the virus develop chronic hepatitis [14]. In the individuals who develop chronic hepatitis, 20 percent of them progress to chronic liver disease, liver failure or hepatocellular carcinoma [14]. Similar to the hepatitis B virus, hepatitis C is able to progress to chronic hepatitis with little to no early acute symptoms at all. Symptoms that originate from the progressive chronic viral hepatitis usually are very mild for a length of time not to exceed six months. On the other hand, chronic hepatitis C may be present without any sign of infection for as long as 20 years. For a few infected individuals, itchy skin may be the first indication, while others may experience pain in the joints, which is often mistaken for rheumatoid arthritis, fibromyalgia or carpal tunnel syndrome. Others with hepatitis B or C may experience long-term disability or even liver failure long before they ever experience any symptoms at all [19]. A complication of chronic hepatitis is cirrhosis of the liver. Cirrhosis of the liver occurs in approximately 15-20 percent of patients with the chronic form of hepatitis [38]. Cirrhosis usually comes about as a result of alcoholism, abuse of Tylenol and complications of hepatitis C virus. If an individual has cirrhosis, the liver is no longer able to function properly because healthy liver tissue is replaced with fibrous tissue. The fibrous tissue eventually hardens and turns into scar tissue. Once this process occurs, the liver begins to fail, as it is incapable of performing all of the normal functions. Inevitably, symptoms will appear, and at this stage there will be no mistake that something is seriously wrong [15].  Symptoms associated with cirrhosis: ŠŠ Ascites (fluid retention causing swelling of the belly, legs or whole body). ŠŠ Persistent jaundice. ŠŠ Fatigue. ŠŠ Disturbances in sleep. ŠŠ Puritis (itchy skin). ŠŠ Loss of appetite, weight loss. ŠŠ Muscle wasting. ŠŠ Hemoptysis (vomiting or coughing blood). ŠŠ Mental disturbances such as confusion, lethargy, extreme sleepiness or hallucinations (hepatic encephalopathy) [15]. In addition, hepatomegaly is present in 50 percent of all patients with viral hepatitis and splenomegaly is seen in 15 percent of cases [14]. Patients may also exhibit lymphadenopathy. Of all the viral types of hepatitis, hepatitis C is often the most asymptomatic [14]. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NDDIC) (2006), 1 to 2 percent of patients with hepatitis C may have additional chronic complications that do not directly involve the liver. The most common is cryoglobulinemia, a single or mixed immunoglobulin, which is noted in the patient who exhibits the following symptoms [33]:
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 Skin rashes, such as purpura, vasculitis or urticaria (hives/ itching).  Joint and muscle aches.  Kidney disease.  Neuropathy.  Cryoglobulins, rheumatoid factor and low-complement levels in serum. Diagnosing hepatitis C If a patient presents with symptoms and/or has a history coinciding with a speculated diagnosis of hepatitis C or any form of hepatitis, the health care provider will need to identify the serologic type. Based upon the serologic type, the practitioner can determine the appropriate treatment. See table below for the diagnostic algorithm for the hepatitis C virus: Sources of infection for persons with hepatitis C

* Hemodialysis; health-care work; perinatal

The diagnosis of hepatitis C is based on the following tests:  The first test is to implement the enzyme immunoassay (EIA) to detect the anti-hepatitis C antibodies [14]. Although there are limitations to the testing based upon the sensitivity of the test, it can typically detect the antibodies within four to 10 weeks after infection [38]. Ideally, a test should have a high sensitivity to ensure that it properly identifies people with the disease. The danger of low sensitivity is that individuals who truly are infected may have a false negative result. Previously, the specificity was so low that 50 percent of all healthy blood donors and some patients with elevated gamma-globulin levels demonstrated false negatives [14]. Unfortunately, that may have previously misled individuals who were truly infected, thus exacerbating a potentially bigger problem that the individual could pass it on to somebody else. Fortunately, the EIA has greatly improved the sensitivity over the past few years [38]. At this time there are three versions of it: the EIA I, EIAII and EIA III [12]. The preferred method is for practitioners to utilize the EIA II or EIA III because they both have excellent sensitivity and specificity, with a lower cost [12]. Hepatitis C can usually be detected at four to six weeks after exposure; however, if the patient is at risk and tests negative at six weeks, repeat the test [12].  The second test that is completed is the recombinant immunoblot assay (RIBA). All positive antibodies detected by the enzyme immunoassay will be confirmed with the RIBA [38]. The RIBA test is similar to a western blot. The RIBA works in the following manner [33]: ŠŠ The serum is incubated on nitrocellulose strips on which four recombinant viral proteins are blotted. The color changes indicate that antibodies are adhering to the proteins. The results are as follows:  The immunoblot test is considered positive if two or more of the proteins react. If the immunoblot test for anti-HCV is positive, the patient has most likely recovered from

