CHAPTER HEPATITIS C (3 CONTACT HOURS) Learning objectives Introduction History Prevalence

Transcription

1 CHAPTER HEPATITIS C (3 CONTACT HOURS) Learnng objectves Descrbe the hstory of the hepatts C vrus. Lst the challenges that researchers have encountered that prevent them from eradcatng the hepatts C vrus worldwde. Descrbe the prevalence of hepatts C worldwde and domestcally. Descrbe the normal functon of the lver. Lst and descrbe the mechansms that the hepatts C vrus uses to slowly and slently destroy the lver. Dstngush the dfference between vral and non-vral forms of hepatts. Identfy and dstngush the dfference between all of the vral forms of hepatts. State the dfference n symptoms that patents may exhbt n acute and chronc hepatts C. Identfy and dscuss the three dfferent dagnostc tests that are mplemented to confrm hepatts C. State the ratonale for dong a lver bopsy on a patent wth hepatts C. Lst the rsk factors that ncrease the lkelhood of contractng the hepatts C vrus. Descrbe the treatment modaltes to control the hepatts C vrus. Identfy and dscuss the educaton nurses can provde patents that are nfected wth the hepatts C vrus. Identfy the expectatons of the nurse who endures a needle-stck njury at work. Descrbe the future of the hepatts C vrus. Introducton Over the past few years, hepatts C has receved a vast array of meda attenton wth the allegatons that rock muscan Tommy Lee and hs ex-wfe, Pamela Anderson, were nfected and lvng wth the hepatts C vrus after sharng a tattoo needle. Therefore, the hepatts C vrus had a new mage wth new faces correlated to the dsease. At that tme, many ndvduals realzed that the hepatts C vrus could happen to anybody, regardless of one s fame, fortune and/or socoeconomc status. Although hepatts C has receved sgnfcant meda attenton related to the rocker and Playboy model contractng the vrus, ndvduals worldwde are stll becomng nfected wth the hepatts C vrus. The hepatts C vrus has been recognzed as a sgnfcant health concern worldwde snce t s the most common chronc blood-borne nfecton. Unfortunately, the problem wth hepatts C s that many ndvduals may not realze they are nfected because they are asymptomatc or have exhbted lmted symptoms. In addton, many patents who have been nfected wth the vrus have sad that shortly after nfecton they thought they had been exposed to the flu because the symptoms are very smlar n nature. Therefore, an ndvdual may unknowngly spread the vrus to others f partcpatng n rsky behavors that nvolve the exchange of blood products, such as ntravenous (IV) drug use, sharng needles or recevng a blood transfuson from an ndvdual who was nfected wth the vrus. As nurses, we care for patents from all walks of lfe; therefore, t s mportant to be attuned to the nature of the hepatts C vrus to prevent other patents and ourselves from unknowngly becomng nfected wth the vrus. The hepatts C vrus s slent n nature. Therefore, t s mperatve for patents to recognze ther potental rsk factors for contractng the vrus, to ensure that they dsclose ther potental rsky behavors to ther health care provders. Falure to properly recognze and treat hepatts C n a tmely manner may exacerbate the dsease process. Patents who are not treated may potentally suffer from lver cancer, lver falure and/or crrhoss of the lver. Of all the lver transplants performed worldwde, the majorty of the transplants go to ndvduals nfected wth the hepatts C vrus [9]. The Centers for Dsease Control and Preventon (CDC) has recognzed that lver dsease s the 10th leadng cause of death among adults n the Unted States (U.S.). The CDC has estmated that percent of chronc lver dsease s related to the hepatts C vrus [9]. In addton, t s mperatve for health care professonals responsble for carng for ndvduals who may nject IV drugs or partcpate n other rsky behavor that nvolves the exchange of blood to properly screen and educate them about the potental rsks assocated wth ther behavor. Furthermore, before a person receves or donates blood, the blood must be properly analyzed to ensure that t does not contan the hepatts C stran. Falure to adhere to the proper screenng can only exacerbate the worldwde problem because hepatts C s already recognzed as the leadng cause of death from lver dsease n the U.S. Hstory The hstory of hepatts C s unque, as ntally t was recognzed as non-a, non-b hepatts (NANBH) for patents exhbtng characterstcs of the nfecton after recevng a blood transfuson. In the md-1970s, the chef of the Infectous Dsease Secton n the Department of Transfuson Medcne at the Natonal Insttute of Health (NIH), Harvey Alter, reported that a patent who receved a blood transfuson dd not have hepatts A or B, but researchers could not dentfy the causatve organsm. For the next decade, the unknown organsm remaned known as NANBH [13]. Researchers were puzzled by the nature of the vrus, especally because there were 242,000 Amercans nfected every year n the 1980s [9]. In the late 1980s, scentsts and researchers fnally dscovered the causatve agent of the NANBH vrus, and the name was offcally changed to the hepatts C vrus [42]. Scentsts dscovered that the causatve agent of the hepatts C vrus was an enveloped, sngle-stranded rbonuclec acd (RNA) vrus [24]. The hepatts C vrus belongs to the flavvrae famly n whch t s not ntegrated nto the host genome [2]. hepatts C vrus. Frst of all, there s more than one genotype, a genetc structure, of the vrus found worldwde. At ths tme, scentsts have acknowledged that there are sx known genotypes and more than 50 subtypes of hepatts C [33]. The numerous genotypes and subtypes of the vrus have mpared researchers tryng to eradcate the dsease process. In the U.S., the most common genotype form of hepatts C s genotype one, whch s composed of 1a and 1b, and accounts for 80 percent of the hepatts C cases n the U.S. [18]. Therefore, n the U.S., the most common genotype for the hepatts C vrus s the frst one. The second challengng component of hepatts C s that only humans and chmpanzees have exhbted the varous hepatts C strans, whch also lmts the ablty of scentsts to properly elaborate on the research of the vrus. In addton, accordng to Bennett, 2007: The prmary mmune response to hepatts C s mounted by cytotoxc T lymphocytes. Unfortunately, ths process fals to eradcate nfecton n most people; n fact, t may contrbute to lver nflammaton and, ultmately, tssue necross. The ablty of hepatts C to escape mmune survellance s the subject of much speculaton. One lkely means of vral persstence reles on the presence of closely related but heterogeneous populatons of vral genomes [2]. Thrd, the majorty of patents, 85 percent ntally nfected