COURSE DESCRIPTION This continuing education course will review six types of hepatitis: Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, Hepatitis E, and Hepatitis G. Information about symptoms, diagnosis, treatment, and prevention is included. The majority of information for this course is taken directly from non-copyrighted educational information provided by the Food and Drug Administration and the Centers for Disease Control and Prevention. Copyright Information The information in sections Introduction Hepatitis C were downloaded and copied from the FDA Website (www.fda.gov) on 10/2/07. FDA website states that the information is in the public domain and may be republished, reprinted and otherwise used freely by anyone without the need to obtain permission from FDA. The information in sections Hepatitis D Summary (excluding Hepatitis G) were downloaded and copied from the CDC Website (www.cdc.gov) on 10/2/07. CDC website states that the information is in the public domain and may be republished, reprinted and otherwise used freely by anyone without the need to obtain permission from CDC. Information on hepatitis G is a compilation of non-copyrighted information from various websites. Rev 3.0 2/2015 1
COURSE TITLE: How Much Do You Know Hepatitis? Authors: The Food and Drug Administration + The Centers for Disease Control and Prevention + Lucia Johnson, MA Ed, CLS(NCA), MT(ASCP)SBB Director of Continuing Education NCCT Number of Clock Hours Credit: 2 Course # 1228214 P.A.C.E. Approved: Yes X No OBJECTIVES Upon completion of this continuing education course, the professional should be able to: 1. List three functions of the liver. 2. List causes of hepatitis. 3. Name six specific viruses that cause hepatitis. 4. For each type of hepatitis discussed, describe: a. Symptoms, b. Transmission, c. Treatment, d. Long-term effects of infection, and e. Prevalence of disease in the United States. Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions. 2
INTRODUCTION Hepatitis is a condition that affects the liver, causing it to become inflamed. That s bad news for anybody, because the liver is an organ with some very important jobs. Although it only weighs about three pounds, the liver is the largest organ inside your body. It has more than 500 known functions including filtering harmful substances from the blood, digesting fats from food, and storing the sugar your body uses for energy. There are several things that can cause hepatitis, including a virus, a bacterial infection, liver injury caused by a toxin (poison), and even an attack on the liver by the body's own immune system. There are six types of hepatitis: A, B, C, D, E and G. However, the condition is usually caused by one of three viruses: Hepatitis A, Hepatitis B, or Hepatitis C. Hepatitis A The hepatitis A virus (HAV) is spread from person to person by putting something in the mouth that has been contaminated with the feces of a person with the virus. This is called fecal-oral transmission. For this reason, the virus is more easily spread in areas with poor sanitary conditions. Unfortunately, a person with HAV may not have any signs or symptoms of HAV, so they may not realize they have it. Older people are more likely to have symptoms of HAV than children, and most symptoms last between three weeks and six months. HAV usually includes a sudden onset of flu-like symptoms, such as: Fatigue Fever Nausea/Vomiting Diarrhea Severe stomach/abdominal pain Loss of appetite Health Tip You can help prevent the spread of HAV disease by always washing your hands with soap and water after using the bathroom, changing a diaper, and before preparing or eating food. A test of body fluid (serum), performed in a doctor s office or clinic, can help determine if someone has an HAV infection. The good news is that people who recover from HAV develop antibodies that provide life-long protection from future infections. So they can t get it again, and they can t transmit the virus to others. About 22,700 cases of HAV, or about 38 percent of all hepatitis cases, are reported every year in the U.S., and about one third of Americans have evidence of past infection (immunity). HAV infection does not develop into chronic liver disease. 3
Most cases of HAV only require a treatment of bed rest and abstinence from all sexual activity. There are two medical options that have been approved as safe by the FDA for the prevention of HAV, the hepatitis A vaccine and Immune Globulin. The vaccine is recommended for: Travelers to areas with increased rates of HAV Men who have sex with men All children 12 through 23 months of age Those who live with people infected with HAV Injecting and non-injecting illegal drug users People with chronic liver disease People who have clotting disorders Those who engage in sexual activity with people infected with HAV The vaccine includes two doses given at least 6 months apart. The vaccine may be started whenever a person is at risk of infection, and may be given at the same time as other vaccines. The risks of the vaccine, if any, are very low. Mild side effects have been reported, including soreness, headache, loss of appetite, and tiredness. The HAV vaccine could protect