Hepatitis Nursing CE Course for RNs and LPNs

curs one to four months following acute illness, consists of an individual achieving a greater sense of well-being and positive health, improved skin color, and loss of symptoms. If a patient does not fully recover from an illness, such as HBV and HCV, they may be in an asymptomatic carrier state, but the disease is still present in the body (Hoffman & Sullivan, 2020; Norris, 2019).

            In addition to the findings on a physical assessment, patients with hepatitis will have altered serum liver function tests. Elevated liver enzymes are indicative of liver dysfunction in hepatitis. Aspartate aminotransferase (AST), alanine transaminase (ALT), bilirubin (both total and direct), and ammonia levels are expected to be elevated in hepatitis. Albumin levels are anticipated to be low and may accompany ascites due to the intravascular colloidal osmotic pressure changes. Other signs and symptoms, such as jaundice and pruritus, are closely correlated with changes in liver enzymes. The severity of the signs and symptoms depends upon the type of hepatitis and the degree of inflammation in the liver (Hoffman & Sullivan, 2020).

                  The signs and symptoms of HAV depend on its phase. Many individuals may have few to no symptoms. Individuals who have HAV may experience fever, chills, malaise, nausea, jaundice, anorexia, and abdominal discomfort. Dark urine, pruritis, diarrhea, vomiting, urticaria, cough, splenomegaly, and acholic stools occur within a few days of illness. On assessment, a healthcare provider may note an enlarged spleen or liver within those first few days. Between days 4 and 30, patients may present with increased serum albumin and jaundice (Hoffman & Sullivan, 2020). Jaundice occurs in 70% of HAV cases. Once the jaundice peaks, the other symptoms resolve (Hinkle & Cheever, 2018; Hoffman & Sullivan, 2020; Lai & Chopra, 2022; Norris, 2019).

Signs and symptoms are typically found in individuals over the age of 5, while those in early childhood have been found not to experience many signs and symptoms of hepatitis A. The disease is self-limited as the virus sheds in several weeks; signs and symptoms typically resolve within two months. Unlike other hepatitis viruses, HAV does not typically result in chronic illness or fulminant liver failure. In less than 1% of individuals, HAV causes acute fulminant hepatitis, liver failure, or death (CDC, 2021; Lai & Chopra, 2022; Norris, 2019, 2020).

Diagnosis

            A laboratory examination occurs following the collection of health history and physical assessment. Acute HAV infection is confirmed by detecting serum immunoglobulin M (IgM) anti-HAV antibodies; serum IgG may be present if a prior infection occurred. IgM is found in the blood, the first immunoglobulin produced during infection. Levels peak early and decline in 3 to 6 months. In contrast, IgG levels increase after one month and remain elevated, demonstrating long-term immunity following the resolution of an illness or effective vaccination. IgG is the most prevalent immunoglobulin in the blood and extracellular fluid (Lai & Chopra, 2022; Norris, 2019, 2020; Scanlon & Sanders, 2019; WHO, 2022d).

Hepatitis B (HBV)

            HBV is a double-stranded DNA virus that has HBV DNA and DNA polymerase. The virus contains a hepatitis B surface antigen (HBsAg), whereas the core of the virus has a protein called the hepatitis B core antigen (HBcAg). The content within the core contributes to viral replication, which injures the liver and causes dysfunction. This places the patient at risk of developing HDV as well. HBV can cause the patient to develop chronic hepatitis, cirrhosis, and hepatic necrosis and serve as a disease carrier. The virus is found in infected blood, serum, and body fluids. HBV is transmitted through the oral, sexual, or percutaneous routes (needle injection). The incubation period for HBV is 45 to 60 days; the virus stays in the serum for a longer period, thus furthering potential virus transmission (Hepatitis B Foundation, 2022; Hoffman & Sullivan, 2020; Norris, 2019).

Risk Factors/Protective Features

             Although vaccination is widely available and is effective 98% of the time, global HBV cases are the most prevalent and on the rise. Global HBV cases have increased by 1.5 million annually, with 296 million individuals living with HBV. Asia and Africa have the highest number of individuals living with HBV (WHO, 2022c).