wth hepatts C nfectons, wll become chroncally nfected wth the vrus for decades. Unfortunately, the prolonged nfecton leads to severe lver damage because patents are usually unaware that they have the vrus and that t s attackng ther lver daly. The other 15 percent of ndvduals have an acute nfecton of the vrus, whch usually resolves spontaneously after a few weeks or months of exposure to the vrus [18]. Due to the complexty of the structure and hstory of the vrus, t perplexes the overall ablty of scentsts to eradcate t worldwde. Another problem wth hepatts C s that the vrus replcates and mutates throughout the body at massve rates. Therefore, t prevents mmunty as t develops resstant strans of the vrus to the exstng antbodes [14]. Unfortunately, ths replcaton and mutaton process can further exacerbate the complcatons of lver dsease. Prevalence As mpled, hepatts C s an enormous concern for health care professonals natonwde who care for patents who engage n rsky behavors that nvolve the exchange of bodly fluds. At ths tme, accordng to the World Health Organzaton (WHO), an estmated 170 mllon (3 percent) people are chroncally nfected wth hepatts C, and 3 mllon to 4 mllon become nfected every year [42]. Of the ndvduals affected, t s estmated that the hepatts C vrus causes 10,000 to 12,000 deaths annually n the Unted States [33]. Although the prevalence of the hepatts C nfecton vares worldwde, the hghest numbers There are a few challengng components of the of nfectons are reported n Afrca at a rate of Elte Page 1

2 5.3 percent [42]. Although the numbers appear alarmng, the number of ndvduals nfected n the U.S. has decreased over the past decade. The Centers for Dsease and Preventon (CDC) has estmated the followng data [9]: Durng the 1980s, 242,000 Amercans were annually affected by the NANBH. Snce the dscovery of hepatts C, the annual number of nfectons has declned by more than 80 percent to approxmately 41,000 by In addton, accordng to a natonal survey, the Natonal Health and Nutrton Examnaton (NHANES III) of the cvlan, nonndustralzed U.S populaton found that 1.8 percent of Amercans (3.9 mllon) have been nfected wth HCV, of whom 2.7 mllon are chroncally nfected wth the hepatts C vrus. See Table below: Prevalence of HCV nfecton by age and gender, Unted States HCV_nfecton.htm In the lterature of the CDC, t has been noted and speculated that although the WHO and CDC have provded estmated fgures correlatng the patents nfected wth the hepatts C nfecton, the numbers could be potentally skewed. That s because the majorty of the data that has been retreved s from patents who have not been ncarcerated or homeless on the streets. Therefore, t s lkely that there are more ndvduals undagnosed wth the hepatts C who may currently be ncarcerated and/or homeless because the majorty of them do not seek health care. Unfortunately, ndvduals who are ncarcerated then released nto socety or who are homeless may unknowngly spread the vrus wth the exchange of rsky behavor. Pathophysology of the lver and mpact on the hepatts C vrus The defnton of hepatts s an nflammaton of the lver. Therefore, when cells wthn the lver are nflamed, a patent s dagnosed wth hepatts. Under normal crcumstances, the lver s the largest and most massve nternal organ n the body, weghng approxmately klograms ( pounds) [13]. In the grand scheme of thngs, the lver s mass comprses 1/40th to 1/50th of a total adult body s weght and 1/18th of the body s weght durng nfancy [41]. The lver plays an mportant role n producng and secretng ble, recevng nutrents and syntheszng the nutrents nto forms that can be absorbed nto the body s cells [31]. To mantan the demands of ts many roles wthn the human body, the lver requres a large amount of blood. Page 2 The lver receves blood from the arteral and venous systems. The hepatc artery branches from the abdomnal aorta and provdes oxygenated blood at the rate of 400 to 500 mlllters a mnute, whch s about 25 percent of the cardac output. The hepatc portal ven receves deoxygenated blood from the nferor and superor mesenterc vens and the splenc ven at a rate of 1,000 to 1,200 mlllters a mnute. The portal venous blood consttutes 70 percent of the blood supply to the lver [31]. It s astonshng to understand the mportant role of the lver on a daly bass. In essence, the lver plays an mportant role n metabolsm and sustanng lfe wthn the body. For the lver to contnue to functon normally to sustan lfe, ndvduals must take care of ther lver by avodng toxns and other culprts, such as the hepatts C vrus that nduces an nflammatory state wthn the lver. Once the hepatts C vrus enters the body, the vrus nduces hepatocyte njury and death ether by drectly kllng the cells or by actvatng the nflammatory and mmune reacton [27]. Over tme, f the lver becomes nflamed t can obstruct and damage the ble, leadng to cholestass and obstructve jaundce [31]. Cholestass, reduced ble flow, occurs because the gallbladder s located on the nferor surface of the lver and t stores and concentrates the ble from the lver between meals. If the lver becomes nflamed, the flow of ble s altered or ceased. If the ble s stopped, the pgment blrubn, a waste product that s formed when old or damaged red blood cells are broken down and escape nto the bloodstream, then accumulate n massve numbers [10]. In addton, f the nflammatory process s not reversed or treated, lver falure wll occur, leadng to the followng devastatng problems [31]: Intestnal bleedng because the vast amount of blood crculatng causes the lver to become obstructed and swollen. Capllares can eventually collapse, decreasng the blood flow to the lver, and hypoxa of the tssue and scarrng wll develop [26]. Cardorespratory nsuffcency. Renal falure, such as glomerulonephrts [33]. The cardorespratory and renal falure typcally occur together as they are the result of decreased blood flow and organ falure. Types of hepatts It s mportant to understand that there are other types of hepatts. In addton, n order to properly understand the dsease process of the hepatts C vrus, one must understand that the symptoms of all forms of hepatts may be smlar. As health care professonals carng for a patent wth hepatts, f we understand the dfferences of hepatts, we can properly screen for hepatts based on the potental causes and rsk factors people engage n. The two major categores and orgn of hepatts are related to a vral or non-vral processes: 1. Non-vral Non-vral hepatts causes an nflammatory process n the lver, typcally as a result from an exposure to certan chemcals and drugs. The major culprts contrbutng to non-vral hepatts are consumpton of an abundance of alcohol or medcatons such as acetamnophen (Tylenol); both can damage the lver. In addton, there are chemcals n the fumes of pants and bug sprays that may potentate a non-vral hepatts. Other sources of nonvral hepatts nclude bacteral abscesses, Lyme dsease and syphls [14]. The majorty of patents usually recover from non-vral hepatts; however, a small percentage do go on to develop fulmnatng hepatts, hepatc falure or crrhoss of the lver. Fulmnatng hepatts s a syndrome that results from necross of the lver cells and lver falure [31]. 