you for at least 25 years, and protection begins four weeks after the first dose. Immune Globulin is a mixture of antibodies that gives immediate, but temporary protection. It is recommended for short-term protection against hepatitis A, or for people who have already been exposed to HAV. Hepatitis B Hepatitis B is caused by a virus that attacks the liver. The virus, which is called hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. The hepatitis B virus (HBV) is spread by exposure to infected blood and/or body fluids. This is called parenteral or bloodborne spread of infection. Examples of parenteral infection include unprotected sex with an infected partner, by sharing drugs, needles, through tattoos and body piercing, through needlesticks or sharps exposures on the job, or from an infected mother to her baby during birth. Many people infected with HBV have no symptoms at all. However, some show signs of: Flu-like symptoms Joint pain Oddly-colored (clay, gray, tan) bowel movements Long term affects of chronic HBV can include: Lifelong infection Scarring (cirrhosis) of the liver Liver cancer Liver failure Death 4
A blood test is the only way to determine whether someone has an HBV infection. The FDA has approved the first fully automated product that combines both screening and confirmatory tests for HBV. It is approved to test blood and organ donors, and it can also be used to screen blood from cadavers for organ and tissue donation. There are two types of HBV, acute and chronic. Acute infections last several weeks, and usually go away without treatment. Chronic HBV is more prominent in younger children and infants. There are a number of drugs used for the treatment of people with chronic HBV, but there is currently no cure. Though the number of new infections per year has declined from an average of 260,000 in the 1980s to about 60,000 in 2004, there are currently an estimated 1.25 million Americans infected with chronic HBV. Each year, about 80,000 people are infected with HBV, and 4,000 to 5,000 people die from chronic HBV. Some experts estimate that one out of 20 people in the U.S. will be infected with HBV at some time during their lives. A vaccine for HBV has been available since 1982. It is recommended for: All babies, at birth All children 0-18 years of age who have not been vaccinated People of any age whose behavior or job exposes them to HBV-infected blood The vaccine is injected in three doses into a muscle (intramuscular). The second dose is given one month after the first, and the third dose six months after the second. The vaccine has proven to be safe for use in adults as well as children, and it may be given at the same time as other vaccines. It is not recommended for those with yeast allergies. Recent studies indicate that the vaccine provides immunity for at least 23 years. In its chronic state, HBV can lead to primary liver cancer. The Centers for Disease Control and Prevention has recognized the HBV vaccine as the first anti-cancer vaccine, because it can prevent primary liver cancer. Hepatitis C Hepatitis C is the most serious type of hepatitis. Like HBV, the hepatitis C virus (HCV) is spread by direct contact with infected human blood. It is most commonly spread by contaminated tattoo or body piercing needles, or needles used for illegal drug use. Infected mothers also may infect newborns during birth. In rare cases, HCV can be spread through unprotected sex with an infected partner. Infection with HCV can also be transmitted to healthcare workers through on the job needlestick and sharps injuries. Eighty percent of infected people don t show any symptoms, but some show signs of flu-like symptoms. Long-term affects of chronic HCV can include: Lifelong infection Chronic liver disease Death 5
In 2001, the FDA approved two blood tests that indicate if an HCV infection is active. FDA has also approved the Home Access Hepatitis C Test kit for home use, so that people can diagnose themselves at home. HCV can be prevented in the same manner as HBV. Thanks to prevention awareness in America, the number of new infections per year has declined from an average of 240,000 in the 1980 s to about 26,000 in 2004. Still, an estimated 4.1 million Americans have been infected with HCV, and 1 to 5 percent of people with long-term HCV are at risk for liver cancer or cirrhosis. There is no vaccine currently available to prevent HCV. People with mild HCV may be advised by their doctors to eat a nutritious diet, avoid alcohol, and stay in shape to maintain their strength, energy, and overall well-being. Did You Know? HCV is one of the most common causes for liver transplants in adults. For more severe cases, combination therapy using two drugs, interferon and ribavirin, may be necessary. The FDA has approved this treatment for use in children aged 3-17 years. About 10 percent of patients have no side effects, and about 10 percent have very severe side effects, such as suicidal behavior, heart problems, or other internal organ damage. The remaining 80 percent have tolerable side effects such as flu-like symptoms, low red blood cell count (anemia), fatigue, hair loss, and depression. Hepatitis D The hepatitis D virus is considered