Babies born to mothers with HBV are at risk of contracting the virus due to the blood exchange between mother and child. If an infant is infected with HBV from the mother, they have a 90% risk of being a disease carrier. In addition, anyone who may have an exchange of bodily fluids is at risk for developing HBV, including individuals who have unprotected sex or inject drugs. It may also be transmitted via accidental needle sticks, unsterile medical and dental equipment, and sharing personal care items such as razors and toothbrushes. Health care workers are an at-risk population, including nurses, due to potential exposure to blood and blood products. However, the screening of blood products has reduced the transmission of HBV in health care settings (Hepatitis B Foundation, 2022; Hinkle & Cheever, 2018; Norris, 2019, 2020).

Signs and Symptoms

                  Unlike HAV, HBV patients may not experience signs and symptoms for a significant period. Many with HBV unknowingly serve as carriers of the virus, infecting others. HBV symptoms include malaise, jaundice, dark urine, nausea, vomiting, and abdominal pain. Fever is infrequent; hepatomegaly, splenomegaly, enlarged cervical lymph nodes, and jaundice may occur. If the disease continues to impact the liver, the individual’s risk of developing hepatocarcinoma, cirrhosis, or liver failure increases (Hinkle & Cheever, 2018; WHO, 2022c).

Diagnosis

            HBV can be diagnosed if the surface antigen, HBsAg, is found in the serum. Specifically, the diagnosis of HBV occurs when HBsAg levels are greater than 2% in the serum. HBsAg may be detected before the onset of symptoms, during active symptoms, and decline in 3 to 6 months; elevated levels beyond six months indicate that the acute disease is transitioning to a chronic state. Initially, IgM is elevated; over time, IgM declines, and IgG levels increase in the serum. Screening may also include a liver ultrasound (Hepatitis B Foundation, 2022; Hoffman & Sullivan, 2020; Norris, 2019, 2020; WHO, 2022b).

 

Hepatitis C (HCV)

            Hepatitis C is caused by the hepatitis C virus and has an incubation period of up to 26 weeks. HCV is a single-stranded and genetically unstable virus that alters the hepatocyte during endocytosis. The virus is composed of a single RNA strand and appears similar to flaviviruses. This instability has allowed it to develop at least six different genotypes and approximately 70 subtypes. HCV genotypes are 1 (1a and 1b), 2, 3, 4, 5, and 6. Approximately 75% of individuals with HCV in the United States have either genotype 1a or 1b, while 10% to 20% of affected Americans have either genotype 2 or 3 (Kish et al., 2017; Norris, 2019, 2020; American Liver Foundation, 2022).

The ability of HCV to change has made effective treatment and vaccination difficult. The disease can be short-term or long-term, and the individual may be asymptomatic until a secondary illness occurs. Secondary conditions, such as cirrhosis or liver cancer, occur because of the stress on the liver from HCV (CDC, 2020; Hoffman & Sullivan, 2020; Norris, 2020).

Risk Factors/Protective Features

                  HCV is a viral infection found in the blood and transmitted by exchanging bodily fluids via sexual intercourse, needles for tattoos or injections, body piercings, and from mother to child during birth. HIV is a common co-infection, particularly if an individual acquires HCV through drug use. Blood transfusions can be a source of HCV in nations that do not screen donated blood products for the virus (Office of Infectious Disease and HIV/AIDS Policy, 2020; Norris, 2019, 2020).

Signs and Symptoms

            The signs and symptoms of HCV are nondescript, with many patients overlooking them and not seeking treatment. Patients may experience malaise, right upper quadrant pain, and nausea. Jaundice is not as common in HCV as in other hepatitis viruses. The virus can cause a domino effect leading to cirrhosis, hepatocellular carcinoma, and end-stage liver disease (Kish et al., 2017; Norris, 2020).

Diagnosis

            Approximately 40% of individuals infected with HCV know they have the disease. Therefore, collecting a blood sample to test for the virus is key to earlier treatment and preventing poor long-term outcomes. As previously described, specimens are analyzed for the presence of HCV antibodies; if the antibody screen is reactive, the specimen will also be tested for HCV RNA. The testing can be completed by an enzyme immunoassay or enhanced chemiluminescence immunoassay test; if positive, a polymerase chain reaction (PCR) test should be conducted to confirm the diagnosis (CDC, 2020; Kish et al., 2017).

A positive test can occur in patients 6 to 8 weeks following exposure to the virus. HCV testing is recommended at least once after age 18 and during every pregnancy. The rates of HCV have quadrupled from 2010 to 2018 due to increased injection drug use (Office of Infectious Disease and HIV/AIDS Policy, 2020; Norris, 2020).

