Viral hepatitis is endemic in many parts of the world. In the U.S., hepatitis A is the most common cause of symptomatic acute hepatitis, with an estimated 33,000 acute clinical cases in 2003.¹ Most viral hepatitis is caused by one of six viral agents described by the letters A, B, C, D, E, and G. Only B, C, and D can lead to chronic infection. Chronic viral hepatitis has become an epidemic in this country, with hepatitis C causing 2.7 million chronic infections and 8,000 to 10,000 deaths a year.¹ Hepatitis C is the most common cause of cirrhosis and hepatocellular carcinoma and is the reason for most of the liver transplants in this country.²

Viral hepatitis is a systemic infection that attacks the liver, causing inflammation and hepatic cell death. When the liver is inflamed or damaged, it is unable to break down waste products in the blood. Alcohol, certain drugs, and other chemical toxins also can cause hepatitis. In the case of viral hepatitis, the destruction of the liver cells (hepatocytes) is a result of the replication process of the virus. The presence of the virus also prompts an immune response and inflammatory process that can further damage hepatocytes.³

Progress has been made in the development of effective vaccines for hepatitis A and B. Marked drops in acute infections for both hepatitis A and B are attributed to the effectiveness of these vaccines in the U.S.¹ There is currently no vaccine for hepatitis C or for any of the other forms of viral hepatitis. Acute and chronic hepatitis occurs in just about every practice setting, and nurses must be well-informed about the signs, symptoms, routes of transmission, and treatment options.

Symptoms and diagnosis

Infection with viral hepatitis can range from a symptomatic and self-limiting process to a life-threatening acute or chronic disease. When the disease is asymptomatic, many cases are unrecognized and underreported. Patients admitted to the hospital for other reasons may have hepatitis that is undiagnosed because they are not clinically ill, increasing the potential risk of exposure in almost all areas of practice. Therefore, nurses must practice standard and universal precautions consistently in every setting.

All forms of hepatitis have similar symptoms. The onset of illness can be abrupt, with fever, jaundice, malaise, anorexia, dark urine, light stools, nausea, and abdominal discomfort, or it can be asymptomatic, as may be the case in young children.³ The symptoms that usually prompt a patient to visit a physician are dark urine and yellowing of the sclera of the eyes. Laboratory tests that look for antibody and antigen markers are done to establish the type of hepatitis.

Hepatitis A

Hepatitis A (HAV) occurs worldwide and can be of epidemic proportion in some developing countries. HAV is transmitted primarily through the fecal-oral route. Transmission can occur through person-to-person contact, ingestion of contaminated food or water, or through exposure to contaminated blood or blood products.⁴ The infectious agent is found in the stool before symptoms appear.

The incubation period of HAV can be as short as 15 days or as long as 50 days. This long incubation period may make it difficult to determine the source of the infection. There is widespread exposure to HAV early in life in countries with poor sanitation. Person-to-person spread is particularly common among children, who often do not practice good handwashing habits. Day care centers frequently are sites of HAV outbreaks if poor diaper-changing practices are in place. Infected children often are asymptomatic and thus not recognized as having the disease. In adults, the disease can be severe and debilitating during the acute stages and lasts four to eight weeks. Fortunately, recovery usually is complete and chronic infections are not known to occur.⁵

Outbreaks have been related to contaminated water and food, especially seafood from contaminated water. In 1997, an outbreak of 153 cases of hepatitis A was identified in a Michigan school district, with the source identified as contaminated strawberries imported from Mexico and processed and frozen in California.⁶ HAV outbreaks have occurred in hospitals from health care workers’ eating, drinking, and preparing food in work areas. OSHA’s bloodborne pathogen standard, mandatory in all health care settings, strictly prohibits this practice.

HAV preventive measures include education about sanitation, proper washing and cooking of food, safe disposal of feces (such as with diapers), and probably most importantly handwashing before eating and preparing food.

Hepatitis A vaccine now is available for adults and children 2 and older. This vaccine is recommended for people who travel to endemic areas, men who have sex with men, children in communities with elevated rates of HAV, anyone with chronic hepatitis B or C, and people in other specific risk groups. Anyone exposed to HAV should receive immune globulin (IgG) within two weeks of exposure to prevent disease.⁴ Once a person is infected, immunity usually lasts a lifetime. In cases of HAV epidemics, the public health department becomes involved to determine the cause of outbreak and to prevent spread of the disease.

