Hepatitis C

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Disorders of the liver are intricate and often complicated to understand. Because of the vitality of the liver to the basic life process, even simple problems with its system have the potential to cause life-threatening problems. Life-style choices are often a contributing factor in many liver disorders such as: drug abuse and alcoholism. Some problems in the liver occur due to medical treatments that are prolonged for other illness and unfortunately, have an effect of the liver due to its role in processing of medication.


There are many forms of hepatitis including Hepatitis A, B, C, D, and G. For the purposes of this discussion, the concentration will be on Hepatitis C with the understanding that they are all, to a certain degree similar. All hepatitis affect the liver in varying degrees and ways with progression at different levels depending on the type of virus, Hepatitis C appears to be the most common in the United States at this time and its pathology and disease progression will be explored.

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Hepatitis C is a blood borne infection with new cases being reported each year. The most prevalent reason reported for the cause of infection is needle sharing during illegal drug use. Some other reasons include exposure to infected blood at work, typically from needle sticks. Some transmission of the virus from mother to child during childbirth is reported as well about 6% (Tabers, 19th Edition). There is no evidence that breast-feeding spreads HCV. HCV-positive mothers should consider abstaining from breast-feeding if their nipples are cracked or bleeding.Classification of hepatitis as C is a result of a significant proportion of cases of viral hepatitis being neither hepatitis A, hepatitis B, or hepatitis D: with this discovery came the classification of hepatitis C. Hepatitis C was initially referred to as non-A, non-B hepatitis. Recent studies suggest the
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HCV may survive on environmental surfaces at room temperature at least 16 hours bur no longer than 4 days.
There seems to be an increased risk for hepatitis C for persons involved in certain lifestyle choices. The disease itself is primarily blood borne but can also be transmitted sexually and parentally. People with increased risk to hepatitis C are: injection drug users, sexually active people with more than one partner, persons requiring large volumes of blood products or frequent transfusions, and people working in the health care field. Tattooing, body piercing, and intranasal cocaine abuse have been related to some cases (Tabers, 19th ed.)Incubation from exposure to disease can range from 15 to 160 days with an average of 45 days (Stanhope & Lancaster 2004), with symptoms being usually mild. After contracting hepatitis C a person increases the risk for liver problems such as chronic liver disease and can manifest into cirrhosis of the liver and possibly liver cancer later in life (CDC website). With the initiation of blood screening, the occurrences of hepatitis associated with blood transfusions have reduced. Through the efforts of public health programs there is also a reduction in the number of cases associated with shared needles among illicit drug use. Chronic carrier state is possible with this disease and occurs in 85% or more of cases (Stanhope & Lancaster, 2004).


Diagnosis is often made after an asymptomatic person has repeatedly elevated liver enzymes on routing blood test. There does not appear to be any benefit from rest, diet, or vitamin supplementation as previously believed. There is no vaccine for Hepatitis C. The main focus for control and prevention is screening of blood and organ donors and reducing behaviors that increase risk of contracting the disease. Hepatitis C
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along with hepatitis B & D are associated with chronic hepatitis. Chronic use of alcohol and/or exposure to other toxins can also contribute to disease progression. During the physical assessment of the patient with a normal liver, the edge is firm and sharp with a regular ridge and smooth surface. If, during palpation, the liver is below the costal margin medially and laterally it is enlarged. Abnormality includes being enlarged, having an irregular border and having nodules present.
Treatment for hepatitis C that has been approved in the United States is mainly Interferon (interferon alfa-2b). Copstead & Banasik describe Interferons are naturally occurring proteins and glycoproteins made in response to viral infections: they exert a variety of immunomodulating effects that favor viral clearance. (Copstead & Banasik p. 868). A better response to treatment is reported in hepatitis B, almost 50%, with interferon therapy. Hepatitis C patients can expect a 40% response rate; however relapse is present in approximately 50% of those patients. Corticosteroids and immunosuppressant are the common therapies included in treatment. If a person with HCV infection desires to protect liver function, CDC recommends: cessation of alcohol consumption, regular doctor visits, refrain from initiating any new medications without consulting physician prior, and obtain vaccination from hepatitis A especially if liver damage is present. Out of 100 people infected with HCV approximately 75 to 85 will develop long-term infections, 70 people may develop chronic liver disease, 10 20 people may develop cirrhosis over a period of 20 to 30 years, and 1% – 5% may die from the consequences of long term infection such as liver cancer or cirrhosis. Hepatitis C is also the leading indication for liver transplants.


