Hepatitis B: Elevation in the Level of the Liver Enzymes - Literature review Example

Hepatitis B Hepatitis is the inflammation of the liver, resulting to swollen and tender liver (Everson and Weinberg, 2002). That is, there are many inflammatory chemicals being produced and released in the liver which damages the liver cells or hepatocytes. This disease can be diagnosed even of a mild degree through blood test and laboratory analysis on the level of liver enzymes. Elevation in the level of the liver enzymes will mean that there are some degree of liver inflammation occurring. Long-term alcohol intake, toxic chemicals, poisons, drugs or medicines, improper diet, fatty deposits in the liver, autoimmune diseases, non-viral infections like Q fever, and various viral infections including glandular fever and some diseases of the biliary system may cause non-infectious hepatitis. Infectious etiology includes viruses, which attack liver cells. Viral hepatitis includes hepatitis A, B, C, D, E, F and G (Cronin, 2005). Other viruses of both new and old varieties can also attack the liver such as Epstein Barr virus and the Cocksackie virus (Sandler et al., 2002). Hepatitis B is caused by infection with the hepatitis B virus (HBV),(Cronin, 2005) noted that among the many forms of viral hepatitis, Hepatitis B is the most easily spread (contagious) form. Hepatitis B is also present world-wide with many people being the carriers. The virus is infective but there are no symptoms of the virus. There are an estimated of over 300 million carriers around the world. (Adefovir, 2006). Less then half of those with acute HBV infections are typically asymptomatic, they may be infected but have no symptoms. The symptoms of Hepatitis B infection is that after initial contact with the virus symptoms, take on average, around 60 to 90 days to develop (Cronin, 2005). Adults will develop symptoms that vary in severity from mild to severe. One of the early manifestations is low-grade fever accompanied with headache, nausea and vomiting, anorexia and fatigue. Skin rashes, joint pains, muscle aches, diarrhea and constipation may also occur. As the disease progresses, a constant discomfort on the right upper quadrant under the rib cage are felt as the liver becomes inflamed. The defining sign of hepatitis which is jaundice, usually presents after other symptoms begin to resolve (Cronin, 2005). There are two types of Hepatitis B infection: acute (short-term) or chronic (long-term). (Cronin, 2005) stressed that an acute infection is self-limiting, or heals by itself without treatment. Some people are asymptomatic. Those who present symptoms of HBV infection recover fully after 4-8 weeks. An infected person is no longer contagious once the acute infection is over and it guarantees lifelong protection against future infection because of the antibodies developed against HBV. In a small percentage of people, the HBV continues to remain in the liver and blood for 6 months or more, leading to chronic HBV infection. These people are known as carriers and they can easily spread the virus as long as the condition lasts. Estimates suggest that 400 to 500 million people worldwide are HBV carriers (Adrienne M Buggs and Joseph K Lim, 2006). The morbidity and mortality rate in chronic hepatitis B is significantly high. The risk of developing cirrhosis and hepatocellular carcinoma (liver cancer) is associated with chronic hepatitis B because it silently damages the liver as the years go by (Hoofnagle, 2002).(Adrienne M Buggs and Joseph K Lim, 2006) emphasized that an estimated 20% of the total deaths per year in the world accounts to viral hepatitis-induced liver disease. The hepatitis B virus spread from an infected person to another both parenterally and sexually through body fluids and secretions. A lot of HBV transmissions are via the mucous membranes exposure or percutaneous exposure to infectious body fluids such as blood, saliva, serum, semen and vaginal fluids, including menstrual blood (Adrienne M Buggs and Joseph K Lim, 2006). Contact with the infected body fluid can occur from sexual contact, sores, cuts in the skin, body contacts, sports, sharing infected materials and others (Heathcote, 2001). The hepatitis B virus spread from an infected person to another both parenterally and sexually through body fluids and secretions. Contact with the infected body fluid can occur from sexual contact, sores, cuts in the skin, body contacts, sports, sharing infected materials and