hepatitis C and has a persistent antibody.  The immunoblot test is considered indeterminate if only one positive band is detected. If the immunoblot test is negative, the EIA result was probably a false positive.  A third test that may be completed is the polymerase chain reaction (PCR) to detect the hepatitis C ribonucleic acid (RNA). The RNA test is an excellent test; however, it is very expensive. Therefore, the majority of the time the two previously mentioned lab tests are completed. The RNA test is implemented once the diagnosis and/or results of the anti-HCV antibody test are completed and/or under the following circumstances [38]: ŠŠ In patients with negative results on the enzyme immunoassay in whom acute infection is suspected. ŠŠ In patients who have hepatitis with no identifiable cause. ŠŠ In patients with known reasons for false negative results on antibody testing. ŠŠ For the confirmation of the viremia and the assessment of treatment response. Viremia is the presence of the virus in the blood stream. It is important since three out of four seropositive patients with hepatitis C also have viremia. In addition to any of the confirmatory diagnostic tests, all patients at risk and/or whom test positive for the hepatitis C antibodies will have the following lab tests completed [14]:  Liver function tests (LFTS) to assess for any liver injury. ŠŠ The amniotransferases are the hallmark of all forms of hepatitis. There are two main components of amniotransferases that are included in the liver function test [25]:  Alanine aminotransferase (ALT); formerly serum glutamate pyruvate transaminase [SGPT]).  Aspartate aminotransferase (AST); formerly serum glutamic-oxaloacetic transaminase [SGOT]. Typically, as a rule of thumb, the ALT is severely elevated early in the phase with the ALT levels often rising to several thousand units per liter in patients with acute viral hepatitis. The highest ALT levels – often more than 10,000 U per L – are usually found in patients with acute toxic injury subsequent to, for example, acetaminophen overdose or acute ischemic insult to the liver [25]. The levels of AST and ALT are usually reversed in cirrhosis of the liver; AST is higher than the ALT [33]. ŠŠ Lactate dehydrogenase (LDH) is less specific than AST and ALT as a marker of hepatocyte injury [25]. ŠŠ Bilirubin and the alkaline phosphates are usually elevated and may remain elevated throughout the infection [12]. In severe liver damage and/or cirrhosis, the responsible physician and/or nurse practitioner (ARNP) may notice the following diagnostic lab values [33]:  AST is higher than the ALT.  Alkaline phosphates and gamma glutyamyl transpeptidase are elevated. However, in the acute phase of hepatitis C, they are usually normal.  Low platelet and low white blood cells (WBC) and high serum globulins (such as the immunoglobulins and rheumatic factor indicating severe fibrosis and/or cirrhosis.  Albumin, bilirubin and prothrombin time (PT) are normal until the end stage of liver damage. Another important diagnostic tool to complete is a blood test to assess for the specific genotype of the hepatitis C virus. The genotype is helpful in defining the epidemiology of the hepatitis C virus and more importantly, it is helpful in making treatment recommendations, which will be discussed in further detail below.
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Once the genotype is identified, it does not need to be tested again, as the genotypes do not change during the course of infection [33]. In addition, if a patient tests positive for the genotype two or three, a liver biopsy is not required because the treatment plan has a high sustained viral response rate (SVR) to the medications prescribed [14]. Liver biopsy A controversial test that may be completed is a liver biopsy. Many physicians believe that it is not necessary for diagnosis; however, it facilitates the ability to grade the severity of the disease and stage the degree of the fibrosis and permanent architectural damage [33]. In addition, if a patient has the genotype 1a, 1b, or 4, a liver biopsy may be recommended since the SVR is not as good in preventing a relapse [14]. Therefore, if a liver biopsy is completed, the practitioner will understand the extent of liver damage to provide better treatment opportunities for the patient. The hepatitis C virus elicits the following changes in the tissue of the liver [33]:  Necrosis and inflammation at the edge of the portal areas, socalled “piecemeal necrosis” or “interface hepatitis.”  Necrosis of hepatocytes and focal inflammation in the liver parenchyma.  Inflammatory cells in the portal areas (“portal inflammation”).  Fibrosis may exist in an early stage of the hepatitis C virus infection; however, it is usually confined to the portal tracts, an intermediate stage consisting of expansion of the portal tracts and bridging between portal areas or to the central area. In the late stage of frank cirrhosis, there is an architectural disruption of the liver with fibrosis and regeneration. There are numerous scales utilized to stage the degree of fibrosis, however, the most common is the following: ŠŠ One common classification is a scale from 0 to 4 where stage 0 indicates no fibrosis; stage 1 indicates enlargement of the portal areas by fibrosis; stage 2 indicates fibrosis extending out from the portal areas with rare bridges between portal areas; stage 3 indicates many bridges of fibrosis that link up portal and central areas of the liver; and stage 4 indicates cirrhosis. Although there are numerous tests to confirm the diagnosis and to assess the degree of the damage to the liver, it is imperative to ensure the proper treatment plan is initiated for each patient. Due to the complexity of the disease process, the multiple array of variables and the limited symptoms a patient may exhibit over the course of the infection, the first key is confirming the diagnosis of the antihepatitis C antibodies. Once the virus has been confirmed with the EIA and RIBA, then the additional testing is implemented to provide a diagnostic analysis of the degree, severity and epidemiology of the hepatitis C virus. Treatment of hepatitis C Due to the difficult nature of hepatitis C virus, early treatment doesn’t happen because the majority of patients do not exhibit any symptoms. In addition, at this time there is no cure and/ or vaccination available for the hepatitis C virus. Therefore, the treatment modalities are geared toward controlling the symptoms, depending upon the severity of the disease process and/or lifestyle that the patient is currently living. For instance, a patient who continues to engage in risky behaviors will only exacerbate the symptoms and the severity of the disease process. When the patient is diagnosed and the manner in which the liver has been affected will determine the treatment modality and potential outcome for the individual. There are multiple variables to consider in treating hepatitis C that