2. Vral Vral hepatts s the common systemc nfecton or dsease process that results n the hepatc cell destructon, autolyss and necross. In the majorty of patents, the hepatc cells wll eventually regenerate wth very lttle to no resdual damage at all. Nonetheless, f old age and a serous underlyng dsorder are factors, complcatons from vral hepatts therefore become almost certan. The prognoss for vral hepatts then becomes poor f edema and hepatc encephalopathy occur [26]. Accordng to the majorty of data, there are fve major types of vral hepatts. It s mperatve for health care professonals to recognze the dfferent types of vral types of hepatts as they may concde wth partcular behavors and lfestyles that may put an ndvdual at rsk for contractng a partcular vrus. The fve major types of hepatts are as follows: [26]. Type A, hepatts A (HAV) s nfectous or short-ncubaton hepatts. It s contracted through the fecal, oral route n contamnated water, food or undercooked shellfsh. The vrus can also be transmtted by nfected blood. The majorty of patents, 45 percent n urban areas, have the hepatts A antbodes n ther bloodstream [31]. In order to prevent the spread of hepatts A, patents need to avod unsantary condtons wthn the food and water chan systems. Another potental method of transmsson occurs at day care centers for chldren where workers fal to wash ther hands approprately between each daper change. The ncubaton perod for hepatts A s four to sx weeks; however, a person s most contagous durng the fecal sheddng, whch s at ts peak for 10 to 14 days before the onset of symptoms [31]. Fortunately, a vaccnaton for hepatts A s avalable. The CDC (2008) recommends all chldren obtan the hepatts A vaccnaton at a mnmum of 12 months, followed by a second sx months later [4]. The CDC recommends adults wth chronc lver dsease, those who travel to hgh-rsk countres, and men who have sex wth men receve the vaccnaton n a two-shot seres, wth the second admnstraton sx to 12 months after the frst. [4]. Elte

3 Type B, hepatts B (HBV) s a serum or long-ncubaton hepatts. Hepatts B s contracted wth nfected blood, bodly fluds and/or contamnated needles. Hepatts B s consdered a sexually transmtted nfecton (STI) because t s transmtted n blood and bodly fluds. Unfortunately, the vrus s usually found among people who are also postve for the human mmunodefcency vrus (HIV). Mandatory screenng of blood donors has greatly reduced the ncdence of post-transfuson hepatts B cases. However, transmsson contnues to be a major problem among drug abusers who share needles. Another potental rsk of transmsson s mother to nfant transmsson. However, over the past few years, women who seek prenatal care are properly screened pror to delvery. In addton, f a woman who dd not receve prenatal care or was not screened enters a faclty to delver, she s screened pror to the delvery. If a woman tests postve and/or s n the three-month wndow of potental nfecton, the nfant wll receve the hepatts B vaccnaton and ntravenous mmunoglobuln (IVIG) to prevent the chld from contractng the hepatts B vrus. In addton, all ndvduals, especally those who have rsky occupatons such as nurses are requred to obtan the three-shot hepatts B seres. It s mperatve for nfants to be treated approprately, because the CDC has estmated that approxmately 90 percent of babes who contract the hepatts B vrus nfecton wll become chronc carrers, and of those, 25 percent wll de of lver cancer or crrhoss [8]. Therefore, f the nfant has no rsk factors he or she wll receve the hepatts B vaccnaton at brth or 1 month, then the second n two months, and the thrd dose no earler than 24 weeks, wth an average admnstraton at 6 months [4]. The CDC recommends that adults receve the frst vaccnaton at any tme, then the second one to two months later and the thrd vaccnaton sx months after the frst [4]. Type E was formerly grouped wth the hepatts types C and D under the name non-a. Non-B hepatts s mostly common n young adults and s more severe n pregnant women. Hepatts E s not prevalent n the U.S. and s more common n developng, endemc countres as t s transmtted va the fecal-oral route. It clncally resembles hepatts A because they are both transmtted va the fecal-oral route. Accordng to the Clncal Gudelnes n Famly Practce, there s another form of vral hepatts: hepatts G. Hepatts G s found n 1.5 percent of all blood donors among chldren and adults [38]. The nfecton has been reported n up to 20 percent of adults wth chronc hepatts B and/or hepatts C; therefore, a co-nfecton can exst as both of the vruses can be transmtted by blood and bodly products [6]. The unque component of hepatts G s that the symptoms are extremely mld and there s no treatment for the vral nfecton. In addton, there s no serologcal testng avalable to assst n the dagnoss process [38]. At ths tme, only hepatts A and B have a vaccnaton to prevent and/or reduce the rsk of nfecton. Fortunately, all chldren who have wellbaby physcals wll receve the vaccnatons to prevent the transmsson f ther parents comply. Rsk factors for contractng the hepatts C vrus The prmary mode of transmsson for hepatts C s through njecton drug use or a blood transfuson. However, n some cases, there appears to be no known exposure to rsk factors for patents who have tested postve for the hepatts C vrus. There s speculaton that these may be ndvduals who have not dsclosed ther lfestyle and rsky behavors. The Natonal Dgestve Dseases Informaton Clearnghouse (NDDIC) n 2006 recognzed that the followng ndvduals are at the hghest rsk of contractng the vrus [33]. Men. Alcoholcs. relable test two years later. The adjustment n the testng proved to be worthwhle as the ncdence of contractng the hepatts C vrus fell to a 1 n 100,000 unts of a chance [17]. Today, the testng has become so accurate that the rsk of nfecton has decreased to about 1 ncdent per 2 mllon unts. [32]. In addton, before ndvduals donate blood at any bankng center, they are asked a seres of questons to rule out the rsk that ther blood s contamnated. Donors who are found to be any of the followng are prohbted from donatng blood and wll be entered nto