to be a defective virus because it needs cells infected with HBV to survive. HDV can be acquired either as a co-infection (occurs simultaneously) with hepatitis B virus (HBV) or as a superinfection in persons with existing chronic HBV infection. HBV-HDV co-infection may have more severe acute disease and a higher risk (2%- 20%) of developing acute liver failure compared with those infected with HBV alone. HBV-HDV superinfection is seen in chronic HBV carriers who acquire HDV superfection. The disease usually develops into chronic HDV infection. Progress to cirrhosis is believed to be more common with HBV-HDV chronic infections. Signs and symptoms of HDV are the same as HBV but are usually more severe. They include: Jaundice Fatigue Abdominal pain Loss of appetite Nausea, vomiting Joint pain Dark (tea colored) urine 6
HDV transmission occurs when blood or body fluids from an infected person enters the body of a person who is not immune. It is spread by the same methods as described for HBV. Risk groups for HDV infection include: Injection drug users Men who have sex with men Hemodialysis patients Sex contacts of infected persons Healthcare and public safety workers Infants born to infected mothers (very rare) Because HDV is dependent on HBV for replication, HBV-HDV co-infection can be prevented with either pre- or postexposure prophylaxis for HBV. However, no products exist to prevent HDV superinfection of persons with chronic HBV infection. Thus, prevention of HDV superinfection depends primarily on education to reduce risk behaviors. Blood tests can be performed to determine the presence of HDV infection. Certain blood tests are commercially available in the United States. Other blood tests are available only in research laboratories. In general, the global pattern of HDV infection corresponds to the prevalence of chronic HBV infection; however, several distinct features of the distribution of HDV infection have been identified. In countries with a low prevalence of chronic HBV infection, HDV prevalence is generally low among both asymptomatic HBV carriers (<10%) and among patients with chronic HBV-related liver disease (<25%). HDV infection in these countries occurs most commonly among injecting drug users and persons with hemophilia. In countries with moderate and high levels of chronic HBV prevalence, the prevalence of HDV infection is highly variable. o In southern Italy and in parts of Russia and Romania, the prevalence of HDV infection is very high among both asymptomatic HBV carriers (>20%) and among patients with HBV-related chronic liver disease (>60%). o Other countries, including northern Italy, Spain, Turkey, and Egypt, have a moderate prevalence of HDV infection among asymptomatic HBV carriers (10%-19%) and among patients with chronic HBV-related liver disease (30%-50%). However, in most of Southeast Asia and China, where the prevalence of chronic HBV infection is very high, HDV infection is uncommon. In some South American countries in the Amazon River Basin, periodic epidemics of HDV infection have occurred among chronic HBV carriers in relatively isolated regions. Disease related to HDV infection in these outbreaks has been very severe, with rapid progression to fulminant hepatitis and case-fatality rates of 10%-20%. The cause of the atypical course of HDV infection in these populations is unknown. 7
Treatment and medical management of acute HDV infection is supportive care. Interferon-alpha may be useful in treating chronic HDV infection. Liver transplants can be considered in very serious cases. HEPATITIS E Hepatitis E virus (HEV), is the major cause of enterically transmitted non-a, non-b hepatitis worldwide. HEV is transmitted primarily by the fecal-oral route and fecally contaminated drinking water is the most commonly documented type of transmission. Although hepatitis E is most commonly recognized to occur in large outbreaks, HEV infection accounts for >50% of acute sporadic hepatitis in both children and adults in some high endemic areas. Unlike hepatitis A virus, which is also transmitted by the fecal-oral route, person-to-person transmission of HEV appears to be uncommon. However, nosocomial transmission, presumably by person-to-person contact, has been reported to occur. HEV is uncommon in the United States. Virtually all cases of acute hepatitis E in the United States have been reported among travelers returning from high HEV-endemic areas, mostly South Asia and North Africa. HEV occurs most frequently in persons aged 15-40 years. Signs and symptoms of HEV include: Jaundice Fatigue Abdominal pain Loss of appetite Nausea, vomiting Dark (tea colored) urine Risk factors for infection among persons with sporadic cases of hepatitis E have not been defined. There is no evidence that a chronic phase of the disease occurs. It is known that more severe disease occurs in pregnant women. In pregnant women, especially those in the 3 rd trimester, 15%-20% of infected persons will die as compared to a 1%-3% death rate that is seen in the general population. Rare cases in the United States among persons with no history of travel to endemic countries have occurred. No blood tests to diagnose HEV infection are commercially available in the United States. However, several diagnostic tests are available in research laboratories and these tests may be useful in identifying HEV infection. Treatment for HEV is supportive. There is no drug treatment or vaccine available for HEV. To prevent transmission of HEV: Always wash your hands with soap and water after using the bathroom, changing a diaper, and before preparing and eating food. Avoid drinking water (and beverages with ice) of unknown purity, uncooked shellfish, and uncooked fruits or vegetables that are not peeled or prepared by you. 8