Hepatitis D (HDV)

                  For someone to acquire HDV, they must have HBV; without it, the virus is incomplete. HDV is part of the Deltaviridiae family and contains RNA. HDV can have severe long-term implications, as HBV furthers liver inflammation and places the individual at risk for the most severe form of hepatitis, hepatocellular carcinoma, and death. The incubation period for HDV is 2 to 8 weeks (Hoffman & Sullivan, 2020; Norris, 2020; WHO, 2022c;).

Risk Factors/Protective Features

                  Individuals who contract HDV have previously or simultaneously acquired HBV as well. As such, vaccination against HBV is protective and preventative against HDV. HDV is a virus that is found in the blood. Individuals who inject drugs or receive hemodialysis are at risk of contracting HDV. Maternal to fetal virus transfer is rare compared to the other forms of viral hepatitis (Norris, 2020; WHO, 2022c).

Signs and Symptoms

                  HDV has similar signs and symptoms to HBV. However, patients infected with HDV are more likely to develop fulminant and chronic liver failure and cirrhosis than those with HBV alone (Hinkle & Cheever, 2018; Norris, 2020).

Diagnosis

            HDV is diagnosed when HDV antibodies or HDV RNA is found in the serum. Specifically, the serum will contain anti-HDV IgG and IgM, and HDV RNA (Norris, 2020; Scanlon & Sanders, 2019; WHO, 2022d).

  

Hepatitis E (HEV)

                  HEV is a single-stranded, unenveloped virus; the disease has four genotypes. Only types 1 and 2 are seen in humans, whereas 3 and 4 are found in animals. Like HAV, HEV is transmitted per the fecal-oral route. The disease is found in contaminated water sources in areas with poor sanitation. Genotype 1 is associated with contaminated water and is thus more common in humans than genotype 2. Genotype 3 tends to be in undercooked meat, such as pork and animal liver. The incubation period is 2 to 8 weeks. The disease tends to stay acute; however, long-term HEV occurs in immunocompromised individuals, such as HIV, cancer, and organ transplant recipients. The transition from acute to chronic disease occurs in 2% of patients with HEV (Hinkle & Cheever, 2018; Hoffman & Sullivan, 2020; Norris, 2020; WHO, 2022e).

Risk Factors/Protective Features

                  HEV is similar to HAV in terms of at-risk populations. However, pregnant women with HEV have a more severe illness and risk developing fulminant liver failure. A pregnant patient contracting HEV in the second and third trimester poses a more significant risk. Approximately 20 to 25% of pregnant patients in the third trimester with HEV die from the disease (Norris, 2020; WHO, 2022e).

Although HEV rarely causes chronic disease, those with a compromised immune system are at a higher risk of developing a chronic form of the disease, morbidity, and mortality. Severe disease leading to the loss of life occurs in 2% of HEV cases. HEV is found most frequently in East and South Asia (Norris, 2019; WHO, 2022e).

Signs and Symptoms

            The signs and symptoms of HEV are similar to HAV (Norris, 2020). Initially, the patient will likely experience nausea, vomiting, and anorexia. As the infection progresses, patients typically experience jaundice, dark urine, and pale stools (Hinkle & Cheever, 2018; Norris, 2020; WHO, 2022e).

Diagnosis

                  HEV appears clinically like other hepatitis viruses. As such, it is essential to identify whether an endemic is occurring and if water has been contaminated. Serum tests are conducted to determine whether anti-HEV IgM antibodies are present. Reverse transcriptase polymerase chain reaction (RT-PCR) can detect HEV in the serum or stool (WHO, 2022e).

Chronic Viral Hepatitis

            Patients with hepatitis for longer than 3 to 6 months are deemed to have chronic viral hepatitis. HBV and HCV place the patient at risk for chronic hepatitis due to hepatocellular injury and inflammation (Hinkle & Cheever, 2018; Norris, 2020).        

Risk Factors/Protective Features

                  In patients with HBV, HCV, or HDV, developing chronic hepatitis is a risk despite treatment. HCV has the highest rates of chronic viral hepatitis due to a lack of treatment in patients who have been asymptomatic for years. Eighty-five percent of individuals who have HCV are likely to transition to chronic viral hepatitis. Patients who are older, male, immunocompromised, drink alcohol, and/or take hepatotoxic medications are at greater risk for developing chronic hepatitis. Approximately 25% of individuals with chronic hepatitis will develop associated conditions, such as cirrhosis or liver cancer; typically, this occurs within 20 to 30 years of diagnosis (Hoffman & Sullivan, 2020; Norris, 2019).