the blood bank regstry as a deferral regstry that s vewed natonwde at any blood center [1]: Anyone who has ever used llegal ntravenous drugs (llegal IV drugs). Men who have had sexual contact wth other men snce Anyone who has ever receved clottng factor concentrates. Anyone wth a postve test for the HIV/AIDS vrus. Men and women who have engaged n sex for money or drugs snce Anyone who has had hepatts snce hs or her 11th brthday. Anyone who has had babesoss or Chagas dsease. Type C, hepatts C (HCV) encompasses 20 Patents wth crrhoss. percent of vral hepatts cases, ncludng the People over the age of 40 years old. majorty of post-transfuson cases. Ths vrus Untl 1990, ndvduals who receved blood s elaborated on throughout ths course. transfusons were the man rsk-factor group who Type D or delta hepatts (HDV) can acqured the hepatts C nfecton. At that tme, be responsble for up to 50 percent of all there were nadequate and unrelable screenng fulmnant hepatts cases, whch have a very methods to properly recognze and dagnose the hgh mortalty rate. In addton, delta hepatts hepatts C vrus, and many people unknowngly s found n up to 1 percent of vral cases. The became nfected wth the vrus. It was not untl People are at greater rsk of contractng unque component about hepatts D s that t the md- to late 1980s that the CDC mplemented hepatts C f they had a blood transfuson occurs n ndvduals nfected wth hepatts B. blood donor screenng to assess for HIV and pror to Although one potentally could Therefore, a patent cannot become nfected hepatts C (NANBH) antbodes before any blood be nfected wth the hepatts C vrus after a wth hepatts D unless he/she has hepatts B. transfuson. At that tme, the CDC speculated that blood transfuson today, the rsk has declned The ratonale s that the delta vrus depends the rsk for becomng nfected wth hepatts C sgnfcantly. If an ndvdual contracts the upon the hepatts B vrus to replcate [31]. was about 1 n 200 unts of blood. hepatts C vrus after a blood transfuson In essence, a person s at rsk of contractng In May 1990, the Food and Drug Admnstraton today, the nfected patent wll have detectable HDV f he/she s exposed to blood, bodly (FDA) approved and lcensed an enzyme antbodes wthn 12 weeks after the blood fluds and/or contamnated needles, smlar to mmunoassay (EIA) test for hepatts C. The transfuson [38]. HBV. Wthn the U.S., type D typcally occurs EIA test dentfes the presence of the hepatts Any ndvdual who has a past or current n people who frequently are exposed to blood C antbodes n the blood. Unfortunately, the hstory of expermentng wth IV drugs or along wth blood products, such as hemophla EIA had a very hgh ncdence of false postves, ntranasal cocane can become nfected wth patents and IV drug users. forcng an adjustment to a more senstve and the vrus. At ths tme, ndvduals who nject Elte Page 3 Anyone who has taken Tegson for psorass. Anyone who has rsk factors for Crueutzfeldt- Jakob dsease (CJD) or who has an mmedate famly member wth CJD. Anyone who has rsk factors for varant CJD. Anyone who spent three months or more n the Unted Kngdom from 1980 through Anyone who has spent fve years n Europe from 1980 to the present. All of the research and data s congruent on the most common rsk factors for contractng the hepatts C vrus. In addton, see table for a dagram elctng the most common rsk factors for contractng the hepatts C vrus.

4 drugs are the largest source of patents who are becomng nfected wth the hepatts C vrus, at an estmated 60 percent. There has been no correlaton to the tme frame n partcpatng n ths rsky behavor because t only takes one tme to nject nfected blood nto a ven, whch can have a deadly consequence. It has been speculated that over 50 percent of cases are transmtted by IV drug use [32]. Any ndvdual who has receved any organ n whch the donor had hepatts C nfecton. Although ths may have occurred more frequently pror to the 1990s, the rsk has reduced dramatcally wth the knowledge and approprate screenng pror to a transplant. However, there s always a wndow of opportunty, an average of three months, n whch an ndvdual may have become unknowngly nfected. In hosptals an outpatent facltes, t s possble for patents to contract a nosocomal nfecton. Varous facltes natonwde have documented patent-to-patent converson of hepatts C by colonoscopy, hemodalyss and n surgery [38]. Any health care professonal who has been exposed to unsterle equpment or prcked wth a needle that has nfected blood may become nfected wth hepatts C. Ths can occur durng an njecton or whle performng a procedure on a patent who has the vrus. Therefore, as nurses we need to utlze unversal precautons at all tmes to reduce the rsk of transmsson. It has been estmated that wth needle stck njures, a nurse s rsk s [38]: Hepatts B s transmtted n 30 percent of exposures. Hepatts C s transmtted n 3 percent of exposures. HIV s transmtted n 0.3 percent of exposures. Any ndvdual who has used unsterle equpment or attended a ste that s not adherng to FDA gudelnes for body percng, tattoong, mancures/pedcures and/or acupuncture. Any ndvdual who uses an nfected person s toothbrush, razor or anythng else that may have blood on t. Therefore, patents should be dscouraged from sharng any supples that could have a droplet of blood on them. Any ndvdual who receved a clottng factor concentrate (such as ant-hemophlc factor), a blood plasma derved product, before 1987 when effectve means to screen for hepatts C were not avalable may be at rsk for contractng the hepatts C vrus. The CDC has noted that except for one outbreak of the hepatts C vrus from a sngle type of contamnated ntravenous mmunoglobuln, other plasma-derved products, ncludng mmune globuln for ntramuscular (IM) njecton, have not been assocated wth the transmsson of hepatts C n the U.S. [9]. Page 4 An nfant born to a woman nfected wth the hepatts C nfecton. Researchers have speculated that maternal-fetal transmsson s rare, and s usually assocated wth a co-nfecton of HIV [38]. However, t s mportant to recognze that the potental rsk s apparent. There has been no conclusve evdence whatsoever that hepatts C can be spread va breast-feedng [4]. At one tme, t was speculated that hepatts C mght be transmtted durng sexual actvty, but there have been numerous studes conducted on ths potental rsk factor, and even spouses of patents wth hepatts C have a less than 5 percent chance of beng nfected wth the vrus. In addton, researchers have noted that the majorty of tme when hepatts C does occur between ntmate partners, t s more common n countres where hepatts C s common n the general populaton. In contrast, the CDC (2006) has