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Given the information as states in an article in AARP the Magazine entitled Time bomb: a deadly hidden epidemic is about to explode hepatitis C is Americas most common blood-borne virus, fully four times more prevalent than HIV (p 34). With the monetary resources given for research for more visual illnesses, one could wonder what is being done to combat hepatitis C. There are multiple areas to locate information on the subject. The Center for Disease Control (CDC) has a wealth of information on the subject of hepatitis and has even developed strategic plans to combat the problem of infection. Some of theses things include the goal of prevention and control efforts. The main goal of prevention is to reduce new infections by reducing transmission of the virus. The second main goal is to reduce the risk of chronic liver disease of those infected individuals through medical management and education and ongoing counseling. The focus for attaining these goals is to identify the person at risk for new infection and provide those individuals with education including how to reduce the risk of infection, provide for testing of the disease and provide appropriate medical services if the person is found to already have HCV and make referrals to substance abuse treatment facilities when needed. The goal also proposes the changing behaviors in the high risk groups would significantly reduce disease transmission. Appropriate testing, medical management and substance abuse counseling and treatment should reduce the risk of chronic liver disease.
Implementation of those goals is quite a daunting and expensive task. Funding is needed as well as support from the medical community. One step in the implementation
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process is to identify those persons already infected with HCV. Due to the large number of people in the United States that are already infected, those persons need to be identified so treatments and programs can be implemented. Testing should be routinely offered to persons most likely to be infected with HCV. In addition, anyone who wishes to know their HCV infection status should be provided the opportunity for testing. In all instances, testing should be accompanied by appropriate counseling and referral for medical follow-up.
Persons for whom routine HCV testing is recommended include: persons who ever injected illegal drugs, including those who injected once or a few times many years ago, persons who received a blood transfusion or organ transplant before July 1992, persons who received clotting factor concentrates before 1987, persons who were ever on long-term dialysis, children born to HCV positive mothers, and healthcare workers after needle stick exposure. The first line for identification of the afore mentioned people would be health care professionals. The CDC states
To identify persons who should be counseled and tested for HCV, health care professionals in primary care, specialty, and public health settings should routinely question patients about risk factors for infection, including history of injecting drug use. Current injecting drug users are often not seen in primary care or other traditional health care settings. However, targeted outreach in other settings may be particularly effective in reaching this population. These settings include correctional institutions, drug treatment programs, programs for high risk youth, HIV counseling and testing sites, and STD clinics. Persons infected with HCV because of medical risk factors (e.g., transfusion, hemophilia, chronic hemodialysis) should be identified by health care professionals and through educational efforts provided by patient organizations. Many of these persons have been tested for HCV and testing should be encouraged for those not previously tested. (CDC website).


Hepatitis C has the potential to be an epidemic. If health care workers and governmental agencies can work together to combat the problem, strides can be achieved to contain and prevent future transmission. In order for the goals set forth by the CDC to become a reality: education of health care workers and the general population, detection of those at risk and already infected, and treatments for infected persons and drug users need to be developed to assist with the issue.


References
Center for Disease Control website: http://www.ede.gov/ retrieved 7/17/2004
Copstead , L, and Banasik, J. (2000). Pathophysiology: Biological and behavioral
perspectives (2nd ed.). New York: W.B. Saunders Company
Kozier, B., Erb, G., Audrey, J. & Burke, K., (2000). Fundamentals of nursing: Concepts,
process, and practice 6th ed). Upper Saddle River, New Jersey. Prentice Hall.


Tabers Cyclopedic Medical Dictionary (1997). (19th ed). Philadelphia F.A.
Davis Company.

Varian, Nanette (2004). Time bomb: a deadly hidden epidemic is about to explode.
ARP the Magazine. July/August 34-37.