Signs and Symptoms

            The signs and symptoms of chronic viral hepatitis vary and do not suggest a specific disease outcome. Typically, patients report fatigue, decreased appetite, and jaundice. If the patient develops liver failure, they are likely to experience thrombocytopenia, oliguria, ascites, edema, and changes in mentation associated with hepatic encephalopathy (Hoffman & Sullivan, 2020; Norris, 2020).

Diagnosis

                  A patient may be asymptomatic, and a workup for chronic hepatitis may be initiated due to an elevated liver function panel. In individuals with chronic hepatitis, elevated AST and ALT levels will occur; however, the severity of the disease is based upon the precipitating virus. HBV, HCV, and HDV cause chronic hepatitis (Norris, 2020).

Treatment/Management

 

Nonpharmacological Management: Fecal-Oral Route Transmission-Based Hepatitis Viruses

Patients experiencing hepatitis caused by fecal-oral route transmission have commonly encouraged nonpharmacological recommendations for care. Treatment for HAV and HEV is individualized based on the patient's symptoms and lab values; there is no specific recommended treatment. The patient will need supportive care, which includes promoting good health and reducing the risk of further trauma to the liver. The patient and family should be educated on proper sanitation and bathroom hygiene to prevent the spread of disease. The healthcare provider will need to review the list of medications the patient is prescribed and determine if any medications should be discontinued during the viral illness (Grossman & Porth, 2014; Hinkle & Cheever, 2018; Hoffman & Sullivan, 2020; National Institutes of Health [NIH], 2019; WHO, 2019a).

Patients should be encouraged to rest and maintain nutrition. The patient must have optimum nutrition to support immune function. Fluid and electrolyte status must be assessed and balanced, especially if the patient is experiencing excessive nausea, vomiting, and diarrhea. Due to the risk of dehydration, oral fluids should be encouraged and transitioned to intravenous if unsuccessful. (Grossman & Porth, 2014; Hinkle & Cheever, 2018; Hoffman & Sullivan, 2020; NIH, 2019; WHO, 2019a).

A high-quality diet rich in healthy foods and small, frequent meals may help if the patient is experiencing anorexia. Patients should be encouraged to consume a high-calorie diet due to the liver’s inability to store glycogen. High-quality hand hygiene should be encouraged to prevent spreading the infection to others (Hinkle & Cheever, 2018; Hoffman & Sullivan, 2020).

Nonpharmacological Management: Bodily Fluid/Percutaneous Transmission-Based Hepatitis            

There are universal recommendations for the nonpharmacological management of hepatitis viruses transmitted via bodily fluids or percutaneously (HBV, HCV, and HDV). Patients should be encouraged to hydrate and consume a diet low in fat and high in fruits, vegetables, and whole grains. The liver is responsible for creating and releasing bile, which emulsifies dietary fat. Vitamin supplements may be helpful; patients should avoid alcohol, tobacco, and medications that tax the liver (Hoffman & Sullivan, 2020).

It is recommended that patients with hepatitis maintain appointments with all providers, including hepatologists and/or gastroenterologists. It is crucial to assess and address any psychosocial issues due to changes in the patient’s life, such as anxieties related to being hospitalized, missing work, and avoiding sexual contact. Patients should be educated on preventing transmission to others (American Liver Foundation, 2022; Hepatitis B Foundation, 2022; Hinkle & Cheever, 2018).

A liver transplant may be required if a patient’s disease becomes severe and causes end-stage hepatic failure. This will not cure underlying hepatitis (usually HBV or HCV); however, it will prevent disease progression. HCV is a leading cause of liver failure necessitating a transplant. Patients should be screened for liver cancer, as 80% of liver cancers are due to chronic HBV or HCV infections. Liver cancer screening consists of alpha-fetoprotein AFP) in the serum, ultrasound computed tomography (CT), or magnetic resonance imaging (MRI; American Society of Clinical Oncology, 2022; Hoffman & Sullivan, 2020; Norris, 2019).

Pharmacological Prevention and Management

HAV

            HAV vaccines are available for individuals 12 months and up. However, if an infant travels, they may be given one hepatitis A vaccine at 6 months. Children and adults may be given the Vaqta or Havrix vaccines as a two-dose series. For a three-dose vaccination series, providers may opt to administer Twinrix. For travelers, immune globulin, GamaSTAN, has been approved as a prophylactic treatment. IgG may be given following exposure to HAV (CDC, 2021; Norris, 2019, 2020). 