are dependent upon the phase of the virus, damage and genotype of the virus. See table for the treatment algorithm. Algorithm for treatment Make the diagnosis based on aminotransferase elevations, antiHCV and HCV RNA in serum. i Assess for suitability of therapy and contraindications. Discuss side effects and the likelihood of a beneficial treatment outcome. i Test for HCV genotype. Consider doing a liver biopsy to assess the severity of the underlying hepatitis and need for current therapy. i Genotype 1: Test for HCV RNA level immediately before starting therapy (baseline level). i Genotype 1: Start therapy with peginterferon alfa-2a in a dose of 180 mcg weekly or peginterferon alfa-2b in a dose of 1.5 mcg per kg weekly in combination with oral ribavirin in two divided doses of 1,000 mg daily if body weight is < 75 kg (165 lbs) or 1,200 mg daily if > 75 kg. i Genotype 2 or 3: Start therapy with peginterferon alfa-2a in a dose of 180 mcg weekly or with alfa-2b in a dose of 1.5 mcg per kg weekly and oral ribavirin 800 mg daily in two divided doses. i All patients: At weeks 1, 2 and 4 and then at intervals of every 4 to 8 weeks thereafter, assess side effects, symptoms, blood counts and aminotransferase levels. i Genotype 1: At week 12, retest for HCV RNA level. If HCV RNA is negative or has decreased by at least two log 10 units (such as from 2 million IU to 20,000 IU or from 500,000 IU to 5,000 IU or less), continue therapy for a full 48 weeks, monitoring symptoms, blood counts, and ALT at 4- to 8-week intervals. If HCV RNA has not fallen by two log 10 units, stop therapy. i Genotype 2 or 3: At 24 weeks, assess aminotransferase levels and HCV RNA and stop therapy. i All patients: After therapy, assess aminotransferase levels at 2to 6-month intervals. In responders, repeat HCV RNA testing 6 months after stopping. According to the CDC and the National Institutes of Health (NIH), treatment of hepatitis C is recommended if any of the following conditions are present since they are at the greatest risk of developing cirrhosis [30]:  A positive test result indicating the hepatitis C antibodies by the EIA or RIBA.  A confirmatory positive test for hepatitis C-RNA. Many physicians will treat without the RNA due to the expense and reliability of the EIA and RIBA.  A liver biopsy if deemed necessary based on the genotype, which may indicate significant liver damage.  Elevated levels of ALT in the blood. Once the patient has exemplified any of the diagnostic measures indicating that hepatitis C virus is present in their body, treatment is initiated immediately. The nurse caring for the patient with hepatitis C should not stereotype or judge the patient regardless of the
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patient’s personal lifestyle choices. One of the most important things nurses can demonstrate is compassion and support to the patient. Throughout a nurse’s career, regardless of the area or specialty, a nurse will be responsible for the well-being of a patient with hepatitis C. In addition to the compassion and support provided to the patient in a non-judgmental demeanor, nurses should provide education to their patients to prevent further liver damage. All patients should adhere to the following recommendations regardless of the genotype, extent of the virus and the lifestyle of the patient [27]:  Rest to minimize the energy demands of the body, especially during the acute phase. Therefore, the patient should avoid any strenuous exercise.  Dietary management should include high caloric foods in small, frequent portions throughout the day to prevent anorexia and muscle wasting. It is important to encourage patients not to overindulge themselves during meals. In addition, patients with cirrhosis of the liver should avoid salt and high protein in their diet.  Encourage patients to drink at least 135 ounces of fluid a day to prevent dehydration. If the patient is experiencing extreme nausea and vomiting, he/she may need to be hospitalized to replace the fluid loss. In addition, the nurse can offer and recommend ice chips to maintain hydration without inducing vomiting.  Avoid all alcohol and any hepatotoxic medications, such as Tylenol or any component of Tylenol. Another medication to avoid is morphine sulphate. Doing otherwise can greatly increase one’s chances of developing cirrhosis and liver failure.  Avoid illegal drug use. Do not share needles or other drug paraphernalia.  Avoid body piercing and tattooing. People who do undergo piercing or tattooing should be absolutely certain the equipment is sterile.  Avoid risky sexual behavior. Don’t engage in unprotected sex with multiple partners or with one partner whose health status is uncertain. Sexual transmission between monogamous couples may occur, but the risk is low [28].  Vaccination to the hepatitis A and B viruses is recommended to provide immunity to those specific viruses before potential transmission occurs, which can further damage the liver. It is imperative that the nurse reiterates to the patient the importance of complying with the follow-up appointments with his/her physician. Due to the complexity of the disease and variables, the physician will need to monitor the effectiveness of the patient’s treatment and the extent of the disease process at various intervals. In addition to the education and guidelines recommended for patients to care for themselves, they should begin treatment with antiviral medications. Dependent upon the patient’s lifestyle, willingness to comply and/or other medical diagnosis, physicians may find themselves in a precarious situation when initiating treatment as the medications may induce more harm. On the flip side, some physicians decide to pursue the medications because there is no way to know which patients will develop cirrhosis of the liver and/ or liver cancer. The recommended dose and duration of treatment is dependent upon the genotype and the extent of the liver damage. Regardless, all patients are treated with interferon and Ribavirin. The main difference between the treatment regimens is the dosing and length of the treatment. According to the NDDIC (2006), the following is recommended as the treatment modalities based on the genotype typing alone [33]:  Patients with the genotype one, which is the most common in the U.S., respond better to interferon and Ribavirin at the highest