Hepatitis B

Hepatitis B (HBV) is a major problem in the U.S. and of concern for unvaccinated health care workers. OSHA requires employers to offer the hepatitis B vaccine free to health workers in high-risk occupations. Hepatitis B is transmitted primarily through percutaneous and perimucousal routes, such as through needlesticks, needle sharing, and sexual transmission, as well as from an infected mother to her baby at birth. As with all hepatitis, some cases are asymptomatic.

Hepatitis B occurs in all geographic regions, especially in Southeast Asia. The Centers for Disease Control and Prevention estimates that there were 21,000 new acute hepatitis B cases in the United States in 2003 alone. These cases contribute to the estimated 1.25 million chronically infected individuals who provide a reservoir for the virus, contributing to an estimated 73,000 new infections annually.¹ HBV causes both acute and chronic liver disease. Usually, the infection resolves and the virus clears from the blood. However, in some people the virus remains, and they become chronic carriers of the disease. Many people with chronic hepatitis know of no exposure and have no known history of disease.

Acute HBV can be diagnosed by testing blood for the presence of the hepatitis B surface antigen (HBsAg) and for IgM antibody to hepatitis B core antigen (anti-HBc IgM). Chronic hepatitis is diagnosed when HBsAg remains in the blood for over six months. Children who contracted the disease through vertical transmission (mother to baby) have the highest risk for chronic infection.⁷ A blood test showing the hepatitis Be antigen (HBeAg) indicates a high level of viremia, and the disease is highly transmissible to people exposed to blood and body fluids from this individual source.

Some people with chronic hepatitis go on to develop cirrhosis and cancer of the liver, which may not be recognized until later in life. Interferon and lamivudine are approved treatments for chronic disease.⁸ Treatment is not without major adverse effects and may not be effective in eliminating the virus from the body. In patients who have successful response to treatment with antiviral agents (as manifested by clearance of HBeAg and hepatitis B DNA in the blood), the relapse rates are rare, and results of therapy appear to be long-lasting.⁹ Follow-up care for all cases of HBV should be done by a specialist whenever possible.

Hepatitis B vaccine is routinely recommended for high-risk groups, including for health workers with exposure to blood and body fluids and for all infants. If exposure to HBV occurs to a nonimmune person, hepatitis B immune globulin (HBIG), which provides passive immunity, is given. The specific indications for HBIG are percutaneous exposures (needlesticks), sex with an infected person, and perinatal exposure. The hepatitis B vaccine is given at the same time.

Hepatitis D (HDV), known as the “delta virus,” is always associated with hepatitis B. HDV can be acquired as a coinfection or a super infection in patients with chronic HBV. HDV coinfections may have a more severe acute disease than HBV alone.³ Antiviral treatment is recommended, but response is poor. The symptoms are the same as other forms of hepatitis, and the mode of transmission is primarily the same as hepatitis B.

Hepatitis C

Hepatitis C (HCV) is the most common bloodborne infection in the U.S. The incubation period is about two weeks to six months. Most of those infected have no symptoms. In the acute stage of disease, signs and symptoms, if present, may include fatigue, anorexia, nausea, fever, and a tender liver. The infected person often is anicteric (without jaundice). In a few cases, HCV is self-limited, but up to 85% of those infected will develop chronic hepatitis.² Coinfection with HIV causes a more rapid progression to end-stage liver disease. HCV is the most common reason for hepatocellular carcinoma and liver transplants in the U.S.²

The risk factors for acute hepatitis C are injection drug use, intranasal cocaine use, a history of STDs, occupational needlestick injury, multiple sex partners, blood transfusion before 1992, and a low socioeconomic level.² Hemophiliacs, who had a high incidence of disease, now are less likely to be infected because blood products now are tested and inactivated for HCV. The use of shared nasal straws for cocaine contributes to the transmission of the virus, but many cocaine users also use intravenous drugs, also a risk factor. Babies born to HCV-infected mothers demonstrate at birth a 4% to 7% positivity rate. If the mother is co-infected with HIV, the infection rate increases to 14%. The transmission of HCV through breast milk has not been documented.² Sexual transmission is not considered a major risk unless there is a history of STDs and multiple sex partners. Alcoholism compounds the damage inflicted on the liver by the virus.