HBV

            HBV has a vaccination series to prevent the acquisition and spread of the virus. The vaccination is highly effective, preventing viral acquisition in at least 98% of recipients. The vaccinations are given intramuscularly. Infants should receive their first HBV vaccination dosage within 24 hours of birth, followed by two to three other doses given at least four weeks apart. The vaccine can also be administered within 7 days of exposure for post-exposure prophylaxis (Hepatitis B Foundation, 2022; Norris, 2020; WHO, 2022b).

            Patients with HBV may require pharmacological treatment with interferons and nucleoside analogs. Patients commonly take tenofovir disoproxil (Viread) or entecavir (Baraclude). These medications can slow the progression of the disease, preventing cirrhosis and liver cancer; however, there is a risk of hepatotoxicity with nucleoside analogs (Lok, 2019; WHO, 2022b).

HCV

            Currently, a vaccination for HCV is not available. Patients with HCV should be administered oral antivirals; the direct-acting antiviral medications can cure HCV in 8 to 12 weeks in 95% of individuals and prevent further complications such as cirrhosis and liver cancer. However, many individuals must take medications for at least 6 months or longer. These medications vary depending on the strain of the virus, viral load, presence of liver damage in the body, any previous treatment for HCV, and any other current infections (American Liver Foundation, 2022; Hoffman & Sullivan, 2020; Office of Infectious Disease and HIV/AIDS Policy, 2020).

            Traditional and effective medications, ribavirin (Virazole) and pegylated-interferon (PEG-IFN), have been used for several years; however, interferon has numerous exclusion criteria, making many individuals ineligible. As such, newer treatments have evolved, though many require multiple medications and the use of ribavirin (Virazole). Sofosbuvir/velpatasvir (Epclusa) must be given with ribavirin (Virazole). Glecaprevir/pibrentasvir (Mavyret) and sofosbuvir/velpatasvir/voxilaprevir (Vosevi) are used to manage all HCV genotypes with treatment ranging from 8 to 12 weeks. The medications work at various points in the HCV viral replication cycle. Examples of genotype-specific medications include simeprevir (Olysio) plus sofosbuvir (Sovaldi) and ledipasvir/sofosbuvir (Harvoni) for genotype 1a, sofosbuvir (Solvaldi) plus ribavirin (Virazole) for genotypes 2, 3, and 4, and ledipasvir/sofosbuvir (Harvoni) for genotypes 5 and 6. The most common side effects are headache and fatigue; however, some medications can cause anemia. The healthcare team should assess serum laboratory data, changes in the patient’s physical assessment, and potential risk for drug resistance (American Liver Foundation, 2022; Kish et al., 2017; Lagging et al., 2018).

HDV

            There is no specific treatment for HDV as it is treated with and like HBV. As such, patients receive interferon and antivirals. It is worth noting that the recurrence of HDV is high even when interferon is appropriately administered. The interferon should be administered for at least 48 weeks. Preventing HBV will assist in preventing HDV. Therefore, it is recommended that all receive the HBV vaccination series. However, there is no specific vaccination for HDV (Hinkle & Cheever, 2018; Hoffman & Sullivan, 2020; Norris, 2019, 2020).

HEV

            Treating a patient with HEV is based on the patient’s symptoms. Unfortunately, there is no readily available vaccination for HEV. However, WHO identified that an HEV vaccine is available and licensed in China, though unavailable in other countries. If a patient is given a medication to treat HEV, the medication of choice is typically ribavirin (Virazole), especially in the immunocompromised population. However, medication therapy is not frequently used as the disease is usually self-limited (Hoffman & Sullivan, 2020; WHO, 2022e).

Chronic Viral Hepatitis

                  Medications to treat the precipitating virus (i.e., HBV or HCV) will be used to manage chronic viral hepatitis. For instance, patients with HBV may take interferons and/or nucleotide analog agents (Norris, 2020).

 

Evidence-Based Nursing Practice/Implications for Nursing

            By 2030, the WHO seeks to abolish HBV; this goal is contingent upon promoting greater education, awareness, and prevention using the HBV vaccination series. Postpartum and pediatric nurses are well-poised to educate new parents on the HBV vaccination series. Hepatitis causes loss of time at work and school; nurses are in a great position to promote health and wellness in preventing and caring for patients with hepatitis (Hinkle & Cheever, 2018; Seto et al., 2018).