dose 1,000-1,200 milligrams (mg) a day for a full 48-week course.  Patients with genotypes two and three are two to three times more likely to respond to interferon-based therapy than patients with genotype 1. Furthermore, using a combination therapy of interferon and peginterferon 800 milligrams (mg) a day for a 24week course is adequate to reduce the risk of chronic hepatitis C. There are two types of interferon that may be prescribed to a patient with the hepatitis C virus [33]:  The first is alpha interferon, which is a host protein that is made in response to viral infections and has a natural antiviral component. There are recombinant forms of alpha interferon that have been produced with several formulations (alfa-2a, alfa-2b, consensus interferon) to treat hepatitis C. Over the past few years, the standard forms of interferon are being replaced by pegylated interferon (peginterferon).  Peginterferon is an alpha interferon that has been modified chemically by the addition of a large inert molecule of polyethylene glycol. Pegylation changes the uptake, distribution and excretion of interferon, which prolongs the half-life. Thus, it improves the benefit the frequency of the administration of the antiviral medication peginterferon. At this time, peginterferon can be given once weekly, and it provides a constant level of interferon in the blood, in contrast to the standard interferon which had to be given several times weekly, with intermittent and fluctuating levels in the body. In addition, peginterferon is more active than standard interferon in inhibiting hepatitis C virus and yields a higher, sustained SVR. ŠŠ Peginterferon alfa-2a is given subcutaneously (SQ) at a fixed dose of 180 micrograms (mcg) per week. ŠŠ Peginterferon alfa-2b is given subcutaneously weekly in a weight-based dose of 1.5 mcg per kilogram (kg) per week (thus in the range of 75 to 150 mcg per week). According to the CDC, the typical side effects of interferon are the following [6]:  Initially, the patient may exhibit flu-like symptoms (fever, chills, headache, muscle and joint aches, fast heart rate), but the symptoms usually subside with continued treatment.  Later, the patient experiences fatigue, hair loss, low blood count; (exacerbating leukopenia). Additional symptoms are difficulty thinking, moodiness and depression.  Severe rare side effects, seen in less than two out of 100 persons, includes thyroid disease, depression with suicidal thoughts, seizures, acute heart or kidney failure, eye and lung problems, hearing loss and blood infection. In even more rare circumstances, death has occurred due to liver failure and/or a blood infection; it is usually increased in patients with cirrhosis of the liver. Pregnant women should never be treated with interferon. The other commonly prescribed medication is ribavirin, an oral antiviral agent that has activity against a broad range of viruses. However, if it is prescribed by itself, it has little or no effect on the hepatitis C virus. According to the CDC, the combination therapy side effects include all of the following [6]:  The previously mentioned side effects with interferon alone and anemia because ribavirin has an enormous potential to induce an anemic state in the patient. Therefore, if a patient has kidney failure, combination therapy will not be recommended. The rationale is that normally erythropoieten is derived from the kidneys; therefore, if the kidneys are not working properly, the anemia induced by the medication will only exacerbate the ability of the kidneys to function.
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The stringent medication guidelines and recommendations will be exhausting to the patient’s body. At times, the patient may feel sicker than he/she ever did with the hepatitis C virus. Therefore, before patients begin their six- to 12-month journey on the antiviral medications, they need to be properly informed about the medications and side effects. In addition, patients should follow up with their practitioners and inform them about any major side effects as the dose may need to be adjusted and/or further testing may be needed. On a positive note, there is hope that if the patient adheres to recommendations and tolerates the medication, there is a 70 percent chance that the virus will be eliminated from the body. In combination with therapy, ribavirin and interferon should improve the serum ALT and eliminate detection of the hepatitis C RNA in up to 70 percent of patients [33]. It is amazing that with proper therapy, the hepatitis C virus may be undetected in the bloodstream. Some patients will relapse if therapy is ceased or if they are on monotherapy alone. Therefore, in order to deem a response as “sustained,” the hepatitis C RNA must remain undetectable and the ALT levels should be normal for six months or more after ceasing therapy [33]. Typically, if the patient’s ALT returns to normal, the treatment can be tapered. Even patients who receive the great news that their viral levels (RNA-hepatitis C antibodies) are undetected and the ALT is within normal limits will always need to care for their liver by avoiding alcohol, hepatotoxic medications and the potential exchange of any blood or bodily fluids. Liver transplant Unfortunately, not everyone responds to treatment, which may lead to the need for a liver transplant. Unfortunately, this option is riddled with many problems due to the limited supply of livers available for patients worldwide. The first problem patients encounter is that they may not be eligible for a transplant if any of the following are present [16]:  A patient who actively drinks alcohol and/or uses any form of an inappropriate or illegal drug. Individuals with active alcohol or substance abuse problems may continue living the unhealthy lifestyle that contributed to their liver damage. Because transplantation in such patients could result in failure of a newly transplanted liver, organ association networks have reserved transplants of the limited supply of organs for patients who are more likely to accept lifestyle changes.  A patient who is diagnosed with any form of a cancer. A patient who has liver cancer only because of the hepatitis C virus may be eligible, depending upon the severity and staging of the cancer. However, if an individual has cancer in any other area, he/she likely will not receive a liver transplant.  A patient who has advanced heart and/or lung disease. Unfortunately, both of these conditions prevent a transplanted liver from surviving because the body is already overworking to sustain the diseased heart or lungs.  A patient who has any form of a severe infection. There are many infections, such as methicillin-resistant staphylococcus aureus (MRSA) that prohibits the ability of many broad-spectrum antibiotics to eradicate it in the body. Therefore, if a patient has a severe or life-threatening infection, the transplant will not be initiated, because it will only complicate the problem and threaten the success of the surgery.  A patient with massive liver failure. The brain and other organs, such as the heart and lungs, may also be affected, therefore limiting the success of the transplant.