HEPATITIS G Hepatitis G (HGV) was first described in 1996. It appears to be related to the hepatitis C virus. Very little is known about HGV. It is not known for causing serious liver disease or chronic disease, and it is possible that it is not a true hepatitis virus. Persons infected with HGV are often infected with HCV or HBV. However, many persons have only evidence of HGV infection, i.e., positive blood tests. In the United States, HGV has been identified in 1%-2% of blood donors. Like HBV and HCV, HGV is known to be transmitted via transfusion of blood and blood products. Because of this, persons with hemophilia, chronic anemia, and other chronic diseases needing frequent transfusions are at high risk for contracting HGV. Hemodialysis patients are also at high risk. Those populations with medium risk for HGV infection are the same as those for other bloodborne pathogens. Infection with HGV is usually mild and brief, and there is little evidence of serious complications. HGV has been identified in as many as 20% of patients with long-lasting hepatitis, some of whom also have HCV. Other information: Diagnosis of HGV can only be made through blood tests available at research laboratories. There is no specific treatment for HGV. Bed rest, avoidance of alcohol, and healthy diet are recommended. Using recommended bloodborne pathogen safety methods will minimize the chance of becoming infected with HGV. CONCLUSION The liver is a vital organ with many functions. Many of these functions become impaired when hepatitis viruses infect liver cells. The hepatitis viruses have different methods of transmission, treatment, and prevention. The chart on the following pages summarizes information on the five types of hepatitis (hepatitis G is not included). Who knows when hepatitis H will be discovered? 9
THE FIVE FACES OF HEPATITIS Centers for Disease Control and Prevention How It Is Spread Symptoms Treatment Prevention Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E By drinking water or eating food contaminated with fecal material that contains the virus. Fly-like symptoms such as fatigue, nausea, vomiting, abdominal discomfort, dark urine, and jaundice. Liver enzymes may be elevated. Bed rest and avoidance of intimate contact. Can last between 3 weeks to 6 months. Two approved vaccines: immune globulin for short-term protection and for patients already exposed, and hepatitis A vaccine for long-term protection Always wash hands with soap and water after using the bathroom, changing a diaper, and before preparing or eating food; wash fresh food thoroughly Exposure to infected blood, unprotected sex with an infected person, sharing contaminated needles, and travel to countries with a high rate of infection. Infected mothers also may infect newborns. Loss of appetite, nausea, vomiting, fever, fatigue, abdominal pain, dark urine, or jaundice. No symptoms in some people. Interferon alpha. HBV vaccine recommended for newborns, infants, and teenagers provides immunity for at least 5 years. Direct contact with human blood, which can occur from being pricked accidentally by a contaminated needle, injecting illegal drugs, and sharing razors or toothbrushes with an infected person. More than half have no symptoms. Others have appetite loss, fatigue, nausea, fever, dark yellow urine, and jaundice. Liver enzymes may be elevated. Interferon alpha or a combination of interferon and the drug ribavirin. No vaccine. Contact with infected blood. Requires HBV to replicate, so it infects either at the same time as HBV or those who already have HBV. Same as for HBV but typically more severe: appetite loss, fatigue, nausea, vomiting, abdominal pain. Interferon alpha for HBV may have some effect. No vaccine specific for HDV. HBV, HCV, and HDV have same prevention methods: follow Standard Precautions in the healthcare setting, receive tattoos/body piercing only from licensed individuals who follow proper infection control procedures, advise injectable drug addicts to not share needles, avoid ingestion of potentially contaminated food and beverage in developing countries where sanitation is an issue, and have protected sex until you know your partner is free of potentially infectious bloodborne pathogens. For In addition, for HBV and HDV prevention, receive the HBV vaccination. Water contaminated with fecal material, especially in developing countries, and contaminated uncooked shellfish, fruits, and vegetables. Abdominal pain, dark urine, fever, jaundice, nausea, and vomiting. Bed rest. No drug treatment or vaccine. Always wash hands with soap and water after using the bathroom, changing a diaper, and before preparing or eating food; wash fresh food thoroughly 10