contrbuted sexual exposures wth an alarmng 15 percent of all of the hepatts C cases. However, the CDC reterates that the rsk s low for transmttng the hepatts C vrus through sexual ntercourse, but t s exacerbated n adults who have unprotected sex wth multple partners [9]. Some researchers have speculated that ndvduals wth HIV nfecton appear to be at a hgher rsk of co-nfecton wth the hepatts C [38]. The CDC has contrbuted hemodalyss, employment n the health care feld and brth to a hepatts C-nfected mother n combnaton for 5 percent of the total cases [9]. In addton, the source of nfecton typcally cannot be postvely dentfed n 10 percent of acute hepatts C cases and about 30 percent of chronc cases. The Natonal Insttute of Dabetes and Dgestve and Kdney Dseases (NDDIC) states that these random nfectons are most lkely caused as the result of someone comng n contact wth blood or body fluds from an nfected person through an open sore, cut or medcal njecton. Another varable for health care provders to contemplate s the noton that a few ndvduals who have become nfected wth the vrus are reluctant to seek care, as they may have to acknowledge that they have a past drug abuse and addcton cycle. The consensus among the majorty of experts s that acqurng hepatts C from an nfected ndvdual through casual contact such as shakng hands, kssng, huggng or sharng eatng utensls s not feasble [17]. Clncal presentaton of hepatts Unfortunately, over 80 percent of people wth hepatts C do not exhbt any symptoms ntally n the nfectous process. Symptoms that do appear may be so mld and vague that the nfected ndvdual may not notce them or may attrbute to other causatve factors. Unfortunately, the ndvdual who self-dagnoses may not seek medcal care because he/she does not perceve the symptoms to be severe. Another alarmng factor s that a person may not exhbt symptoms untl years after the ntal nfecton. Unfortunately, after ths prolonged tme, there wll have been a vast array of chronc and usually rreversble damage to the lver and body. On a postve note, the small percentage of ndvduals who experence some form of symptoms n the early acute phase wll notce symptoms approxmately 5-12 weeks after the ntal exposure. The majorty of nfected ndvduals who have exhbted symptoms have descrbed the symptoms as a flu-lke llness wth duratons that last approxmately a few weeks to several months. There are numerous symptoms that are assocated wth hepatts C vrus and a few that tend to be more common than others [15]. In addton, the majorty of practtoners dstngush hepatts as ether acute or chronc. Symptoms of acute vral hepatts In general, the symptoms for acute vral hepatts may begn abruptly or could very well develop over a long perod of tme. As prevously mentoned, ndvduals may mstake the nfecton of hepatts C for the flu, as more often than not the symptoms are mld. An ndvdual who s experencng flulke symptoms most often complan of fever, chlls, headache, fatgue and muscle aches. In addton to flu-lke symptoms, some patents experence gastrontestnal problems that may be exacerbated wth symptoms of nausea and vomtng. In addton, there usually s a general feelng of dscomfort, whch radates from the upper rght porton of the abdomen and feels lke a sharp pan that ntensfes wth rough, purposeful movements. The uncomfortable pan may lead someone to lose hs or her appette, lose weght, or even develop dehydraton due to the nausea and vomtng. A few patents may develop jaundce, whch s yellowng of the skn and the whtes of the eyes, and dark urne. Chldren however, typcally do not develop jaundce. Ffty percent of all patents wll experence mld tchng, rrtablty, muscle pan, drowsness and lght colored stools. In a quarter of patents, jont aches accompaned by darrhea are experenced, whle 10 percent experence an enlarged spleen [19]. The most common symptoms assocated wth the acute phase of the hepatts C vrus are: Nausea. Vomtng. Darrhea. Loss of appette. Fatgue. Pan over the lver (on the rght sde of the abdomen, just under the rb cage). Jaundce A condton n whch the skn and the whtes of the eyes turn yellow. Dark-colored urne (may look lke cola or tea). Stools become pale n color (graysh or clay colored) [15]. Although the ntal symptoms may be mld wth nausea and vomtng and/or the flu, mportant ones are pan n the lver, jaundce and change n the urne and/or stool. As a practtoner, t s mportant to recognze these Elte

5 symptoms n combnaton wth the lfestyle and/or rsk factors that may put the patent at rsk for becomng nfected wth the hepatts C vrus. Because of the vague symptoms, many patents do not seek the care of ther prmary health care provder. But f a patent presents wth symptoms related to acute hepatts C or for another reason, hs or her health care provder could notce durng a normal exam a mld enlargement of the lver or tenderness. In a few cases, patents may have spder vens or palmar erythema noted durng the physcal exam [33]. If the ndvdual has prolonged nausea and vomtng, dehydraton may be a serous rsk, dependng on age and other medcal condtons. In order to assess the patent for dehydraton, the followng symptoms may be noted: Fatgue or weakness. Confuson or dffculty concentratng. Headache. Anura (not urnatng). Irrtablty [15]. Symptoms of chronc hepatts It s mperatve to deally screen and dagnose a patent n the acute phase of hepatts to prevent chronc nfecton. Seventy to 90 percent of ndvduals who have been nfected wth the vrus develop chronc hepatts [14]. In the ndvduals who develop chronc hepatts, 20 percent of them progress to chronc lver dsease, lver falure or hepatocellular carcnoma [14]. Smlar to the hepatts B vrus, hepatts C s able to progress to chronc hepatts wth lttle to no early acute symptoms at all. Symptoms that orgnate from the progressve chronc vral hepatts usually are very mld for a length of tme not to exceed sx months. On the other hand, chronc hepatts C may be present wthout any sgn of nfecton for as long as 20 years. For a few nfected ndvduals, tchy skn may be the frst ndcaton, whle others may experence pan n the jonts, whch s often mstaken for rheumatod arthrts, fbromyalga or carpal tunnel syndrome. Others wth hepatts B or C may experence long-term dsablty or even lver falure long before they ever experence any symptoms at all [19]. Symptoms assocated wth crrhoss: Asctes (flud retenton causng swellng of the belly, legs or whole body). Persstent jaundce. Fatgue. Dsturbances n sleep. Purts (tchy skn). Loss of appette, weght loss. Muscle wastng. Hemoptyss (vomtng or coughng blood). Mental dsturbances such as confuson, lethargy, extreme sleepness or hallucnatons (hepatc encephalopathy) [15]. In