Secondly, there is a long waiting list headed by the United Network for Organ Sharing (UNOS). Within the United States alone, there are currently more than 17,000 individuals on the list for a liver transplant, thus making it the second most transplanted organ after the kidney. In 2002, more than 5,300 liver transplants were performed in the U.S. [16]. It is apparent that liver disease is not only a serious medical condition, but is increasingly becoming an epidemic. One of the main focuses of UNOS is to prioritize individuals needing a transplant and to ensure that only the most desperate are on the top of the waiting list. UNOS is able to accomplish this monumental task by utilizing a scoring system method. Measurements are used from clinical and laboratory data. This helps to divide individuals into separate groups and calculate which individuals have the greatest need for a transplant. However, in the spring of 2002, UNOS overhauled its scoring system method, which ranked individuals based solely on the severity of the disease and categorized them into statuses 1, 2A, 2B or 3 [16]. Another risk that patients must contemplate if they are lucky enough to receive a liver transplant is the chance that their body may reject the foreign organ. To reduce the risk of rejection, patients will be on anti-rejection, immunosuppressant medications for the rest of their lives to facilitate the body’s acceptance of the liver. It is normal for our bodies to dispute any foreign object for survival and to keep homeostasis within the body. A transplanted liver is seen as threatening, and antibodies from the individual’s immune system are created and multiplied to destroy the new liver [37]. There are two main types of rejection that a patient may experience [16]: 1. Immediate, or acute, rejection occurs just after surgery when the body immediately recognizes the liver as foreign and attempts to destroy it. Acute rejection occurs in about 2 percent of the patients. 2. Delayed, or chronic, rejection can occur years after surgery, when the body attacks the new liver over time and gradually reduces its function. This occurs in 2-5 percent of patients. The most common prescribed anti-rejection medications are tacrolimus and cyclosporine [3]. Cyclosporine has also demonstrated the ability to have anti-viral activity against the human immunodeficiency virus (HIV), herpes simplex (HSV) and the vaccinia virus [33]. Everything has the potential to induce additional, unwanted side effects. The most common side effects related to the anti-rejection medications are [11]:  Elevated blood pressure (HTN).  Mood swings.  Elevated blood sugar.  Weakness in the muscles and bones.  Headaches (H/A).  Nausea, vomiting, diarrhea.  Kidney failure or dysfunction. In addition to anti-rejection medications, patients are typically prescribed another medication to reduce the risk of hepatitis C resurfacing in the body. Therefore, they may begin their combination therapy of interferon-ribavirin as previously prescribed. The purpose of prescribing the combination therapy once again is to prevent the virus from recurring [3]. The dosing regimen and length of treatment is individualized, based upon the patient and genotype. After patients have been advised of all of their treatment options, they should be encouraged to seek additional data on credible Internet sites and/or the literature should be provided to them in the
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office. The individual needs to understand that risks are involved with pursuing a treatment modality. It is imperative that they are fully aware of all their options and that the decision is theirs. As nurses and health care professionals, we need to inform patients with a compassionate demeanor and respect their decisions, regardless of our own perceptions and ideas. Patients need to have some form of control in their lives, as many will loose their dignity and self-worth as they fight for their life when they battle the hepatitis C virus. Patients coping with the hepatitis C virus For many who are infected with hepatitis C, the social stigma that is attached to the disease can be very difficult to live with. The realization that they may potentially die, or that others may be afraid to be around them, is not easy to deal with. An individual’s self-esteem can be greatly affected by it, as it is usually seen as a disease that affect’s only alcoholics and those who are in a lower socioeconomic status. The potential fatigue and the knowledge that it is a long-term illness only exacerbates the difficulty and emotions of an individual living with hepatitis C. Because the treatments can be painful and uncomfortable as their bodies are depleted, the only comfort may be the knowledge that if they adhere to the treatment, there is a possibility that they may be able to recover completely [20]. But the dream of living in recovery may never be feasible if the individual avoids health care because of the stigma, costs, or lack of transportation or health insurance. Many individuals with hepatitis C are depressed, thus hurting their ability to socialize effectively with loved ones and acquaintances. The hepatitis C Support Project in San Francisco describes the struggles people with hepatitis C encounter on a daily basis: “People with hepatitis C experience a lot of stigma; it can be really hard. You may avoid talking to friends or family about the disease because you are worried about how they will react. You may feel a temptation to pull away from people you care about rather than risk them knowing. The fact is that now, more than ever, you need people to rely on. Keeping open and honest relationships with your family and close friends is key to your own well-being” [40]. Unfortunately, many people infected with hepatitis C become anxious as they worry how their family and friends will view them. In reality, statistics demonstrate that hepatitis C infects individuals from all socioeconomic backgrounds. In addition, the general public appears to be more sympathetic to those suffering from hepatitis C. The American Gastrointestinal Association recently conducted a survey of the public’s view and understanding of hepatitis C. They questioned approximately 500 people diagnosed with hepatitis C and 1,230 without the disease. The survey found the following: 74 percent of the people infected with hepatitis C believe that others think the disease only infects unhealthy people or drug addicts. However, when uninfected people were asked, it turned out that only 30 percent thought that only the unhealthy or drug addicts were infected with hepatitis C. Only 12 percent said that “people like themselves” did not get hepatitis C [40]. The qualitative study demonstrated that people with hepatitis C do experience some form of stigma, but that the stigma is not as bad as they perceive. In addition, it would be interesting to analyze the educational level and socioeconomic status to assess whether it affected people’s perception of others infected with the hepatitis C virus. It is very important for people who are infected with the hepatitis C virus to inform their families, spouses or sexual partners. However, with any disease process, the patient is the only individual who is