others (Heathcote, 2001). A lot of HBV transmissions are via the mucous membranes exposure or percutaneous exposure to infectious body fluids such as blood, saliva, wound exudates, serum, semen and vaginal fluids (including menstrual blood) from either a person with acute or chronic HBV infections (Cronin, 2005). Hepatitis B virus gains entry to another person in several ways. The most important route for the spread of HBV is by sexual contact. HBV gains entry to the body through contact with the mucous lining or breaks in the lining of the rectum, vagina, urethra or mouth. At great risk are heterosexual and homosexual persons with multiple partners, those with a recent history of sexually transmitted disease or who are sexual partners of HBV carriers (Adrienne M Buggs and Joseph K Lim, 2006). According to (Cronin, 2005) and (Hensley, 2005), blood and serous fluids contains the highest concentrations of the hepatitis B virus. The blood that contains the HBV can remain contagious or infectious for weeks or longer, even if it is dried. Blood exposure is relatively an efficient mode of transmission. Intravenous illegal drug users are at high risk for HBV infection because of needle-sharing that may result to direct parenteral inoculation of HBV-infected blood into their veins (Hensley, 2005). Work-related blood exposure is another risk factor. Health care workers who handle blood and instruments in drawing blood may become infected with HBV. Needlestick injuries with used needles or other injuries from sharp instruments with HBV-infected blood and blood splashes onto the eyes, mouth or break in the skin, put the medical personnel at risk of becoming infected (Cronin, 2005). (Adrienne M Buggs and Joseph K Lim, 2006) added that other groups who are equally at risk with exposure to HBV-infected blood are recipients of blood and blood-products transfusions and patients undergoing hemodialysis. Although accounting for only a small proportion of cases reported, the other mode of HBV transmission by percutaneous exposures include tattooing, ear piercing and acupuncture with needles that were not properly cleaned and sterilized. Toiletries items such as razors and toothbrushes that carry blood from a person who is infected with the virus can spread the HBV (Hensley, 2005). In addition, another important mode of transmission is perinatal transmission, in which the virus is passed by contact of infected maternal blood and body fluids in the birth canal to the newborn’s mucous membranes during delivery (Cronin, 2005). Although lower concentrations of HBV are found in semen, vaginal fluid and saliva as well, saliva can be a medium of transmission through bites(Hensley, 2005). Prevention is central to the control of HBV transmission. Hepatitis B care and treatment costs are substantial and if left untreated, can have a serious long term sequelae and possibly facilitate the transmission to others. Primary and secondary prevention are essential components of the response to HBV infections. (Brown et al., 2006) noted that primary prevention for hepatitis B targets uninfected individuals. It aims to reduce risk factors for disease acquisition. (McAvoy and Hayes, 2005) added that primary prevention is defined as the deterrence of known risk factors from setting off the infection process. (Department of Health, 2004a) delineated the four major components of the primary prevention of HBV infection through hepatitis B vaccination: 1) maternal screening to prevent perinatal HBV infection.and postexposure prophylaxis of newborns born to mothers who are potentially infectious; 2) hepatitis vaccination of all infants as part of the usual immunization schedule to prevent childhood infection; 3) anyone 18 years old or younger not previously vaccinated; and 4) vaccination of high–risk adult populations such as medical personnel who are exposed to blood and body fluids, people who have multiple sex partners or who have a history of sexually transmitted diseases, household contacts and sex partners who have hepatitis B, people who have blood-clotting disorders, such as hemophilia, and received clotting factors from human donors, people who have kidney disease that requires them to undergo hemodialysis and people who will spend more than 6 months in parts of the world where hepatitis B endemic (Cronin, 2005) (Rushing et al., 2005), (Cronin, 2005) stressed that pre-exposure immunization is the most effective way to avert transmission of infectious diseases