addton, hepatomegaly s present n 50 percent of all patents wth vral hepatts and splenomegaly s seen n 15 percent of cases [14]. Patents may also exhbt lymphadenopathy. Of all the vral types of hepatts, hepatts C s often the most asymptomatc [14]. Accordng to the Natonal Insttute of Dabetes and Dgestve and Kdney Dseases (NDDIC) (2006), 1 to 2 percent of patents wth hepatts C may have addtonal chronc complcatons that do not drectly nvolve the lver. The most common s cryoglobulnema, a sngle or mxed mmunoglobuln, whch s noted n the patent who exhbts the followng symptoms [33]: Skn rashes, such as purpura, vascults or urtcara (hves/tchng). Jont and muscle aches. Kdney dsease. Neuropathy. Cryoglobulns, rheumatod factor and lowcomplement levels n serum. Dagnosng hepatts C If a patent presents wth symptoms and/or has a hstory concdng wth a speculated dagnoss of hepatts C or any form of hepatts, the health care provder wll need to dentfy the serologc type. Based upon the serologc type, the practtoner can determne the approprate treatment. See table below for the dagnostc algorthm for the hepatts C vrus: Sources of nfecton for persons wth hepatts C A complcaton of chronc hepatts s crrhoss of the lver. Crrhoss of the lver occurs n approxmately percent of patents wth the chronc form of hepatts [38]. Crrhoss usually comes about as a result of alcoholsm, abuse of Tylenol and complcatons of hepatts C vrus. If an ndvdual has crrhoss, * Hemodalyss; health-care work; pernatal the lver s no longer able to functon properly because healthy lver tssue s replaced wth The dagnoss of hepatts C s based on the fbrous tssue. The fbrous tssue eventually followng tests: hardens and turns nto scar tssue. Once ths The frst test s to mplement the enzyme process occurs, the lver begns to fal, as t mmunoassay (EIA) to detect the anthepatts s ncapable of performng all of the normal C antbodes [14]. Although there functons. Inevtably, symptoms wll appear, are lmtatons to the testng based upon the and at ths stage there wll be no mstake that senstvty of the test, t can typcally detect somethng s serously wrong [15]. the antbodes wthn four to 10 weeks after Elte Page 5 nfecton [38]. Ideally, a test should have a hgh senstvty to ensure that t properly dentfes people wth the dsease. The danger of low senstvty s that ndvduals who truly are nfected may have a false negatve result. Prevously, the specfcty was so low that 50 percent of all healthy blood donors and some patents wth elevated gammaglobuln levels demonstrated false negatves [14]. Unfortunately, that may have prevously msled ndvduals who were truly nfected, thus exacerbatng a potentally bgger problem that the ndvdual could pass t on to somebody else. Fortunately, the EIA has greatly mproved the senstvty over the past few years [38]. At ths tme there are three versons of t: the EIA I, EIAII and EIA III [12]. The preferred method s for practtoners to utlze the EIA II or EIA III because they both have excellent senstvty and specfcty, wth a lower cost [12]. Hepatts C can usually be detected at four to sx weeks after exposure; however, f the patent s at rsk and tests negatve at sx weeks, repeat the test [12]. The second test that s completed s the recombnant mmunoblot assay (RIBA). All postve antbodes detected by the enzyme mmunoassay wll be confrmed wth the RIBA [38]. The RIBA test s smlar to a western blot. The RIBA works n the followng manner [33]: The serum s ncubated on ntrocellulose strps on whch four recombnant vral protens are blotted. The color changes ndcate that antbodes are adherng to the protens. The results are as follows: The mmunoblot test s consdered postve f two or more of the protens react. If the mmunoblot test for ant- HCV s postve, the patent has most lkely recovered from hepatts C and has a persstent antbody. The mmunoblot test s consdered ndetermnate f only one postve band s detected. If the mmunoblot test s negatve, the EIA result was probably a false postve. A thrd test that may be completed s the polymerase chan reacton (PCR) to detect the hepatts C rbonuclec acd (RNA). The RNA test s an excellent test; however, t s very expensve. Therefore, the majorty of the tme the two prevously mentoned lab tests are completed. The RNA test s mplemented once the dagnoss and/or results of the ant-hcv antbody test are completed and/or under the followng crcumstances [38]: In patents wth negatve results on the enzyme mmunoassay n whom acute nfecton s suspected. In patents who have hepatts wth no dentfable cause. In patents wth known reasons for false negatve results on antbody testng. For the confrmaton of the vrema and the assessment of treatment response. Vrema s the presence of the vrus n the

6 blood stream. It s mportant snce three out of four seropostve patents wth hepatts C also have vrema. In addton to any of the confrmatory dagnostc tests, all patents at rsk and/or whom test postve for the hepatts C antbodes wll have the followng lab tests completed [14]: Lver functon tests (LFTS) to assess for any lver njury. The amnotransferases are the hallmark of all forms of hepatts. There are two man components of amnotransferases that are ncluded n the lver functon test [25]: Alanne amnotransferase (ALT); formerly serum glutamate pyruvate transamnase [SGPT]). Aspartate amnotransferase (AST); formerly serum glutamc-oxaloacetc transamnase [SGOT]. Typcally, as a rule of thumb, the ALT s severely elevated early n the phase wth the ALT levels often rsng to several thousand unts per lter n patents wth acute vral hepatts. The hghest ALT levels often more than 10,000 U per L are usually found n patents wth acute toxc njury subsequent to, for example, acetamnophen overdose or acute schemc nsult to the lver [25]. The levels of AST and ALT are usually reversed n crrhoss of the lver; AST s hgher than the ALT [33]. Lactate dehydrogenase (LDH) s less specfc than AST and ALT as a marker of hepatocyte njury [25]. Blrubn and the alkalne phosphates are usually elevated and may reman elevated throughout the nfecton [12]. In severe lver damage and/or crrhoss, the responsble physcan and/or nurse practtoner (ARNP) may notce the followng dagnostc lab values [33]: AST s hgher than the ALT. Alkalne phosphates and gamma glutyamyl transpeptdase are elevated. However, n the acute phase of hepatts C, they are usually normal. Low platelet and low whte blood cells (WBC) and hgh serum globulns (such as the mmunoglobulns and rheumatc factor ndcatng severe fbross and/or crrhoss. Albumn, blrubn and prothrombn tme (PT) are normal untl the end stage of lver damage. Another mportant dagnostc tool to complete s a blood test to assess