Nursing Care

Nursing care for patients with any hepatitis diagnosis may range from patient education to caring for a patient with severe life-threatening liver damage secondary to either acute or chronic hepatitis. A common goal among health care workers is to reduce the risk and incidence of hepatitis, and education is paramount to that endeavor. Patient education is essential in various settings and would include educating individuals or groups about known risk factors and modes of transmission. Education should also include promoting available vaccines for HAV and HBV, demonstrating appropriate hand hygiene and hygiene practices in general, avoiding contaminated water and food, explaining the risks of travel to certain areas, and what to do if there is potential exposure. Currently, 48 out of 50 states mandate HBV vaccination to enter schools or daycare centers; about half of all states have a similar mandate for HAV vaccination (Hoffman & Sullivan, 2020; Immunize.org, 2019, 2021).

Public health campaigns should include the risk of IV drug use, safer sexual practices, and other ways to decrease blood and body fluids transmission. All healthcare professionals must collaborate to educate patients and work towards an improved standard of care involving needlesticks, sharps incidents, and other possible sources of contamination for caregivers. As patients are diagnosed with hepatitis and will be cared for by their family, education should also include safety precautions to prevent transmission to family members and friends (Ignatavicius et al., 2018).

Nursing will be involved in completing assessments in collaboration with the provider. Within the scope of practice for the nurse, this would include gathering health history information and completing the physical assessment for both subjective and objective data. The patient’s current and historical medications should be reviewed in great detail, including over-the-counter medicines, supplements, and alternative and complementary therapies; some of these can be toxic to the liver and increase the risk of further damage. The nurse may also collect specimens from the patient as ordered and arrange for diagnostic testing such as liver biopsy and other invasive studies. The nurse may be asked to assist the provider directly, but they also provide a source of emotional support for the patient during the procedure. Patients may also need emotional support and education if their workup indicates significant liver damage and the potential for long-term complications. Mental health, including stress and anxiety over life changes, can negatively impact a patient with hepatitis (Ignatavicius et al., 2018).

In collaboration with dietary staff and nutrition experts, the nurse should assess the patient's nutritional needs and discuss with the patient what types of foods they like, dislike, and are interested in eating at this time. Many patients with hepatitis have anorexia and food aversion; finding food that sounds appealing to them can be challenging. The nurse can suggest smaller portions to be eaten more frequently to decrease the risk of nausea and vomiting. Initially, the nurse should encourage a diet high in carbohydrates and calories and lower in fat and protein until the patient regains their appetite. Appropriate levels of fat and protein are then essential to a full recovery. Dietary staff may help find nutritionally dense snacks that appeal to the patient. The provider will collaborate with nursing and dietary staff regarding any recommended vitamins or other supplements based on the nutritional needs and status of the liver, as some vitamins could be problematic until the liver has healed (Ignatavicius et al., 2018).

Patients with hepatitis are vulnerable to fatigue and need adequate rest in the hospital and while recovering at home. Rest is required to decrease metabolic demands and promote more substantial blood flow to the hepatic system to heal and restore liver tissue. The provider may limit the patient’s activity level based on liver enzyme testing results. The amount of activity can be increased if lab results improve, but the activity level should be limited again if liver function tests worsen. The nurse should encourage the patient to rest when they feel tired, pace themselves, and learn to prioritize activities to accomplish their most vital tasks first (Ignatavicius et al., 2018).

Nurses must administer medications if the patient is an inpatient, educate all patients regarding their medications, and monitor for adverse effects. Standard precautions should be implemented. Education for the patient and family regarding infection prevention and health promotion is also essential (Ignatavicius et al., 2018).

The nurse may make referrals to other agencies or case management to assist the patient with medication costs, home health/public health for support at home, and others that might benefit the patient. Patients, particularly those with chronic HCV, often experience lapses in quality care along the continuum of health care. In particular, researchers found patients with a history of substance abuse were less likely to be prescribed treatment and have follow-ups. Nurses can ensure that patients receive appropriate care coordination (Reader et al., 2020).

Future Research

Artificial Intelligence: Predicting Disease Outcomes

                  The University of Florida has begun researching using four artificial intelligence (AI) algorithms to predict HCV. The algorithms use machine learning to determine success versus failure for treatment options. Machine learning considers patients’ comorbidities and lifestyle factors, such as alcohol consumption and smoking (Bennett, 2022).

