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2/14/24, 10:38 AM Realizeit for Student Introduction Viral hepatitis is a systemic, viral infection in which necrosis and inflammation of liver cells produce a characteristic cluster of clinical, biochemical, and cellular changes. To date, five definitive types of viral hepatitis that cause liver di...

2/14/24, 10:38 AM Realizeit for Student Introduction Viral hepatitis is a systemic, viral infection in which necrosis and inflammation of liver cells produce a characteristic cluster of clinical, biochemical, and cellular changes. To date, five definitive types of viral hepatitis that cause liver disease have been identified: hepatitis A, B, C, D, and E. Hepatitis A and E are similar in mode of transmission (fecal– oral route), whereas hepatitis B, C, and D share many other characteristics. Viral Hepatitis Viral hepatitis is a systemic, viral infection in which necrosis and inflammation of liver cells produce a characteristic cluster of clinical, biochemical, and cellular changes. To date, five definitive types of viral hepatitis that cause liver disease have been identified: hepatitis A, B, C, D, and E. Hepatitis A and E are similar in mode of transmission (fecal– oral route), whereas hepatitis B, C, and D share many other characteristics Hepatitis is easily transmitted and causes high morbidity and prolonged loss of time from school or employment. Acute viral hepatitis affects 0.5% to 1% of people in the United States each year. Hepatitis A virus (HAV) was responsible for 3366 cases in the United States in 2017. Incidence rates decreased more than 95% from 1995 to 2011, then increased by 140% from 2011 to 2017. In 2017, large person-to-person outbreaks began occurring, among persons who use drugs and persons experiencing homelessness (Centers for Disease Control and Prevention [CDC], 2017). During the same year, the hepatitis B virus (HBV) was the offending agent in a total of 3407 cases of acute viral hepatitis nationwide. The occurrence rate of viral hepatitis C (HCV) in 2017 was 3186 cases, with an incidence of 1.0 cases per 100,000 population, which represents an increase since 2013. Rates have been influenced by the opioid crisis. An estimated 2.4 million people in the United States are living with HCV infection (CDC, 2017). The number of reported acute hepatitis B cases has remained stable with a slight increase in 2017. The increase is most likely due to increasing injection drug use related to the opioid crisis, and improved surveillance (CDC, 2017). The overall decrease in HBV rates since 1990 is largely due to the use of hepatitis A and B vaccines, the introduction https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 1/7 2/14/24, 10:38 AM Realizeit for Student of universal precautions and blood supply safety measures as well as public health education regarding high-risk behaviors (Goldman & Schafer, 2019). Conversely, the incidence of HAV and HCV infections has been on the rise. It is estimated that 60% to 90% of viral hepatitis cases go unreported (CDC, 2017). The occurrence of subclinical cases, failure to recognize mild cases, and misdiagnosis are thought to contribute to the underreporting. The clinical presentation of hepatitis varies with individual patients as well as with the specific causative virus. Four phases of infectious hepatitis describe the clinical presentation. Phase 1 is the viral replication phase in which patients are asymptomatic but laboratory studies will reveal markers of hepatitis. Phase 2 is the preicteric or prodromal phase when those affected may experience anorexia, nausea, vomiting, fatigue and pruritus. Phase 3 is the icteric phase which is characterized by jaundice and dark urine. Some patients experience abdominal pain from an enlarged liver. Phase 4 is the convalescent phase when signs and symptoms resolve and laboratory values return to normal. Not all patients will experience all phases, especially those with a mild form of the disease (Chi, Cleary, & Bocchini, 2018; Shin, 2018). Hepatitis A Virus The HAV accounts for 20% to 25% of cases of clinical hepatitis in the United States (CDC, 2017). Hepatitis A, formerly called infectious hepatitis, is caused by an RNA virus of the enterovirus family. In the United States, the disease is seen mainly in the adult population. HAV is transmitted primarily through the fecal–oral route, by the ingestion of food or liquids infected with the virus. It is more prevalent in countries with overcrowding and poor sanitation. The virus has been found in the stool of infected patients before the onset of symptoms and during the first few days of illness. Typically, a child or a young adult acquires the infection at school through poor hygiene, hand-to-mouth contact, or other close contact. The virus is carried home, where haphazard sanitary habits spread it through the family. An infected food handler can spread the disease, and people can contract it by consuming water or shellfish from sewage-contaminated waters. Outbreaks have occurred in day care centers and institutions as a result of poor hygiene among people with developmental disability. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 2/7 2/14/24, 10:38 AM Realizeit for Student Hepatitis A can be transmitted during sexual activity; this is more likely with oral–anal contact or anal intercourse and with multiple sex partners (Chi et al., 2018; Goldman & Schafer, 2019; Shin & Jeong, 2018). Hepatitis A is not transmitted by blood transfusions. The incubation period is estimated to be between 2 and 6 weeks, with a mean of approximately 4 weeks (CDC, 2017; Chi et al., 2018; Shin & Jeong, 2018). The illness may be prolonged, lasting 4 to 8 weeks. It usually lasts longer and is more severe in those older than 40 years. Most patients recover from hepatitis A; it rarely progresses to acute liver necrosis or acute hepatic failure resulting in cirrhosis of the liver or death. The mortality rate of hepatitis A is approximately 0.5% for those younger than 40 years and 1% to 2% for older adults. In patients with underlying chronic liver disease, morbidity and mortality are increased in the presence of an acute hepatitis A infection. No carrier state exists, and no chronic hepatitis is associated with the HAV. The virus is present only briefly in the serum; by the time jaundice occurs, the patient is likely to be noninfectious. Although hepatitis A confers immunity against itself, the person may contract other forms of hepatitis. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 3/7 2/14/24, 10:38 AM Realizeit for Student Clinical Manifestations Many patients are anicteric (without jaundice) and symptomless. When symptoms appear, they resemble those of a mild, flu-like upper respiratory tract infection, with lowhttps://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 4/7 2/14/24, 10:38 AM Realizeit for Student grade fever. Anorexia, an early symptom, is often severe. It is thought to result from release of a toxin by the damaged liver or from failure of the damaged liver cells to detoxify an abnormal product. Later, jaundice and dark urine may become apparent. Indigestion is present in varying degrees, marked by vague epigastric distress, nausea, heartburn, and flatulence. The patient may also develop a strong aversion to the taste of cigarettes or the presence of cigarette smoke and other strong odors (Papadakis & McPhee, 2020; Shin & Jeong, 2018). These symptoms tend to clear as soon as the jaundice reaches its peak, perhaps 10 days after its initial appearance. Symptoms may be mild in children; in adults, they may be more severe and the course of the disease prolonged. Assessment and Diagnostic Findings The liver and spleen are often moderately enlarged for a few days after onset; other than jaundice, there are few other physical signs. An HAV antigen may be found in the stool 7 to 10 days before illness and for 2 to 3 weeks after symptoms appear. HAV antibodies are detectable in the serum, although usually not until symptoms appear. Analysis of subclasses of immunoglobulins can help determine whether the antibody represents acute or past infection. Prevention A number of strategies exist to prevent transmission of HAV. Patients and their families are encouraged to follow general precautions that can prevent transmission of the virus. Scrupulous hand hygiene, safe water supplies, and proper control of sewage disposal are just a few of these prevention strategies. Effective (95% to 100% after two to three doses) and safe HAV vaccines are available (Link-Gelles, Hofmeister, & Nelson, 2018). It is recommended that the two-dose vaccine be given to adults 18 years of age or older, with the second dose given 6 to 12 months after the first. Protection against HAV develops within several weeks after the first dose of the vaccine. Children and adolescents 1 to 18 years of age receive three doses; the second dose is given 1 month after the first, and the third dose is given 6 to 12 months later. HAV routine immunization of young children has proved to be effective in reducing disease incidence and maintaining very low incidence levels among vaccine recipients and across all age groups in many settings (Chi et al., 2018; Goldman & Schafer, 2019). As a result of its effectiveness in decreasing HAV, the hepatitis A vaccination recommendations have been expanded to include all children at 1 year of age. Hepatitis A vaccine is also recommended for people traveling to locations where sanitation and hygiene are unsatisfactory. Vaccination is also recommended for those from high-risk https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 5/7 2/14/24, 10:38 AM Realizeit for Student groups, such as men who have sex with men, people who use IV or injection drugs, staff of day care centers, health care personnel and those who work with the virus in research or animal care settings (Chi et al., 2018). The vaccine has also been used to interrupt community-wide outbreaks. A combined HAV and HBV vaccine is available for vaccination of people 18 years of age and older with indications for both HAV and HBV vaccination. Vaccination consists of three doses, given on the same schedule as that used for single-antigen HBV vaccine. For people who have not been previously vaccinated, HAV can be prevented by intramuscular administration of globulin during the incubation period, if given within 2 weeks of exposure. This bolsters the person’s antibody production and provides 6 to 8 weeks of passive immunity. Immune globulin may suppress overt symptoms of the disease; the resulting subclinical case of HAV would produce immunity to subsequent episodes of the virus. Immune globulin is also recommended for household members and sexual contacts of people with HAV. Susceptible people in the same household as the patient are usually also infected by the time the diagnosis is made and should receive immune globulin. Institutional contacts of patients with HAV should also receive post-exposure prophylaxis with immune globulin. Prophylaxis is not necessary for casual contacts of an infected person, such as classmates, coworkers, or hospital employees (Link-Gelles et al., 2018). Although rare, systemic reactions to immune globulin do occur. Caution is required when anyone who has previously had angioedema, hives, or other allergic reactions is treated with any human immune globulin. Epinephrine should be available in case of systemic, anaphylactic reaction. Pre-exposure prophylaxis is recommended for those traveling to developing countries or settings with poor or uncertain sanitation conditions who do not have sufficient time to acquire protection by administration of hepatitis A vaccine (Chi et al., 2018). Medical Management Bed rest during the acute stage and a nutritious diet are important aspects of treatment. During the period of anorexia, the patient should receive frequent small feedings, supplemented if necessary by IV fluids with glucose. Because the patient often has an aversion to food, gentle persistence, and creativity may be required to stimulate appetite. Optimal food and fluid levels are necessary to counteract weight loss and to speed recovery. Even before the icteric phase, however, many patients recover their appetites. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 6/7 2/14/24, 10:38 AM Realizeit for Student The patient’s sense of well-being and laboratory test results are generally appropriate guides to bed rest and restriction of physical activity. Gradual but progressive ambulation hastens recovery. Nursing Management Management usually occurs in the home unless symptoms are severe. Therefore, the nurse assists the patient and family in coping with the temporary disability and fatigue that are common with HAV and educates them to seek additional health care if the symptoms persist or worsen. The patient and family also need specific guidelines about diet, rest, follow-up blood work, and the importance of avoiding alcohol, as well as sanitation and hygiene measures (particularly hand hygiene) to prevent spread of the disease to other family members. Specific education for patients and families about reducing the risk of contracting HAV includes good personal hygiene, stressing careful hand hygiene (after bowel movements and before eating) and environmental sanitation (safe food and water supply, effective sewage disposal). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=lqf9HhURQ5RqpgqAkzH2zVrT2hbWFsCuacrrvtQ3c5e2aqBPaKXEaVcMiuwkAz59F1DmoV… 7/7