including hepatitis B. The hepatitis vaccine if given in series of three shots is proven to be 95% effective against HBV infection. According to (Centers for Disease Control and Prevention, 2002), the use of HBsAg (hepatitis B surface antigens) which is generated by recombinant DNA technology in the hepatitis B vaccine provides protection from HBV infection in preexposure immunization and postexposure prophylaxis. Routine infant immunization is an integral part of a long-term control strategy of HBV infection and its sequelae. WHO has recommended that Hepatitis B vaccine be integrated in childhood immunization schedules in all countries in perinatal hepatitis B virus transmission prevention, WHO recommends that the first dose of hepatitis B vaccine be given to the newborn preferably within 24 hours after birth. Along side with it, WHO recommends also that all pregnant mothers be screened for HBsAg. Infants born to infected mothers should be tracked to assure completion of the hepatitis B vaccine series (2003). Hepatitis B immune globulin (HBIG) and hepatitis B vaccine are two products approved for hepatitis B prevention. HBIG, which is used for postexposure prophylaxis have a high titer of anti-HBs given at the recommended dose of 0.06ml/kg for children and adults, and 0.5 ml for newborns born to infected mothers (Centers for Disease Control and Prevention, 2002). Primary prevention also includes behavioral interventions to reduce the risk factors for infection and this uses the strategy of counseling and education regarding ways to avoid body fluids contact, safe handling of needles and sharps (Department of Health, 2004a). One harm reduction measure counseled to individuals from hepatitis B virus (HBV) infection is by avoiding contact with the body fluids of someone whose health and sexual history are not known. To prevent infection, patients and uninfected individuals are instructed to use condom and latex or plastic gloves when handling blood. Paramount to the instruction is to avoid sharing of any articles which can be contaminated with blood, semen or saliva such as needle, razor and toothbrush (Cronin, 2005). (Brown et al., 2006, Department of Health, 2004a, Glendening et al., 2002) described secondary prevention as strategy aimed at infected individuals in attempting to reduce the risk of transmission to those not infected or re-infection. Activities included in secondary prevention are testing of individuals and counseling on prevention and medical follow-up to HBV-infected persons. The goal of these activities is to prevent further damage to the liver and to reduce the risks for complications (liver cancer, cirrhosis). Behavior change counseling has also been proven to successfully reduce the incidence of hepatitis B transmission. To further counsel patients infected with HBV regarding their illness and diseases, (Adrienne M Buggs and Joseph K Lim, 2006) suggested that be referred to their primary care providers. Patients are also encouraged to practice thorough handwashing. In addition, patients who are food handlers are discouraged to resume work until they are no longer infective. Patients are advised to refrain from using acetaminophen and ethanol, which are known to be hepatoxic drugs to avoid further damage to the liver. They are also instructed not to share personal contaminated articles (e.g. razor, needles and toothbrushes). Most importantly, patients are advised to seek medical follow–up to keep an eye on evidences signifying progression of the disease and development of complications. Hepatitis B occurs frequently in developing countries and lower socioeconomic groups due to overpopulation and poor sanitation (Alter, 1997). Parts of the world where hepatitis B is common include Southeast and Central Asia, the islands of the South Pacific, the Amazon River basin, the Middle East, Africa, Eastern Europe, and China (Cronin, 2005). Countries of high endemicity (HBsAg prevalence 8% or more) consist of all of sub-Saharan Africa, China, Indonesia, Korea, Philippines; the Eastern Mediterranean (except Israel), South and Western Pacific islands, the Amazon River Basin, Dominican Republic and Haiti according to (2003). According to (Hong et al., 2001), of over 300 million carriers of the HBV around the world, 78% are in Asia. To win the battle against the high incidence of the HBV infection, the East Asian and the Southeast Asian countries adopted mass vaccination in national level in the late 1980’s and the end result