required to disclose his or her health status. As nurses are aware, it is not our duty to disclose any personal information to anybody, regardless of our beliefs and values. In April 2003, the Department of Human Health and Services (HHS), implemented a standardized policy to meet a federal law (the Health Insurance Portability and Accountability Act, known as HIPAA) that protects the privacy and dignity of all patients, regardless of their medical conditions. In addition, as research has demonstrated and previously implied, it is highly unlikely that patients’ family members would become infected through sexual transmission or through regular, routine daily contact. However, it would be ideal for a hepatitis C patient to disclose the potential risk, regardless of the prevalence, to allow others to make an informed decision before participating in any potential risks with the patient. However, often people don’t want to disclose their disease to family and friends because they fear the reaction. It has been recommended that if you are caring for a patient contemplating the decision or format to disclose their diagnosis to their loved ones and friends, urge them to:  Be honest.  Educate their loved ones about the disease, including the transmission and risk factors, symptoms and treatment. In addition, the nurse should recommend support groups and encourage loved ones to join the patient. Families who engage in support groups can be uplifting to the patient and give them hope and a sense that they are not alone fighting this potentially deadly disease. Dr. David Thomas, a professor of medicine at Johns Hopkins School of Medicine, says that he always makes sure that his patients with hepatitis C bring their spouses to at least one appointment. In part, he says, this is to make sure that both people fully understand the risks of sexual transmission [40]. Thomas says that people react very differently to the news. Some couples are comfortable with the small risk and do not feel like they need to use condoms. Others are more nervous and want to use protection. There is no right answer. The key is this: The patient and his or her partner must talk about it openly and come to a decision together [40]. The government’s response to hepatitis C The secretary of the Department of Health and Human Services (HHS) and the Advisory Committee on Blood Safety and Availability decided that anyone who may have contracted the hepatitis C virus through a blood transfusion could be identified from a system called look-back notification. Therefore, on Jan. 22, 1998, HHS asked the CDC to develop a comprehensive plan to aid in the prevention, treatment and control of the hepatitis C virus [7]. The CDC responded by developing the national hepatitis C prevention strategy. The CDC coordinated this project by partnering with various agencies, including the Agency for Healthcare Research and Quality (AHRQ), Food and Drug Administration (FDA), Healthcare Financing Administration (HCFA), Health Resources and Services Administration (HRSA), National Institutes of Health (NIH), Substance Abuse and Mental Health Services Administration (SAMHSA), and federal, state and private-sector agencies. The strategy that the CDC incorporated into the plan was to try to prevent and control the infection by the release of credible information pertaining to the hepatitis C virus that could improve people’s health decisions and partnerships with organizations at all levels to promote healthy living [7]. The principle components of the national hepatitis C pevention strategy are: [7].  Education of health care and public health professionals to
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improve the identification of persons at risk for hepatitis C infection and ensure appropriate counseling, diagnosis, medical management and treatment. Education of the public and persons at risk for infection about risk factors for hepatitis C transmission and the need for testing and medical evaluation. Clinical and public health activities to identify, counsel and test persons at risk for hepatitis C infection, and medical evaluation or referral for those found to be infected. Outreach and community-based programs to prevent practices that put people at risk for the hepatitis C infection, and to identify persons who need to get tested. Surveillance to monitor acute and chronic disease trends and evaluate the effectiveness of prevention and medical care activities. Research to better guide prevention efforts.

Nursing and hepatitis As noted, hepatitis C is a known occupational hazard for nurses and doctors. Two percent of the cases of hepatitis C are due to occupational percutaneous exposures, mostly in the form of needle sticks in health care workers, especially nurses. The risk of acquiring the virus from a single needle stick from an infected individual is estimated to be approximately 10 percent. In addition, there have been numerous studies correlating the prevalence and risk of contracting hepatitis C in different health care populations with the role of the individual. They note that oral surgeons are often exposed to aerosolized blood, with a prevalence of contracting the hepatitis C virus as high as 10 percent, four to six times the national average. Dialysis and operating room nurses are at higher risk than non-surgical hospital personnel, with prevalences ranging from 1.5 to 4 percent [21]. Nurses and doctors are continuously caring for others to prevent disease processes and to ensure patients reach their optimal levels. But it is also imperative that they protect themselves at all times when caring for patients. Here are a few measures that nurses can implement to protect themselves:  Always take your time before caring for a patient. Think about your actions before implementing them. As a nurse, it is easy to get carried away by the moment because you are typically being pulled in many directions at once.  Always utilize universal precautions when caring for any patient, regardless of risk factors. Never make a judgment on a patient because of age, sex or race. Hepatitis does not discriminate; it can happen to anyone.  Empty sharps boxes when they are three-quarters full. Do not wait until the needles are overfilling because that will increase your risk of getting a needle stick. A nurse who is pricked at work has a 1.8 percent risk of contracting the hepatitis C virus, meaning two out of every 100 will get infected, with a range of zero to 10 percent [27]. At that moment, many emotions and fears will go through your mind. It is imperative that you wash the area thoroughly with soap and water, notify the supervisor and the employee health nurse. Depending on the protocols at the facility, you may be required to go directly to the emergency room (ER). You must take care of yourself immediately and find a colleague to care for your patients. According to the CDC, the following guidelines are recommended for a health care worker who has had potential exposure to the hepatitis C virus [27]:  Anti-viral agents (e.g., interferon) or immune globulin should not be used for a post-exposure prophylaxis.  The nurse or health care professional will need to have baseline

