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Hepatitis C: the hidden timebomb

Karen Tipping
RGN RM
Senior Clinical Nurse
Rochdale Community
Drug Team

In a new report published in March 2005, The Hepatitis C Scandal, the All-Party Parliamentary Group on Hepatology (APPG) called for the government to demonstrate greater urgency in dealing with the coming "tidal wave" of hepatitis C in the UK. Faced with this hidden epidemic, nurses are set to find themselves increasingly on the frontline.
Nurses have a key role to play in terms of education as many people are dying through ignorance about the disease.(1) This article examines the nature of the hepatitis C virus (HCV) and looks at the nurse's role in tackling this potentially lethal but nevertheless treatable disease.

Government guidance
In 2002 the government published the Hepatitis C Strategy for England, which described existing initiatives and suggested improvements in prevention, diagnosis and treatment. In July 2004 the Department of Health published its Hepatitis C Action Plan for England based on best practice to offer a framework within which the NHS could implement the strategy. Then, in December last year, the government launched the £2m FaCe It campaign, which aims, over the next two years, to increase awareness about HCV, its modes of transmission and how to avoid infection. A telephone information helpline offers confidential advice, while a poster, leaflet campaign and website raise awareness and offer further information. The campaign aims to encourage injecting drug users and other people who might have been exposed to HCV to discuss testing. Nurses, with the appropriate training, are ideally placed to discuss HCV.

Transmission of hepatitis C
Hepatitis C is a bloodborne disease, which was only formally identified by scientists in 1989. It is mainly transmitted via direct blood-to-blood contact. It can be caught through intravenous drug use, blood transfusions from unscreened blood, tattoo needles, acupuncture, electrolysis and body piercing. There have been cases of people becoming infected through sharing razors and even toothbrushes.(1)
Sharing equipment such as blood-contaminated needles and syringes for drug use is a key route of transmission. Shared spoons, filters and water may also transmit infection.(2)
People who have received blood transfusions before September 1991 or blood products before 1986 in the UK may be at risk. There is a high prevalence of HCV in people with haemophilia who received untreated clotting factors before 1986.(2)
Although rare, mother-to-baby infection does occur, with upper estimates of around 6%, increasing to 14-17% when there is co-infection with HIV.(2)
Sexual transmission is possible but is rare, and estimates are less than 5% in regular sexual partners.(2)
Healthcare workers, police, prison staff and even social workers may be at risk of HCV infection through occupational injuries such as needlestick punctures.(2)

Identifying at-risk patients
Although there are a number of important reasons for offering screening for hepatitis C, clients should receive counselling before testing is carried out. The nurse has a central role to play in ensuring that the client understands what a diagnosis of hepatitis C means, what treatment options are available, and what support will be given in the case of a positive diagnosis.
However, unlike HIV, a client with HCV will not necessarily have it for life. Some people will naturally clear the virus, and others may be able to clear it through treatment. This should be communicated to clients at the pretesting stage.
Following appropriate counselling, the following people should be offered testing for hepatitis C:(2)

  • People who have ever injected drugs or are currently injecting drugs.
  • People who received blood transfusions before September 1991 or blood products before 1986.
  • Recipients of organ and tissue transplants in the UK before 1992.
  • Babies born to mothers known to be infected with HCV.
  • Sexual partners of people infected with HCV.
  • Patients with unexplained abnormal liver function tests.
  • Healthcare workers accidentally exposed to blood where there is a risk of transmission of hepatitis C infection.
  • People who have had body piercings or tattoos where infection control procedures are poor.
  • People with HIV.

Testing for HCV
If you think that a client may be at risk, there is an initial antibody test to identify whether the person has ever been infected with hepatitis C. It may take up to three months for antibodies to hepatitis C to become detectable. Therefore, in patients whose exposure has been recent and whose first test is negative, the hepatitis C antibody test should be repeated three months after the last possible exposure to avoid misdiagnosis during the "window period".
If the antibody test is confirmed as positive, the next steps are to establish whether the virus is still present, and if so to determine the extent of the underlying liver disease.
HCV ribonucleic acid (RNA) detection tests - for example, a polymerase chain reaction (PCR) test - will identify a current circulating virus. It is also possible to identify the genotype of the virus and to assess the viral load, which is of particular importance if the patient is to be offered antiviral therapy.
Liver function tests are used to screen for evidence of hepatitis. An ultrasound scan and/or a biopsy may be performed on the liver to help assess the impact of the disease.
Post-test counselling will be required to address the implications of a positive test. Even in the event of a negative test, discussions with the client may be beneficial to address lifestyle issues and, if appropriate, to encourage the person to avoid future high-risk behaviour.

