Key learning points:
– Symptoms of hepatitis will vary from mild to severe
– Nurses working in primary care need to be aware of people at risk of both hepatitis B and C and offer testing in case treatment is necessary
– Treatment for hepatitis B aims to control the virus and thereby reduce inflammation, while treatment for hepatitis C aims to cure patients of the virus altogether
Nurses in primary care will regularly encounter patients with hepatitis. It may not be apparent because patients can be asymptomatic. Hepatitis is inflammation of the liver: the condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer (pictured). Hepatitis viruses are the most common cause of hepatitis in the world but other infections, autoimmune diseases and toxic substances (such as alcohol or certain drugs) can also cause hepatitis.1 This article will focus on viral hepatitis B and C.
About 60% of the liver is made up of hepatocytes, which absorb nutrients and remove harmful substances from the blood. A hepatocyte has an average lifespan of 150 days. The liver has many functions, and as stated by the British Liver Trust, these include:2
– Processing food from the intestine.
– Controlling levels of fats, amino acids and glucose in the blood.
– Combating infections.
– Clearing the blood of particles and infections, including bacteria.
– Neutralising and destroying all drugs and toxins.
– Manufacturing bile.
– Storing iron, vitamins and other essential chemicals.
– Breaking down food and turning it into energy.
– Manufacturing, breaking down and regulating numerous hormones, including sex hormones.
– Making enzymes and proteins responsible for most chemical reactions in the body, for example those involved in blood clotting and repair of damaged tissue.
Symptoms of hepatitis may be mild, including tiredness and lethargy, loss of appetite, nausea and vomiting. They may be attributed to other things. Or the symptoms may be more severe – abdominal pain, joint pain, pale-coloured stools and jaundice. Acute hepatitis will last no more than a few months, while chronic hepatitis defined as lasting longer than six months with long-term inflammation, causes damage to the liver.
Liver disease constitutes the third commonest cause of premature death in the UK.3 Health professionals in primary care are well placed to tackle liver disease. In fact, The Lancet even made it one of the 10 key recommendations of its report on detecting and treating liver disease.3
Hepatitis B
Hepatitis B virus is transmitted by contact with an infected person’s blood or body fluids.4 The prevalence rate is believed to be between 0.1% and 0.5% of the UK population.5 People at risk of hepatitis B infection include:6
– Healthcare workers.
– Those living in prison.
– Babies born to infected mothers.
– Both male and female sex workers.
– Men who have sex with men.
– People who inject drugs.
– People who have sexual contact with infected or high-risk people.
– People who have HIV or other STDs.
– People receiving haemodialysis.
– Victims of sexual attack or needlestick injuries.
– Travellers who visit, or are from, areas where hepatitis B is common.
Hepatitis B is preventable if patients are vaccinated. This should be offered by practice nurses if they are aware of any of the above risks and especially when patients are travelling outside the UK.
Patients can also be offered a blood test for hepatitis B, especially if they are in one of the high-risk categories. If the result is hepatitis B surface antigen positive, they have current infection and should be referred to a specialist.
Patients with acute hepatitis B may not require any treatment and might show few symptoms. Blood tests will need to be checked regularly by the GP, but most people will recover completely after a few months.7 If infection persists after six months, this is known as chronic hepatitis B. The patient should be referred to a hospital liver specialist.
Treatment options include:
– Watch and review blood tests six-monthly or annually in a specialist centre – some patients’ immune systems will control the infection and if there is no damage to the liver there is no rush for treatment.
– Treat with a 48-week course of weekly interferon (alfa 2a) injections. This is not suitable for some patients because of side-effects including flu-like symptoms, tiredness, depression, low mood and irritability. This is a finite course of treatment. If patients can tolerate it, it has less drug resistance and a higher likelihood for hepatitis B surface antigen clearance.8
– Oral antiviral therapy. Tenofovir (Viread) and entecavir (Barraclude) are now the first-line oral treatments.9
The aim of treatment is to bring the viral levels under control and thereby reduce inflammation in the liver. The choice of medication will be decided by the hepatologist. The dose of oral medication will be one tablet every day. For most patients this will be a long-term option.