testing for the hepatitis C antibodies to ensure he or she was not already pre-exposed because antibodies will not show up right after the injury. In addition to testing for the hepatitis C antibodies, liver function tests will be completed to assess for the presence of ALT activity. The nurse or health care worker will be required to have follow-up testing for the hepatitis C antibodies every four to six months and to assess for ALT activity. (If earlier diagnosis of the hepatitis C infection is desired, testing for the hepatitis C RNA may be performed between four and six weeks.)  The presumed source needs to be tested for hepatitis C antibodies. In addition, it is imperative that the patient be made fully aware of the injury, as it is against the law to run random tests on patients without informing them.  The physician will be able to detect whether the nurse has hepatitis C antibodies circulating in his or her body by detecting them through the enzyme immunoassay (EIA) lab test. If the EIA is positive, the diagnosis will be confirmed by the recombinant immunoblot assay (RIBA) or polymerase chain reaction (PCR) lab tests. Hepatitis C in the future As a nation and society, it would be wonderful if we could eradicate all forms of hepatitis, regardless of the causes or people’s risky behaviors. At this time, that seems unlikely. However, researchers have various studies and projects aimed at ways to screen and hopefully eliminate infection with the virus. According to the NDDIC, a major focus of the hepatitis C research has been to develop a tissue culture system to enable researchers to study the virus outside of the human body. In 2005, the goal was achieved when three different laboratories were able to create tissue culture systems of the hepatitis C genotype two strains. The researchers are optimistic that this breakthrough will allow them to assess how the virus is spread, whether it can be blocked by antibodies and the most conducive antiviral drugs [33]. According to the Hepatitis International Foundation, studies being implemented at this time include [34]:  Researchers are collaborating to formulate a genetic screening tool to confirm the diagnosis and to properly treat patients early in the disease process.  Chrion Corp., a leader in hepatitis C research, is collaborating with the St. Louis University School of Medicine to study the safety and effectiveness of Chiron’s investigational hepatitis C vaccine. This Phase I clinical trial will test the vaccine in humans for the first time.  OraSure Technologies is teaming up with Schering-Plough to develop and market the first oral test to detect hepatitis C virus antibodies. This easier, one-step test would be a major step forward in the efforts to identify infected individuals. Conclusion The hepatitis C virus does not discriminate. Any person who partakes in risky behaviors or who works in an environment that potentially exposes him or her to blood-borne pathogens is at risk of contracting a potentially deadly infection such as the hepatitis C virus. Over the past few decades, worldwide attention to HIV has made health care workers aware of the risks of contracting that disease. However, health care professionals are more likely to contract the hepatitis C virus or hepatitis B than HIV when they are exposed to blood-borne pathogens. Therefore, it is imperative that they treat each individual patient as potentially infected and take their time in implementing any procedures or tasks while caring for the patient.

