Monday, April 18, 2011

Hepatitis in Ambulatory Care: The Need for New Strategies and Solutions

Hepatitis in Ambulatory Care: The Need for New Strategies and Solutions
The following article was originally published in Preventing Infection in Ambulatory Care, the quarterly e-publication from the Association for Professionals in Infection Control and Epidemiology (APIC). To learn more about receiving this resource and joining APIC, visit To learn more about APIC, visit

Hepatitis, inflammation of the liver, is usually caused by a range of viruses labeled A – E. The most common forms, A, B and C, remain a serious, ongoing health concern. Hepatitis A is caused by fecal-oral transmission due to poor environmental sanitation or inadequate personal hygiene. While Hepatitis A is generally self-limiting and non-fatal, there is no cure for Hepatitis B or C, which can result in chronic infection and death. Hepatitis B virus (HBV) and C (HCV) are transmitted through contact with infected blood and body fluids, including during drug use and sexual activity. Perinatal transmission of HBV can occur from an infected mother. However, HBV is not transmitted through breastfeeding. Casual contact, including touching, hugging, kissing, sneezing, kissing or coughing do not spread the hepatitis virus.

HBV remains a worldwide health problem. The World Health Organization (WHO) estimates that more than 2 billion people have been infected with HBV and that 350 million have chronic liver infections. WHO also reports that the HBV is 50 to 100 times more infectious than HIV and that 25% of adults with HBV will later die from cirrhosis or hepatic cancer. Worldwide deaths attributable to HBV are estimated at 600,000.[1]

However, in the United States, the Centers for Disease Control and Prevention (CDC) report a steady decline in HBV. The decline is attributed to the Occupational Safety and Health Administration regulation of bloodborne pathogen exposure risks and increased childhood vaccinations. While today's rates are the lowest ever reported, it is important to remember that HBV has not been eradicated. It remains a serious health, social, and financial burden for those who contract the disease. In the United States, the CDC estimates that 1.2 million Americans are living with chronic HBV and 3.2 million are living with chronic HCV.[2]

Recognition of HBV and HCV, especially in ambulatory patients, is clinically challenging. Symptoms present slowly and can be nonspecific. Nausea, vomiting, diarrhea and fatigue may be attributed to other causes and, without laboratory confirmation of hepatitis infection, may remain indistinguishable from other illnesses. Individuals who eventually recover may never know they were exposed and, in some cases where symptoms are absent, may have no reason to think they have contracted a viral infection. Jaundice, the hallmark of liver disease, is present in only approximately 30% of cases and occurs later in the progression of the disease. A health history given by an ambulatory care patient may not be a complete or reliable source of information, especially if that individual is unaware of a previous infection or its type.

While surveillance statistics have improved over past decades, the threat from HBV and HCV remain serious. Clinical vigilance by ambulatory providers is essential to minimize the public health threat. But vigilance may be confounded by multiple factors. For example, HBV or HCV infection may be acute or chronic. The onset may be insidious and difficult to detect. Infections may resolve or remit but can reemerge in response to immunosuppression triggered by other diseases or drugs. Over time, chronic infections can lead to liver inflammation, damage, cirrhosis, and cancer.

In January 2010 the Institute of Medicine (IOM) released a new consensus report Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C. This report focused national attention on the 5.3 million Americans (or 2% of the population) who are currently living with HBV and HCV. The IOM report concluded that the current approach to the prevention and control of chronic HBV and HCV is not working and recommended increased knowledge and awareness about chronic viral hepatitis among healthcare providers, social service providers, and the public; improved surveillance for HBV and HCV; and better integration of viral hepatitis services.[1,2,3]

Following the publication of the IOM report, Sen. John Kerry introduced the "Viral Hepatitis and Liver Cancer Control and Prevention Act," proposed legislation in August 2010 that would authorize funding of $600,000 million over five years to fight the disease. As Kerry points out, if no new action is taken, total medical costs for patients with HCV infection could increase more than 2.5 times— from $30 billion to more than $85 billion over the next 20 years.

The Kerry bill also addresses the IOM call for improved service integration by increased interagency coordination between the CDC, the National Institutes of Health, the National Cancer Institute, the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, the Agency for Healthcare Research and Quality, and the Department of Veterans Affairs. Kerry's bill is sister legislation to the bill Rep. Mike Honda (D-Calif.) introduced in the House in October 2009.[4]

While these legislative initiatives muster community and congressional support, front line clinicians must confront the challenges of hepatitis on a daily basis. While a new national strategy is being debated, what is the best course of action for infection preventionists? Follow these four steps to implement your own hepatitis action plan.

1. Protective Safety Strategies
  • Use gloves and other barriers as needed; do not rely on scrub attire for protection.
  • Reinforce to all clinicians that eyeglasses do not provide sufficient protection from splashes and sprays. A wraparound eye shield is required.
  • Never re-enter single use IV bags or medication vials.
  • All syringes, whether used with a needle or needleless connector, must be handled as a single use disposable item.
  • Make sure healthcare worker vaccinations are complete.
  • Never leave injectable medications and supplies, whether new or used, unsecured.

2. Patient Centered Solutions
  • Encourage participation in vaccination programs.
  • Help identify and instruct regarding protection against disease transmission related to high-risk behaviors and sexual contact.
  • Support hepatitis screening and follow-up medical care, as indicated.
  • Refer patients to support services and counseling for chronic illness management.
  • Emphasize that prevention is best means of self-protection.

3. Vigilance and Surveillance
  • Understand the prevalence of hepatitis in your community and public health risks in special populations you serve.
  • Monitor and report, as part of your surveillance program, the incidence of hepatitis in your facility.
  • Include bloodborne diseases, including HBC and HCV, and known risk factors in patient histories and assessments.
  • Carefully monitor and directly observe the safe use of needles and syringes, including disposable supplies used with blood glucose meters.
  • Assure that any exposures to blood/body fluids are promptly reported and treated.

4. Information and Education

1. Hepatitis. World Health Organization website. Available at Accessed 8/17/2010

2. Viral hepatitis. Centers for Disease Control and Prevention website. Available at Accessed 8/15/2010.

3. Colvin, HM; Mitchell AE, editors. Hepatitis and liver cancer: a national strategy for the prevention and control of Hep B and C. Committee on the prevention and control of viral hepatitis, Institute of Medicine, 2010. Available at Accessed 8/17/2010.

4. Kerry and Honda: Disrupting a deadly disease: Hepatitis defense can save thousands of lives a year. Washington Times. 8/10/2010. Available at

No comments:

Post a Comment