Advising clients on avoiding hepatitis C
Nurses may provide patients with information about the risks of infection and how they may be avoided. There is no vaccine to protect against hepatitis C, but there are a number of things that can be done to avoid becoming infected with the virus (see Table 1).(2)

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Symptoms
Usually people infected with hepatitis C have no initial symptoms - only 25-35% have any symptoms during the early stages, and these may easily be attributed to other ailments. The majority of people with the virus have no symptoms for many years. In fact, symptoms may not appear for up to 30 years after infection.(1)
The early symptoms include nausea, fatigue and jaundice.(1) Gastrointestinal symptoms may include vomiting, diarrhoea, constipation, bloating, indigestion and abdominal pain. Cognitive symptoms include "brain fog" - when a person has difficulty concentrating and thinking clearly. Psychological symptoms include depression, irritability and mood swings, as well as sleep disturbances, skin problems and loss of libido.(3) It's hardly surprising that diagnosis may not be obvious from this varying collection of symptoms.

Disease progression
The effects of infection vary from one person to another. Some people will clear the virus at the acute stage, but between 60% and 80% of people will develop chronic infection.(2) Of these, some will remain well and never develop liver damage, and many will develop only mild-to-moderate liver damage. Of those chronically infected with hepatitis C, 5-20% will develop cirrhosis of the liver, and a small percentage of these people will progress to primary liver cancer.(2)

Treatment
Hepatitis C is becoming increasingly treatable, with current drug therapies clearing the infection in 55% of cases overall.(3) Treatment as recommended by the National Institute for Clinical Excellence (NICE) consists of taking two drugs - pegylated interferon and ribavirin.(4) Treatment is deemed to be "effective" if the HCV is no longer detectable in the blood six months after treatment has been completed; this is known as a sustained virological response (SVR).
Patients with chronic HCV are usually managed under the supervision of specialists, who tailor treatment based on the patient's particular viral load and genotype. Patients with genotype 1 will need 48 weeks of treatment and have around a 50% chance of achieving an SVR.(2) Those with genotypes 2 and 3 usually only need 24 weeks of treatment, and the SVR is around 80%.(2)
ViraferonPeg (Schering-Plough) is currently the only pen delivery system approved for administering pegylated interferon for chronic HCV. ViraferonPeg allows precise, individualised weight-based dosing. A self-priming action automatically removes air bubbles before self-administration, while the small needle minimises discomfort.
Treatment may cause side-effects, including headaches, nausea and flu-like symptoms. The nurse may need to offer support to patients undergoing treatment, both in teaching them to self-administer the weekly injection and in offering support if side-effects do occur.

Conclusion
With growing awareness about hepatitis C, nurses will have a key role to play in helping identify at-risk patients, counselling them and providing support during testing and treatment. Access to up-to-date information to pass on to patients will be vital. Now is the time for nurses to take a proactive part in helping to defuse this potential timebomb.

References

  1. The All-Party Parliamentary Group on Hepatology. The Hepatitis C Scandal Report. London: APPG; March 2005.
  2. NHS FaCe It campaign. Available at URL: http://www.hepc.nhs.uk
  3. The Hepatitis Trust. Available at URL: http://www.hepcuk.info
  4. National Institute for Clinical Excellence. Interferon alfa and ribavirin for the treatment of chronic hepatitis C guidance. Available at URL: http://www.nice.org.uk

Resources
NHS FaCe It
T:0800 451451
W:www.hepc.nhs.uk

Hepatitis Trust
T:0870 200 1200
T:020 7371 0081
W:www.hepcuk.info

British Liver Trust
T:01425 463080
W:www.britishliver trust.org.uk

National Drugs Helpline (FRANK)
T:0800 776600
W:www.ndh.org.uk