Works Cited: sAdvancing Transfusion and Cellular Therapies Worldwide. (2007). Blood donation: Frequently asked questions. Retrieved online January 26, 2008 at http://www.aabb.org/Content/Donate_Blood/Blood_Donation_FAQs/ sBennett, N. (2007). Hepatitis C. Retrieved online January 5, 2008 at http://www.emedicine.com/ped/topic979.htm sBioMedicine. 2003-2008. Cyclosporine inhibits hepatitis C in-vitro. Retrieved online January 26, 2008 at http://www.biomedicine.org/biology-news/Cyclosporine-inhibits-hepatitis-C-virus-in-vitro-2726 sCDC (2008) Recommended immunizations schedule for persons 0-6 months. Retrieved January 27, 2008 at http://www.cdc.gov/ vaccines/recs/schedules/downloads/child/2008/08_0-6yrs_schedule_pr.pdf sCDC Viral hepatitis C-FAQ (2007). Retrieved online January 1, 2008 at http://www.cdc.gov/ncidod/dis- eases/hepatitis/c/faq.htm sCDC. Viral hepatitis: Fact Sheet (2007). Retrieved online January 29, 2008 at http://www.cdc.gov/ncidod/ diseases/hepatitis/c/ faq.htm#6d sCDC Viral hepatitis. (2001). National hepatitis C Prevention Strategy. Retrieved online January 9, 2008 at http://www.cdc.gov/ ncidod/diseases/hepatitis/c/plan/index.htm sCDC (2006). Viral hepatitis B. Retrieved online January 27, 2008 at http://www.cdc.gov/ncidod/diseases/ hepatitis/b/acip.htm sCDC. Viral hepatitis C-Plan (2006). Retrieved online January 4, 2008 at http://www.cdc.gov/ncidod/dis- eases/hepatitis/c/plan/ HCV_infection.htm sCohen, S. (2006). Merck. Cholestasis. Retrieved online January 25, 2008 at http://www.merck.com/mmhe/ sec10/ch135/ch135c. html sDept of Surgery. (2007). Center for Liver Disease and Transplantation. Retrieved online January 9, 2008 at http://www.livermd. org/life.html#side%20effects sDesai, S., & Isa-Pratt, S. (2000). Clinicians guide to laboratory medicine: A practical approach. Lexi- Comp: Hudson sDrake, S. (2004). Mass of a human liver: The physics facebook. Retrieved online January 25, 2008 at http://hypertextbook.com/ facts/2004/MaryPennisi.shtml sDunphy, Lynne M & Winland-Brown, Jill E., Porter, Brian O., Thomas, Debera J., (2007) Primary Car: The Art and Science of Advance practice Nursing. (2nd ed). FA Davis Company: Philadelphia sE Medicine Health. Hepatitis C Symptoms (2005). Retrieved online January 9, 2008 at http://www.emedi- cinehealth.com/ hepatitis_c/page3_em.htm sE Medicine Health. (2005). Liver Transplants. Retrieved online January 9, 2008 at http://www.emedicine health.com/liver_ transplant/article_em.htm sFDA Consumer magazine March-April (1999). Retrieved on January 1, 2008 at http://www.fda.gov/fdac/ features/1999/299_hepc. html sFong, T. & Schoenfield, L. (2008). Hepatitis C. Retrieved at Medicine Net online January 4, 2008 at http://www.medicinenet.com/ script/main/art.asp?articlekey=915&pf=3&page=2 sJanis and friends hepatitis C support website. (2006) Retrieved online January 9, 2008 at http://www. janis7hepc.com/Symptoms. htm#Flu%20like%20symptoms sHepatitis C An Epidemic for Anyone: Living with hepatitis C. (2008) Retrieved online January 26, 2008 at http://www.epidemic. org/theFacts/hepatitisC/livingWithhepatitis/ sHepatitis C-A Silent Epidemic (2002). Retrieved online January 1 2008 at http://www.lectlaw.com/med/ med17.htm sHepatitis Foundation International (2003). The ABC’s of hepatitis. Retrieved online January 25, 2008 at http://www.hepfi.org/ living/liv_abc.html sHepatitis Foundation International (2003). Caring for your liver: Basic Liver care. Retrieved online Janu- ary 25, 2008 at http:// www.hepfi.org/living/liv_caring.html sIgnatavicius, D., & Workman, M. L. (2006). Medical Surgical Nursing: Critical Thinking for Collabora- tive Care. (5th ed). Elsevier: St. Louis sJohnston, D. (1999). Special Considerations in interpreting liver function tests. American Family Physi- cian. Retrieved online January 27, 2008 at http://www.aafp.org/afp/990415ap/2223.html sKowalak, J. & Hughes, A. (Eds). (2002). Atlas of pathophysiology. Springfield: PA. sLippincott, Williams & Witkins (2007). Professional Guide to Pathophysiology. 2nd ed Wolters: Phila- delphia. sMayoclinic hepatitis C Prevention (2007). Retrieved online January 9, 2008 at http://www.mayoclinic. com/health/hepatitis-c/ DS00097/DSECTION=9 sMayoclinic hepatitis C Risk Factors (2007). Retrieved online January 1 2008 at http://www.mayoclinic. com/health/hepatitis-c/ DS00097/DSECTION=4 sMayoclinic hepatitis C Treatment (2007). Retrieved online January 1,2008 at http://www.mayoclinic. com/health/hepatitis-c/ DS00097/DSECTION=8 sMcCance, K.L., Huether, S.E. (1994). Pathophysiology: The biologic basis for disease in adults and children. 2nd ed. Mosby: Missouri. sMcPhee, Stephen J., & Papadakis, Maxine A., Tierney, Lawrence M., Jr. (2007). Current medical diagno- sis and Treatment: (46th ed.). New York: McGraw-Hill. sNational Digestive Diseases Clearinghouse (November 2006). Chronic hepatitis C: Current Disease Man- agement. Retrieved online January 28, 2008 at http://digestive.niddk.nih.gov/ddiseases/pubs/chronichepc/ sNational Nurses Advisory Council. Liver Wellness: Viral hepatitis. Retrieved online January 26, 2008 at http://www.hepfi.org/ nnac/index.htm#hcv sNetdoctor. (2005) hepatitis C (infectious liver inflammation type C). Retrieved online January 1, 2008 at http://www.netdoctor. co.uk/diseases/facts/hepatitisc.htm sRibavarin & hepatitis C. (2007). Info Sheet 28. Retrieved online January 26, 2008 at http://www.hepqld. asn.au/factsheets/28%20 -%20Ribavarin%20-%20Factsheet.pdf sUniversity of Virginia health system. (2007). Liver, Biliary, & Pancreatic Disorders. Retrieved online January 9, 2008 at http:// www.healthsystem.virginia.edu/UVAHealth/adult_liver/livertrn.cfm sUphold, C., & Graham, M.V. (2003) Clinical Guidelines in Family Practice. (4th ed). Barmarrae: Gainesville. sU.S. Food and Drug Administration: FDA Consumer Magazine. (July-August 2001). Retrieved online January 26, 2008 at http:// www.fda.gov/fdac/features/2001/401_hepc.html sWeb MD: Coping with hepatitis C (2005-2008). ) Retrieved online January 26, 2008 at http://www. webmd.com/hepatitis/hepcguide/hepatitis-c-coping sWikipedia. Hepatitis C. Retrieved online January 4, 2008 at http://en.wikipedia.org/wiki/hepatitis_C sWorld Health Organization. Hepatitis C. (2008). Retrieved online January 1, 2008 at http://www.who.int/ mediacentre/factsheets/ fs164/en/print.html

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Review Questions After reading the course, complete the questions below. Check you answers at the end of this page.

HEPATITIS C

1. The Centers for Disease Control and Prevention (CDC) has recognized that liver disease is the 10th leading cause of death among adults in the United States (U.S.). True False 2. In the U.S., the most common genotype form of hepatitis C is the genotype two. True False

3. It is estimated that the hepatitis C virus causes 10,000 to 12,000 deaths annually in the United States. True False

4. The most common method of transmitting the hepatitis C virus is injecting drugs. True False

5. The first diagnostic test implemented when screening for the hepatitis C virus is RIBA. True False 6. There are two types of interferon that may be prescribed to a patient with the hepatitis C virus. True False

7. Within the United States, there are currently 2,000 individuals on the list for a liver transplant, making it the fourth most transplanted organ. True False

8. After a successful liver transplant, one of the common side effects related to anti-rejection medications is elevated blood pressure. True False 9. Anti-viral agents (e.g., interferon) or immune globulin should not be used for a post-exposure prophylaxis. True False

10. Nurses who injure themselves at work with a needle stick should immediately wash the area with soap and water and inform their supervisor and the employee health nurse. True False

1.T 2.F 3.T 4.T 5.F 6.T 7.F 8.T 9.T 10.T
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