            AI has the potential to assist in diagnosing and treating hepatitis patients. The researchers recommend using AI to explore incidences of hepatitis complications, such as hepatic encephalopathy and hepatocellular carcinoma. It is recommended that further research using machine and deep learning in AI is needed to enhance earlier diagnosis and care of the hepatitis patient. Artificial intelligence has the potential to identify at-risk HCV patients 2 to 3 years before initial diagnosis or onset of signs and symptoms (Doyle et al., 2020; Liu et al., 2021; Shergill, 2021).

HBV Cure

In addition to preventing HBV, there is a global push to cure the virus. A cure requires complete seroconversion of HBV. The International Coalition to Eliminate HBV (ICE-HBV) has a team of more than 50 scientists researching a cure for HBV. The goal is to slow or stop cellular division from occurring. Researchers predicted that a cure for HBV is likely to come from multiple medications that address the episomal covalently closed DNA, the existence of HBV DNA within the large human genome, the large antigen load, and the exhausted immune response within the liver (Fanning et al., 2019; Lee et al., 2021; Revill et al., 2019).

Research also suggests that a cure for HBV may come from a direct attack on the core protein. Core protein allosteric modulators (CpAMs) may be able to prevent DNA replication. Other scientists concur that CpAMs are promising as a possible HBV cure (Schlicksup et al., 2018; Viswanathan et al., 2020).

New Goals

WHO seeks to combat the morbidity and mortality caused by hepatitis through encouraging vaccination, diagnostic testing, administration of medications, and education. The goal is to reduce new infections by 90% and deaths by 65% between 2016 and 2030. To accomplish this, all stakeholders, such as healthcare providers, nurses, patients, and families, must be on board and actively engaged in activities to screen for and treat the illness. Nurses have an excellent opportunity to contribute to the decrease and possible cessation of hepatitis through health promotion (WHO, 2022a).

References

American Liver Foundation. (2022). Treating hepatitis C. https://liverfoundation.org/for-patients/about-the-liver/diseases-of-the-liver/hepatitis-c/treating-hepatitis-c/#medication-regimens-according-to-hcv-genotype

American Society of Clinical Oncology. (2022). Liver cancer: Screening. https://www.cancer.net/cancer-types/liver-cancer/screening#:~:text=Screening%20options%20for%20liver%20cancer,magnetic%20resonance%20imaging%20(MRI)

Bennett, D. (2022). UF Health researchers use artificial intelligence to better predict hepatitis C treatment outcomes. https://ufhealth.org/news/2022/uf-health-researchers-use-artificial-intelligence-better-predict-hepatitis-c-treatment

Centers for Disease Control and Prevention. (2020). Hepatitis C. https://www.cdc.gov/hepatitis/hcv/index.htm

Centers for Disease Control and Prevention. (2021). Hepatitis A. https://www.cdc.gov/vaccines/pubs/pinkbook/hepa.html#:~:text=onset%20of%20symptoms-,Pathogenesis,weeks%20before%20onset%20of%20illness

Doyle, O. M., Leavitt, N., & Rigg, J. A. (2020). Finding undiagnosed patients with hepatitis C infection: An application of artificial intelligence to patient claims data. Scientific Reports, 10. https://doi.org/10.1038/s41598-020-67013-6

Fanning, G. C., Zoulim, F., Hou, J., & Bertoletti, A. (2019). Therapeutic strategies for hepatitis B virus infection: towards a cure. Nature Reviews Discovery, 18, 827-844. https://www.nature.com/articles/s41573-019-0037-0

Grossman, S., & Porth, C. (2014). Porth's pathophysiology concepts of altered health states (9th ed.). Wolters Kluwer Lippincott Williams & Wilkins.

Hepatitis B Foundation. (2022). What is Hepatitis B? https://www.hepb.org/what-is-hepatitis-b/what-is-hepb/

Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth's textbook of medical-surgical nursing (14^th ed). Wolters Kluwer.

Hoffman, J. J. & Sullivan, N. J. (2020). Davis advantage for medical-surgical nursing: Making connections to practice (2^nd ed). F. A. Davis.

Ignatavicius, D., Workman, M., & Rebar, C. (2018). Medical-surgical nursing concepts for interprofessional collaborative care (9th ed.). Elsevier.