Patients who start oral anti-viral therapy will be monitored by the hospital. This will be initially on a three-month basis to ensure treatment is working, assessed by blood tests. Once established on therapy, patients will be seen on a six-month basis. Both tenofovir and entecavir are generally well tolerated, but side-effects to watch for include nausea, vomiting and muscle aches.
Although hepatitis B can be treated easily with medication, some patients have had the inflammation for long enough to cause cirrhosis of the liver, which can put them at risk of developing hepatocellular carcinoma (HCC). Patients with cirrhosis need to attend for ultrasound scanning and review at a hospital on a six-monthly basis. If cirrhosis is identified at an early stage, treatment may be suitable, including liver transplantation.
Hepatitis C
Hepatitis C is also a blood-borne virus. There are six genotypes. Around 75% of people infected will develop chronic hepatitis C infection. If untreated, or unsuccessfully treated, patients can develop cirrhosis. A significant proportion develop liver cancer. Once cirrhosis has developed, hepatic decompensation and other potentially fatal complications can occur and liver transplantation may be required.10 Estimates suggest that 214,000 individuals are chronically infected with hepatitis C in the UK. Most infection (approximately 90%) is genotype 1 and genotype 3.11 People at risk of hepatitis C include:
– Users of injected drugs.
– Those who have received infected blood transfusions or blood products.
– Those who have had sexual contact with an infected person.
– People with renal failure.
– Babies born to infected mothers.11
The National Institute for Health and Care Excellence (NICE)12 also considers people at high risk if they are born or brought up in a country with an intermediate or high prevalence (2% or greater) of chronic hepatitis C. Although data is not available for all countries, for practical purposes this includes all countries in Africa, Asia, the Caribbean, Central and South America, Eastern and Southern Europe, the Middle East and the Pacific islands.
Symptoms are variable, but may include tiredness, weight loss, loss of appetite, nausea, flu-like symptoms such as fevers, night sweats and headaches. More advanced disease may include jaundice and problems concentrating.13
There is no vaccine against hepatitis C, but if patients have any of the above risks, they can be offered a blood test to check for the hepatitis C antibody. If the antibody is negative, that is conclusive. If the antibody is positive, the disease is not confirmed unless a hepatitis C polymerase chain reaction (PCR) is also positive. NICE12 recommends that GPs and practice nurses should offer testing to at-risk people.
A patient with a positive hepatitis C test should be referred to a hepatologist or an infectious diseases doctor. This could be in an outreach clinic, or in a hospital. Treatment has previously been with weekly pegylated interferon subcutaneous injections alfa 2 a (Pegasys) or 2 b (Viraferon peg) and ribavirin tablets for six months to one year. The side-effect profile of interferon includes flu-like symptoms, depression (including suicidal ideation), anxiety, nausea, palpitations, thyroid problems, diarrhoea and lethargy. Ribavirin (Copegus or Rebetol) can cause anaemia, rash, reduced appetite, weight loss, headaches, dizziness, palpitations and shortness of breath. Refer to the British National Formulary (BNF)14 for a full list of side-effects.
Treatment for hepatitis C has evolved rapidly since the middle of 2014 and there are new oral treatments that are now accessible. These are known as direct-acting antivirals (DAAs) and are approved by NICE. These are high-cost drugs, but treatment has now reduced to eight weeks, 12 weeks or 24 weeks depending on the physician’s choice and the NHS England guidelines.10
From June 2014, NHS England has been operating an early access programme for defined patients and those with very advanced liver cirrhosis.15 From June 2015 there has been a cirrhosis commissioning policy.10 This means that many patients with cirrhosis have now been treated and the next phase of treatment reaches out to the non-cirrhotic patients.
At present, treatment for hepatitis C is not offered by GPs. NHS England realises that prescribing for people with hepatitis C is complex. The process of identifying and establishing operational delivery networks (ODNs) for hepatitis C has been launched and is led by regional teams.16 There are 22 ODNs in England and these were established by the end of August 2015. The ODNs provide clinical leadership over a given geography, co-ordinating high-quality patient care through specialist multidisciplinary teams (MDTs) and delivering oral therapies in mainly outpatient settings.