References Food and Drug Administration. How Much Do You Know Hepatitis? www.fda.gov. Obtained 10/2/07. Centers for Disease Control and Prevention. The Five Faces of Hepatitis. www.cdc.gov. Obtained 10/2/07. Centers for Disease Control and Prevention. Hepatitis D Fact Sheet/Slide Presentation. www.cdc.gov. Obtained 10/2/07. Centers for Disease Control and Prevention. Hepatitis E Fact Sheet/Slide Presentation. www.cdc.gov. Obtained 10/2/07. TEST QUESTIONS How Much Do You Know Hepatitis? # 1228214 Directions: Before taking this test, read the instructions on how to complete the answer sheets correctly. If taking the test online, log in to your User Account on the NCCT website www.ncctinc.com. Select the response that best completes each sentence or answers each question from the information presented in the module. If you are having difficulty answering a question, go to www.ncctinc.com and select Forms/Documents. Then select CE Updates and Revisions to see if course content and/or a test questions have been revised. If you do not have access to the internet, call Customer Service at 800-875-4404. 1. Which one of the following is NOT a function of the liver? a. digesting fat b. removing harmful substances c. storing fat d. storing sugar (glucose) 2. Hepatitis can be caused by all of the following EXCEPT. a. bacterial infection b. hepatitis A c. polio virus d. toxin 3. Which one of the following hepatitis viruses is spread by the fecal-oral route? a. hepatitis A b. hepatitis B c. hepatitis C d. hepatitis D 11
4. Which one of the following hepatitis viruses is spread by contact with infectious blood and/or body fluids? a. hepatitis A b. hepatitis C c. hepatitis E d. none of the above 5. Hepatitis A accounts for about of all hepatitis cases reported annually in the United States. a. 8% b. 18% c. 28% d. 38% 6. Which one of the following is a TRUE statement about hepatitis A? a. Jaundice is a major symptom of hepatitis A. b. Many people infected with hepatitis A do not have symptoms. c. The hepatitis A vaccine is given after an individual has been exposed to hepatitis A. d. People who recover from hepatitis A can get the disease again. 7. Infection with hepatitis B can cause all of the following EXCEPT. a. cancer of the liver b. cirrhosis c. dysentery d. death 8. Each year, about people in the United States die from chronic hepatitis B. a. 4,000 5,000 b. 60,000 c. 80,000 d. 1.25 million 9. Oddly-colored bowel movements are a sign/symptom of which type of hepatitis virus? a. hepatitis A b. hepatitis B c. hepatitis C d. hepatitis D 12
10. Which one of the following is a FALSE statement about hepatitis B? a. Chronic hepatitis B is more common in younger children and infants. b. Hepatitis B screening and confirmatory tests are available to test blood and organ donors. c. The hepatitis B vaccine is given in one dose. d. The hepatitis B vaccine is recommended for all babies at birth. 11. Vaccination for hepatitis B can prevent primary liver cancer. a. True b. False 12. Hepatitis B and hepatitis C have all of the following in common EXCEPT. a. Both can cause chronic infection. b. Both can cause death. c. Both can be prevented through vaccination. d. Both are spread through contact with infected blood/body fluids. 13. What percentage of persons infected with long-term HCV in the United States are at risk for liver cancer or cirrhosis? a. 1-5% b. 6-10% c. 11-15% d. 16-20% 14. There are treatments for hepatitis B and hepatitis C that will cure the diseases. a. True b. False 15. Which one of the hepatitis viruses is one of the most common causes for liver transplants in the United States? a. hepatitis A b. hepatitis B c. hepatitis C d. hepatitis D 16. Hepatitis D virus requires which one of the following hepatitis viruses to cause an infection? a. hepatitis A b. hepatitis B c. hepatitis C d. hepatitis G 13
17. Hepatitis B-hepatitis D co-infection generally results in all of the following EXCEPT. a. an easier cure of both viruses b. higher risk of acute liver failure c. more cases of chronic infection d. more severe acute disease 18. Which one of the following groups is NOT at risk for hepatitis B infection? a. babies born of infected mothers b. intravenous drug users who share needles c. individuals having unprotected sex with infected partners d. vaccinated healthcare workers 19. Hepatitis A virus and hepatitis E virus have all of the following in common EXCEPT. a. Both are common in the United States b. Both are transmitted by fecal-oral route c. Chronic disease is rare or not known to occur d. Methods of preventing transmission are the same 20. What percentage of blood donors in the United States have tested positive for hepatitis G? a. 0.5 1% b. 1 2% c. 3 4% d. 5 6% 21. Which one of the following is a FALSE statement about hepatitis G? a. Hepatitis G is not known for causing serious liver disease. b. Individuals requiring blood transfusions are at risk for contracting hepatitis G. c. Persons infected with hepatitis G often are also infected with hepatitis B or hepatitis C. d. Treatment for hepatitis G infection includes bed rest and interferon alpha. *End of Test* 14