Chronic HCV is an insidious process that usually progresses slowly for several decades without symptoms or physical signs until chronic liver inflammation causes necrosis and fibrosis and eventually an RNA serum test detects circulating virus in the blood. An infected person should be monitored closely and evaluated for the presence and severity of chronic liver disease. Liver enzyme elevations do not indicate the degree of liver damage, and further assessment is necessary for a more definitive answer. An ultrasound of the liver may rule out other causes of liver disease, and a liver biopsy provides histological evidence of liver destruction due to chronic hepatitis.

Vaccines and immunoglobulin product for HCV do not exist, because the body does not develop protective antibodies for all the genotypes of hepatitis C, which makes the development of a vaccine difficult and limits response to therapy. But advances in immunology and innovative approaches to immunization make it likely a vaccine will be developed in the future.²

When infection control practices are not used in the health care workplace, nosocomial transmission of HCV is possible and has been reported in hemodialysis centers where medication vials and supplies are shared. The risk of spread of HCV from an infected health care worker to a patient is low. If a health worker is exposed to blood in the workplace, the source patient and the employee should be tested for serological markers to hepatitis. If the source patient is positive for HCV, the health care worker should be tested for HCV virus and for liver enzyme abnormalities at specific intervals. If conversion to hepatitis C positive occurs, further medical follow-up and treatment may be recommended.

Treatment of hepatitis C

Once chronic hepatitis C is established, patients 18 and older with compensated liver disease are treated with antiviral drugs to reduce the viral load and to prevent or slow disease progression. Treatment is unequivocally recommended for the group of patients with chronic hepatitis C who are at the greatest risk for progression to cirrhosis.² Currently, the most effective treatment is a combination of pegylated interferon and ribavirin. Treatment typically includes weekly doses of injectable pegylated interferon and daily oral doses of ribavirin, preferably managed by a gastroenterologist or a specialist familiar with HCV disease treatment.² Flulike symptoms occur early on with this treatment. Late adverse effects include fatigue, bone marrow suppression, cognitive changes, irritability, and depression.¹⁰ Therapy for hepatitis C is a rapidly changing area of clinical practice. Treatment recommendations for HCV will likely require frequent updates in the years to come.¹¹

Patients with alcoholism and active IV drug abuse should delay or discontinue treatment until addictions are under control. Patients with decompensated liver disease should be considered for liver transplant.

Other types of viral hepatitis

Hepatitis E is an enterically transmitted form of hepatitis with a course similar to that of HAV.³ There does not appear to be a chronic form of disease. Pregnant women in the third trimester may be at an increased risk for complications. Hepatitis E has occurred in the United States only as an imported infection. Hepatitis G recently has been identified, but its role in acute viral hepatitis has not yet been completely established.

Nursing implications

Nurses need to be alert for signs of hepatitis in patients and in themselves. During nursing assessment, the history is important to determine whether there is a risk for any type of hepatitis, such as travel, IV drug use, or previous blood transfusion. If the history is positive, the information needs to be relayed to the physician. The nurse needs to maintain a nonjudgmental attitude to obtain an accurate history and provide information about treatment. Those in high-risk groups need to be aware that they should not donate blood and serum; should avoid alcohol and nonprescription drugs, such as acetaminophen; and should be vaccinated for other types of hepatitis. Follow-up care with medical assessments is important for good outcomes. Care of people with hepatitis requires strong nursing assessment skills and compassion. Nurses provide important support during the long chronic phase of disease and can encourage patients to join support groups.

Nurses face a risk of exposure during procedures involving blood and body fluids. Along with being vaccinated against hepatitis B, the nurse needs to follow standard and universal precautions, even if a client’s history does not indicate a risk for hepatitis. OSHA requires the use of safety equipment whenever available. The nurse needs to advocate for the use of new safety equipment as it comes on the market. Safe work practices, such as proper needle disposal, also are important. Accidental injuries must be reported promptly so the worker can be evaluated and treated if necessary. Reporting typically includes documentation of work activity, source of exposure, and any subsequent confirmed transmission. By following these guidelines, the nurse can provide a safe environment for both worker and patient