Hepatitis C treatment is complex and clinicians are asked to follow prescribing rules provided by NHS England. The new DAAs are used in combinations and that is why they should be prescribed by specialists. For patients the treatment is getting easier, especially those on tablet-only medication.
These have lesser side-effects than interferon and ribavirin. The aim of hepatitis C is to cure patients of the virus altogether. The new oral treatments for chronic hepatitis C infection will achieve cure rates of about 90%.3
Once cured, non-cirrhotic patients will be discharged from the hospital clinic. Cirrhotic patients will be kept under six-month review and surveillance by ultrasound scan to check for development of liver cancer.
Conclusion
Nurses working in primary care are in an ideal environment to identify patients at risk for hepatitis B and C. A general discussion can probe easily into their background and assess their risk. Offering testing is important so that patients can access treatment if they are positive for hepatitis B or C. It is also important for nurses to be aware of treatment options for both hepatitis B and C so they can have an initial conversation with patients.
References
1. World Health 0rganization. What is hepatitis? who.int/features/qa/76/en/ (accessed 6 April 2016).
2. British Liver Trust. Hepatitis B. britishlivertrust.org.uk (accessed 10 April 2016).
3. The Lancet Commission. Addressing liver disease in the UK: a blueprint for attaining excellence in health care are reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity and viral hepatitis. The Lancet 2014;27:1-45.
4. Public Health England. Hepatitis B: guidance, data and analysis, 2014. gov.uk/government/collections/hepatitis-b-guidance-data-and-analysis#diagnosis-and-management. (accessed 8 April 2016).
5. Health and Safety Executive. Hepatitis B virus, 2015. hse.gov.uk/biosafety/blood-borne-viruses/hepatitis-b.htm. (accessed 15 April 2016).
6. Hawley C. Understanding viral hepatitis: as easy as A,B C. British Journal of Primary Care Nursing 2012;9:1.
7. NHS Choice. Hepatitis B. nhs.uk/conditions/Hepatitis-B/Pages/Introduction.aspx (accessed 6 April 2016).
8. Perillo R. Benefits and risks of interferon therapy for hepatitis B. Hepatology 2009;49:103-11.
9. Pol S, Lampertico P. First-line treatment of chronic hepatitis B with Entecavir or Tenofovir in ‘reallife’ settings: from clinical trials to clinical practice. Journal of Viral Hepatitis 2012;19 (6):377-386.
10. NHS England (B07/P/a). Clinical Commissioning Policy Statement: Treatment of chronic hepatitis C in patients with cirrhosis, 2015. england.nhs.uk/commissioning/wp content/uploads/sites/12/2015/06/hep-c-cirrhosis-polcy-statmnt-0615.pdf (accessed 6 April 2016).
11. Public Health England. Hepatitis C in the UK 2015 Report, July 2015. PHE publications number: 2015208
12. NICE. Hep B and Hep C testing: people at risk of infection, 2012. nice.org.uk/guidance/ph43/chapter/1-recommendations#/recommendation-5-testing-for-hepatitis-b-and-c-in-prisons-and-immigration-removal-centres (accessed 5 May 2016).
13. British Liver Trust. Hepatitis C, 2016. britishlivertrust.org.uk.
14. British National Formulary 2016 September 2015- March 2016; edition 70. BMJ Group and Pharmaceutical Press, 2016
15. NHS England (AO2/PS/b). Interim Clinical Commissioning Policy Statement: Sofosbuvir+Daclatasvir/Ledipasvir +/- Ribavirin for defined patients with Hepatitis C, 2014. england.nhs.uk/wp-content/uploads/2014/04/sofosbuvir-pol-stat.pdf (accessed 14 April 2016).
16. NHS England. Operational delivery networks for hepatitis C care in adults (final draft), 2015. england.nhs.uk/. (accessed 14 April 2016).