for the specfc genotype of the hepatts C vrus. The genotype s helpful n defnng the epdemology of the hepatts C vrus and more mportantly, t s helpful n makng treatment recommendatons, whch wll be dscussed n further detal below. Once the genotype s dentfed, t does not need to be tested agan, as the genotypes do not change durng the course of nfecton [33]. In addton, f a patent tests postve for the genotype two or three, a lver bopsy s not requred because the treatment plan has a hgh sustaned vral response rate (SVR) to the medcatons prescrbed [14]. Page 6 Lver bopsy A controversal test that may be completed s a lver bopsy. Many physcans beleve that t s not necessary for dagnoss; however, t facltates the ablty to grade the severty of the dsease and stage the degree of the fbross and permanent archtectural damage [33]. In addton, f a patent has the genotype 1a, 1b, or 4, a lver bopsy may be recommended snce the SVR s not as good n preventng a relapse [14]. Therefore, f a lver bopsy s completed, the practtoner wll understand the extent of lver damage to provde better treatment opportuntes for the patent. The hepatts C vrus elcts the followng changes n the tssue of the lver [33]: Necross and nflammaton at the edge of the portal areas, so-called pecemeal necross or nterface hepatts. Necross of hepatocytes and focal nflammaton n the lver parenchyma. Inflammatory cells n the portal areas ( portal nflammaton ). Fbross may exst n an early stage of the hepatts C vrus nfecton; however, t s usually confned to the portal tracts, an ntermedate stage consstng of expanson of the portal tracts and brdgng between portal areas or to the central area. In the late stage of frank crrhoss, there s an archtectural dsrupton of the lver wth fbross and regeneraton. There are numerous scales utlzed to stage the degree of fbross, however, the most common s the followng: One common classfcaton s a scale from 0 to 4 where stage 0 ndcates no fbross; stage 1 ndcates enlargement of the portal areas by fbross; stage 2 ndcates fbross extendng out from the portal areas wth rare brdges between portal areas; stage 3 ndcates many brdges of fbross that lnk up portal and central areas of the lver; and stage 4 ndcates crrhoss. Although there are numerous tests to confrm the dagnoss and to assess the degree of the damage to the lver, t s mperatve to ensure the proper treatment plan s ntated for each patent. Due to the complexty of the dsease process, the multple array of varables and the lmted symptoms a patent may exhbt over the course of the nfecton, the frst key s confrmng the dagnoss of the ant-hepatts C antbodes. Once the vrus has been confrmed wth the EIA and RIBA, then the addtonal testng s mplemented to provde a dagnostc analyss of the degree, severty and epdemology of the hepatts C vrus. Treatment of hepatts C Due to the dffcult nature of hepatts C vrus, early treatment doesn t happen because the majorty of patents do not exhbt any symptoms. In addton, at ths tme there s no cure and/or vaccnaton avalable for the hepatts C vrus. Therefore, the treatment modaltes are geared toward controllng the symptoms, dependng upon the severty of the dsease process and/or lfestyle that the patent s currently lvng. For nstance, a patent who contnues to engage n rsky behavors wll only exacerbate the symptoms and the severty of the dsease process. When the patent s dagnosed and the manner n whch the lver has been affected wll determne the treatment modalty and potental outcome for the ndvdual. There are multple varables to consder n treatng hepatts C that are dependent upon the phase of the vrus, damage and genotype of the vrus. See table for the treatment algorthm. Algorthm for treatment Make the dagnoss based on amnotransferase elevatons, ant-hcv and HCV RNA n serum. Assess for sutablty of therapy and contrandcatons. Dscuss sde effects and the lkelhood of a benefcal treatment outcome. Test for HCV genotype. Consder dong a lver bopsy to assess the severty of the underlyng hepatts and need for current therapy. Genotype 1: Test for HCV RNA level mmedately before startng therapy (baselne level). Genotype 1: Start therapy wth pegnterferon alfa-2a n a dose of 180 mcg weekly or pegnterferon alfa-2b n a dose of 1.5 mcg per kg weekly n combnaton wth oral rbavrn n two dvded doses of 1,000 mg daly f body weght s < 75 kg (165 lbs) or 1,200 mg daly f > 75 kg. Genotype 2 or 3: Start therapy wth pegnterferon alfa-2a n a dose of 180 mcg weekly or wth alfa-2b n a dose of 1.5 mcg per kg weekly and oral rbavrn 800 mg daly n two dvded doses. All patents: At weeks 1, 2 and 4 and then at ntervals of every 4 to 8 weeks thereafter, assess sde effects, symptoms, blood counts and amnotransferase levels. Genotype 1: At week 12, retest for HCV RNA level. If HCV RNA s negatve or has decreased by at least two log 10 unts (such as from 2 mllon IU to 20,000 IU or from 500,000 IU to 5,000 IU or less), contnue therapy for a full 48 weeks, montorng symptoms, blood counts, and ALT at 4- to 8-week ntervals. If HCV RNA has not fallen by two log 10 unts, stop therapy. Genotype 2 or 3: At 24 weeks, assess amnotransferase levels and HCV RNA and stop therapy. All patents: After therapy, assess amnotransferase levels at 2- to 6-month ntervals. In responders, repeat HCV RNA testng 6 months after stoppng. Accordng to the CDC and the Natonal Insttutes of Health (NIH), treatment of hepatts C s recommended f any of the followng condtons Elte

7 are present snce they are at the greatest rsk of developng crrhoss [30]: A postve test result ndcatng the hepatts C antbodes by the EIA or RIBA. A confrmatory postve test for hepatts C-RNA. Many physcans wll treat wthout the RNA due to the expense and relablty of the EIA and RIBA. A lver bopsy f deemed necessary based on the genotype, whch may ndcate sgnfcant lver damage. Elevated levels of ALT n the blood. Once the patent has exemplfed any of the dagnostc measures ndcatng that hepatts C vrus s present n ther body, treatment s ntated mmedately. The nurse carng for the patent wth hepatts C should not stereotype or judge the patent regardless of the patent s personal lfestyle choces. One of the most mportant thngs nurses can demonstrate s compasson and support to the patent. Throughout a nurse s career, regardless of the area or specalty, a nurse wll be responsble for the well-beng of a patent wth hepatts C. In addton to the compasson and support provded to the patent n a non-judgmental demeanor, nurses should provde educaton to ther patents to prevent further lver damage. All patents should adhere to the followng recommendatons regardless of the genotype, extent of the vrus and the lfestyle