of which is a significant decline in the rate of HBV carriers and HBV infections as well. (Huang and Lin, 2000) reported that in Taiwan alone, the carrier rate of the general population were15% to 20% in the early 1980’s. A campaign for vaccination against hepatitis B was launched in 1984 starting with newborns of all infectious mothers to young adults. The incidence of babies born to carrier mothers decreased from 86% to 96% to 12% to 14%. Similarly, the prevalence of HBV infection in children below 6 years decline from 10.5% to 1.7%. These data shows that immunization strategies implemented in Taiwan is effective. (Department of Health, 2004b) described “surveillance as the ongoing and systematic collection, analysis and interpretation of health data for the purposes of planning, implementing and evaluating public health programs.” He added that surveillance aims “to measure the burden of disease; determine risk factors; identify outbreaks; monitor trends; evaluate control measures, interventions and programs; and identify infected persons for medical referral, education and counseling.” Among the challenges to HBV surveillance in Taiwan include: 1) deficiency of resources to follow-up reports of viral infection markers; 2) non-assertive method of screening patients for HBV infections; 3) insufficient laboratory diagnostic testing; 4) inaccurate reporting of cases, and 5) underreporting of HBV infections (Huang and Lin, 2000). Reference (2003) Hepatitis B vaccine. Department of Immunization, Vaccines and Biologicals. ADEFOVIR, F. (2006) Salvage Therapy is Cost-Effective in Chronic Hepatitis B. Absract 6. Digestive Disease Week 2004. ADRIENNE M BUGGS, M., FACEP & JOSEPH K LIM, M. (2006) Hepatitis. IN ROBERT M MCNAMARA, M., FAAEM, FRANCISCO TALAVERA, P., PHD, EUGENE HARDIN, M., FACEP, FAAEM, JOHN HALAMKA, M. & STEVEN C DRONEN, M., FAAEM (Eds.), eMedicine. ALTER, M. (1997) Epidemiology of Hepatitis C. Hepatology, 26, 62S-65S. BROWN, A. E., TOMKINS, S. E., LOGAN, L. E., LAMONTAGNE, D. S., MUNRO, H. L., HOPE, V. D., RIGHARTS, A., BLACKHAM, J. E., RICE, B. D., CHADBORN, T. R., TOOKEY, P. A., PARRY, J. V., DELPECH, V., GILL, O. N. & FENTON, K. A. (2006) Monitoring the effectiveness of HIV and STI prevention initiatives in England, Wales, and Northern Ireland: where are we now? Sexually Transmitted Infections, 82. CENTERS FOR DISEASE CONTROL AND PREVENTION (2002) Sexually Transmitted Diseases Treatment Guidelines 2002. Division of STD Prevention. CRONIN, C. (2005) Hepatitis B. Yahoo Health. DEPARTMENT OF HEALTH (2004a) Strategic Plan: Implementation and Recommendations Prevention Focus Area. New York, New York State. DEPARTMENT OF HEALTH (2004b) Strategic Plan: Implementation and Recommendations Surveillance & Research Focus Area. New York City, New York State. EVERSON, G. & WEINBERG, H. (2002) Living with Hepatitis B: A Survivors' Guide Long Island, NY, Hatherleigh Press. GLENDENING, P. N., TOWNSEND, K. K. & GEORGES C BENJAMIN, M. D. (2002) Maryland Hepatitis C Prevention and Control Plan. Maryland Department of Health and Mental Hygiene. HEATHCOTE, E. (2001) Serum HBV DNA suppression and seroconversion following long-term adefovir, dipivoxil therapy in chronic hepatitis B patients. 52nd Annual Meeting of the American Association for the Study of Liver Diseases. Dallas, Texas. HENSLEY, J., CNM MSN EDD (2005) Epidemiology and Prevention of Viral Hepatitis A to E: An Overview. Colorado Springs, CO, University of Colorado at Colorado Springs. HONG, Z., ZOU, S. & GIULIVI, A. (2001) Hepatitis B and its Control in Southeast Asia and China. Viral Hepatitis and Emerging Bloodborne Pathogens in Canada, 27S3. HOOFNAGLE, J. (2002) Course and Outcomes of Hepatitis C. Hepatology, 36, S21-S29. HUANG, K. & LIN, S. (2000) Nationwide vaccination: a success story in Taiwan. Vaccine, 18, S35-8. MCAVOY, N. & HAYES, P. (2005) Coffee is good for the liver. The Royal College of Physicians of Edinburgh & The Royal College of Surgeons of Edinburgh. RUSHING, S. C., MPH, MONDEAUX, F., MSW, PHD & LANE, L., MPH CANDIDATE (2005) Red Talon STD Profile: STD Treatment and Prevention Capacity within Idaho, Oregon and Washington Tribes. Project Red Talon. Portland, OR, Northwest Portland Area Indian Health Board. SANDLER, R., EVERHART, J. & AL, M. D. E. (2002) The burden of selected digestive diseases in the United States. Gastroenterology, 122, 1500-1511.  Other relevant link: WHO Fact Sheet on Hepatitis B. http://www.who.int/mediacentre/factsheets/en/ Read More