Kish, T., Aziz, A., & Sorio, M. (2017). Hepatitis C in a new era: A review of current therapies. Pharmacy & Therapeutics, 42(5), 316-329. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398625/

Lagging, M., Wejstål, R., Duberg, A-S., Aleman, S., Weiland, O., & Westin, J. (2018). Treatment of hepatitis C virus infection for adults and children: Updated Swedish consensus guidelines 2017. Infectious Diseases, 50(8), 569-583. https://doi.org/10.1080/23744235.2018.1445281

Lai, M., & Chopra, S., (2022). Hepatitis A virus infection in adults: Epidemiology, clinical manifestations, and diagnosis. Retrieved July 10, 2022, from https://www.uptodate.com/contents/hepatitis-a-virus-infection-in-adults-epidemiology-clinical-manifestations-and-diagnosis

Lee, H. W., Lee, J. S., & Ahn, S. H. (2020). Hepatitis B virus cure: Targets and future therapies. International Journal of Molecular Sciences, 22(1), 213. https://doi.org/10.3390/ijms22010213

Liu, W., Liu, X, Peng, M., Chen, G-Q, Liu, P-H., Cui, X-W., Jiang F., & Dietrich, C. F. (2021). Artificial intelligence for hepatitis evaluation. World Journal of Gastroenterology, 27(34), 5715-5726. https://doi.org/10.3748%2Fwjg.v27.i34.5715

Lok, A. F-S. (2019). Hepatitis B treatment: What we know now and what remains to be researched. Hepatology Communications, 3(1), 8-19. https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/hep4.1281

National Institutes of Health (2019). Hepatitis disease-specific research. https://www.niaid.nih.gov/diseases-conditions/hepatitis-research

Norris, T. (2019). Porth's pathophysiology: Concepts of altered health states (10^th edition). Wolters Kluwer.

Norris, T. (2020). Porth's essentials of pathophysiology (5^th edition). Wolters Kluwer.

Office of Infectious Disease and HIV/AIDS Policy. (2020). Hepatitis C basic information. https://www.hhs.gov/hepatitis/learn-about-viral-hepatitis/hepatitis-c-basics/index.html

Reader, S. W., Kim, H-S., El-Serag, H. B., & Thrift, A. P. (2020). Persistent challenges in the Hepatitis C virus care continuum for patients in central Texas public health system. Open Forum Infectious Diseases, 7(8). https://doi.org/10.1093/ofid/ofaa322

Revill, P.A., Chisari, F. V., Block, J.M., Dandri, M., Gehring, A. J., Guo, H., Hu, J., Kramvis, A., Lampertico, P., Janssen, H. P. L., Leverero, M., Li, W., Liang, T. J., Ling, S-G., Lu, F., Capucine Penicaud, M., Tavis, J. E., & Thimme, R. (2019). A global scientific strategy to cure hepatitis B. The Lancet, Gastroenterology & Hepatology, 4(7), 545-558. https://doi.org/10.1016/S2468-1253(19)30119-0

Sanders, V. C., & Sanders, T. (2019). Essentials of anatomy and physiology (8^th ed.). F. A. Davis Company.

Seto, W-K., Lo, Y-R., Pawlotsky, J-M., & Yeung, M-F. (2018). Chronic hepatitis B infection. The Lancet, 392(10161), 2313-2324. https://doi.org/10.1016/S0140-6736(18)31865-8

Shlicksup, C. J., Wang, J. C-Y., Francis, S., Venkatakrishnan, B., Turner, W. W., VanNieuwenhze, M., & Zlotnick, A. (2018). Hepatitis B virus core protein allosteric modulators can distort and disrupt intact capsids. eLife.7. https://doi.org/10.7554/eLife.31473

Shergill, A., Narasimhan, V. L., & Budu, E. (2021). S1112 Artificial intelligence and machine learning-based system for diagnosis of chronic Hepatitis C. The American Journal of Gastroenterology, 116, 5524. https://doi.org/10.14309/01.ajg.0000777980.35182.90

Viswanathan, U., Mani, N., Hu, Z., Ban, H., Du, Y., Chang, J., & Guo, J-T. (2020). Targeting the multifunctional HBV core protein as a potential cure for chronic hepatitis B. Antiviral Research, 182. https://doi.org/10.1016/j.antiviral.2020.104917

World Health Organization. (2022a). Hepatitis. https://www.who.int/health-topics/hepatitis#tab=tab_1

World Health Organization. (2022b). Hepatitis A. https://www.who.int/news-room/fact-sheets/detail/hepatitis-a

Worth Health Organization, (2022c). Hepatitis B. https://www.who.int/news-room/fact-sheets/detail/hepatitis-b

World Health Organization (2022d). Hepatitis D. https://www.who.int/news-room/fact-sheets/detail/hepatitis-d

World Health Organization. (2022e). Hepatitis E. https://www.who.int/news-room/fact-sheets/detail/hepatitis-e