of the patent [27]: Rest to mnmze the energy demands of the body, especally durng the acute phase. Therefore, the patent should avod any strenuous exercse. Detary management should nclude hgh calorc foods n small, frequent portons throughout the day to prevent anorexa and muscle wastng. It s mportant to encourage patents not to overndulge themselves durng meals. In addton, patents wth crrhoss of the lver should avod salt and hgh proten n ther det. Encourage patents to drnk at least 135 ounces of flud a day to prevent dehydraton. If the patent s experencng extreme nausea and vomtng, he/she may need to be hosptalzed to replace the flud loss. In addton, the nurse can offer and recommend ce chps to mantan hydraton wthout nducng vomtng. Avod all alcohol and any hepatotoxc medcatons, such as Tylenol or any component of Tylenol. Another medcaton to avod s morphne sulphate. Dong otherwse can greatly ncrease one s chances of developng crrhoss and lver falure. Avod llegal drug use. Do not share needles or other drug paraphernala. Avod body percng and tattoong. People who do undergo percng or tattoong should be absolutely certan the equpment s sterle. specfc vruses before potental transmsson occurs, whch can further damage the lver. It s mperatve that the nurse reterates to the patent the mportance of complyng wth the follow-up appontments wth hs/her physcan. Due to the complexty of the dsease and varables, the physcan wll need to montor the effectveness of the patent s treatment and the extent of the dsease process at varous ntervals. In addton to the educaton and gudelnes recommended for patents to care for themselves, they should begn treatment wth antvral medcatons. Dependent upon the patent s lfestyle, wllngness to comply and/ or other medcal dagnoss, physcans may fnd themselves n a precarous stuaton when ntatng treatment as the medcatons may nduce more harm. On the flp sde, some physcans decde to pursue the medcatons because there s no way to know whch patents wll develop crrhoss of the lver and/or lver cancer. The recommended dose and duraton of treatment s dependent upon the genotype and the extent of the lver damage. Regardless, all patents are treated wth nterferon and Rbavrn. The man dfference between the treatment regmens s the dosng and length of the treatment. Accordng to the NDDIC (2006), the followng s recommended as the treatment modaltes based on the genotype typng alone [33]: Patents wth the genotype one, whch s the most common n the U.S., respond better to nterferon and Rbavrn at the hghest dose 1,000-1,200 mllgrams (mg) a day for a full 48-week course. Patents wth genotypes two and three are two to three tmes more lkely to respond to nterferon-based therapy than patents wth genotype 1. Furthermore, usng a combnaton therapy of nterferon and pegnterferon 800 mllgrams (mg) a day for a 24-week course s adequate to reduce the rsk of chronc hepatts C. There are two types of nterferon that may be prescrbed to a patent wth the hepatts C vrus [33]: The frst s alpha nterferon, whch s a host proten that s made n response to vral nfectons and has a natural antvral component. There are recombnant forms of alpha nterferon that have been produced wth several formulatons (alfa-2a, alfa-2b, consensus nterferon) to treat hepatts C. Over the past few years, the standard forms of nterferon are beng replaced by pegylated nterferon (pegnterferon). Pegnterferon s an alpha nterferon that has been modfed chemcally by the addton of a large nert molecule of polyethylene glycol. Pegylaton changes the uptake, dstrbuton and excreton of nterferon, whch prolongs the half-lfe. Thus, t mproves the beneft the frequency of the admnstraton of the antvral medcaton pegnterferon. At ths tme, pegnterferon can be gven once weekly, and t provdes a constant level of nterferon n the whch had to be gven several tmes weekly, wth ntermttent and fluctuatng levels n the body. In addton, pegnterferon s more actve than standard nterferon n nhbtng hepatts C vrus and yelds a hgher, sustaned SVR. Pegnterferon alfa-2a s gven subcutaneously (SQ) at a fxed dose of 180 mcrograms (mcg) per week. Pegnterferon alfa-2b s gven subcutaneously weekly n a weght-based dose of 1.5 mcg per klogram (kg) per week (thus n the range of 75 to 150 mcg per week). Accordng to the CDC, the typcal sde effects of nterferon are the followng [6]: Intally, the patent may exhbt flu-lke symptoms (fever, chlls, headache, muscle and jont aches, fast heart rate), but the symptoms usually subsde wth contnued treatment. Avod rsky sexual behavor. Don t engage n unprotected sex wth multple partners or wth one partner whose health status s uncertan. Sexual transmsson between monogamous couples may occur, but the rsk s low [28]. Vaccnaton to the hepatts A and B vruses s recommended to provde mmunty to those blood, n contrast to the standard nterferon Elte Page 7 Later, the patent experences fatgue, har loss, low blood count; (exacerbatng leukopena). Addtonal symptoms are dffculty thnkng, moodness and depresson. Severe rare sde effects, seen n less than two out of 100 persons, ncludes thyrod dsease, depresson wth sucdal thoughts, sezures, acute heart or kdney falure, eye and lung problems, hearng loss and blood nfecton. In even more rare crcumstances, death has occurred due to lver falure and/or a blood nfecton; t s usually ncreased n patents wth crrhoss of the lver. Pregnant women should never be treated wth nterferon. The other commonly prescrbed medcaton s rbavrn, an oral antvral agent that has actvty aganst a broad range of vruses. However, f t s prescrbed by tself, t has lttle or no effect on the hepatts C vrus. Accordng to the CDC, the combnaton therapy sde effects nclude all of the followng [6]: The prevously mentoned sde effects wth nterferon alone and anema because rbavrn has an enormous potental to nduce an anemc state n the patent. Therefore, f a patent has kdney falure, combnaton therapy wll not be recommended. The ratonale s that normally erythropoeten s derved from the kdneys; therefore, f the kdneys are not workng properly, the anema nduced by the medcaton wll only exacerbate the ablty of the kdneys to functon. The strngent medcaton gudelnes and recommendatons wll be exhaustng to the patent s body. At tmes, the patent may feel scker than he/she ever dd wth the hepatts C vrus. Therefore, before patents begn ther sx- to 12-month journey on the antvral medcatons, they need to be properly nformed about the medcatons and sde effects. In addton, patents should follow up wth ther practtoners and nform them about any major sde effects as the dose may need to be adjusted and/or further testng may be needed.