Understanding Hepatitis
Introduction
Hepatitis is at its basic level an inflammation of the liver. However, the condition can be somewhat complex in nature, given the five main strains of the virus: types A, B, C, D, and E. The strains can be caused by different sources and therefore are likely to present with different symptoms, have varying degrees of impact on a person’s health, and require different treatment protocols. According to the World Health Organization “These five types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer” (WHO, 2016). This paper will examine the types of hepatitis that are of the greatest concern to the medical community, as well as the health and welfare of society in general.
Virulence Factors
Hepatitis B (HBV), hepatitis C (HCV), and hepatitis D (HDV) are known to cause both acute and chronic forms of hepatitis. Moreover, given that both cirrhosis and hepatocellular cancer are also caused by these strains, it is estimated that some one million people die each year from hepatitis viruses. Hepatitis strains continue to pose even greater threats in poor countries, although as such countries develop better water treatment and sanitation processes, there has been a reduction in the prevalence in those countries as well. Teles (2017) contends, “Despite all of these advances, viral hepatitis is still a great public health threat” (p. 231).
Mechanism of Pathogenicity
The hepatitis B virus (HBV) is generally contracted either through a break in the mucous membrane or skin, or by means of injection into the bloodstream. Patients may experience fever, chills, anorexia, malaise, abdominal discomfort, and diarrhea. The HBV has an average incubation period of seven weeks. As the virus reaches the liver cells, it multiplies and continuously releases viruses in to the blood. Patients were frequently prone to develop necrosis and cirrhosis related to liver disease, with an increase risk of developing liver cancer.
As a blood-transmitted virus, HCV impacts the liver via circulation. Irshad, Mankotia, and Irshad (2013) explain, “The pathogenesis of HCV infection is quite complex and regulated by host immunity as well as several metabolic activities influencing liver function… Moreover, the persistence of HCV infection is also affected by viral proteins, HCV isotypes and liver metabolism” (p. 7903).
Epidemiology of the Disease
The United States instituted a national surveillance policy for acute viral hepatitis in
1966, which helped in effecting some major changes in the epidemiology of the diseases. From 1995 to 2006, there was a significant decrease in the rate of the three types of viral hepatitis (i.e., A, B, and C). Prevention strategies played a major role in these declines. Additionally, vaccines against both hepatitis A and hepatitis B were introduced. The last reported peak of morbidity due to hepatitis A dates back to 1995. The most significant declines in hepatitis A have been reflected since 1999, largely due to the recommendation that children be routinely vaccinated in those regions of the country that were known to have higher rates of hepatitis A (Wasley, Grytdal, and Gallagher, 2006).
The introduction of a national vaccination strategy coincided with decline in the transmission of HBV in the late 1980s. According to Wasley et al., “The 2006 rate of 1.6 cases per 100,000 population was the lowest recorded since surveillance began in 1966, and represents an estimated decline of >80% since the national strategy was implemented in 1991” (p. 7). Since 1990, significant progress has also been reflected in the reduction of hepatitis B rates among racial and ethnic minorities, which previously had seen disproportionately higher rates of HBV.
Of more recent concern is the dramatically changing occurrence of hepatitis C (HCV) in the United States, the current burden of which has been characterized as critical (Ditah, Ditah, Devaki, Ewelukwa, Ditah, Njei, Luma and Charlton, 2014). According to Ditah et al., “As of 2010, approximately 2.3 million persons were chronically infected with hepatitis C in the US. Most of those infected are prevalent, rather than incident cases. The prevalence of HCV was on the decline, but has stabilized since 2006. Future studies should explore reasons for no decline in HCV prevalence since 2006” (p. 691).
Wong, Russell, and Kruger (2016) suggest that HCV is the main reason for liver transplantation in the U.S. as well as the leading cause of liver-related mortality. According to the same authors, “In the United States, approximately 30,000 new cases of HCV infection
develop yearly; about 3.2 million individuals have chronic HCV infection, and an estimated 50% to 70% of them are unaware of their condition” (Wong et al, p. 37). The major risk factors for hepatitis C virus infection include injection drug use, hemodialysis, and male-to-male sex or other high-risk sexual activity. Although improved blood-screening procedures served to decrease infection through blood transfusion or solid organ transplant, inadequate infection control continues to be a risk for developing HCV.
Symptoms
Although people with chronic HCV often do not present with signs or symptoms of the illness for as many as 20 years, the disease ultimately tends to progress, resulting in higher levels of morbidity and mortality (Zucker, 2010). Patients may report nonspecific fatigue, anorexia, myalgia and arthralgia, symptoms of upper respiratory infection, nausea, intolerance to alcohol and fatty food, right upper quadrant abdominal pain, fever, jaundice, or night sweats (Wong, Russell, and Kruger, 2016). Additional symptoms that emerge with progression of chronic HCV illness include persistent viremia, persistent elevation of liver enzymes, rapid progression to cirrhosis, decompensation, hepato-cellular carcinoma, and possibly the eventual need for liver transplantation (Zucker, 2010). In contrast to hepatitis A and B, as yet there is no vaccination available for HCV. Patient education and screening are therefore crucial as methods of prevention.
Treatment
Although better prevention methods and vaccination are available for hepatitis B infection, it is beneficial to discuss the treatment used for both acute and chronic HBV infection. In cases of acute infection, the illness might be short-lived in nature and will resolve on its own. Rest, ample fluid intake, and proper nutrition may be all that is needed to help the body combat the acute infection. For those cases that do not resolve with less aggressive treatment, antiviral drugs might be indicated. Chronic hepatitis B infection requires different considerations for treatment. According to the Mayo Clinic, “Most people diagnosed with chronic hepatitis B infection need treatment for the rest of their lives. Treatment helps reduce the risk of liver disease and prevents you from passing the infection to others” (2017). Potential treatments may include antiviral medications, interferon injections, or ultimately, given extensive liver damage, liver transplant might be necessary.
Because the primary goal in treating HCV is to clear the virus from the body, i.e., having no HCV virus detected 12 weeks post treatment, antiviral medications are the main course of treatment. “The choice of medications and length of treatment depend on the hepatitis C genotype, presence of existing liver damage, other medical conditions and prior treatments” (Mayo Clinic, 2017). Serious complications can result from chronic hepatitis C infection, which may require a liver transplant. Transplantation alone, however, does not necessarily cure HCV. Post transplant, the infection is likely to recur, which will subsequently require antiviral medication as a means of protecting the new liver from damage. Treatment options for hepatitis C are understandably changing, given the pace of recent research.
Summary
Although some significant advances have been made in understanding, preventing, and treating the various types of hepatitis virus, the disease continues to be considered a public health concern, particularly with respect to HCV. Vaccines have been found to be beneficial for hepatitis A and B, yet no vaccine has yet to be introduced for hepatitis C. Chronic hepatitis, particularly HBV and HCV will require patients to have monitored treatment throughout the course of their lives. Ongoing research continues and therefore it is likely that new treatment options and potential vaccines will result from that research.