Preventing, Recognizing and Treating Hepatitis C Virus

The spread of the Hepatitis C Virus (HCV) is a significant health issue across the United States. An estimated 4.1 million Americans are infected with HCV, and about 80% of those are presenting with no symptoms (National Center, 2006). It is the nurse’s role to provide education about prevention, exposure, and treatment of HCV in all aspects of the disease. If the nurse successfully fills the role of a patient advocate, collaborator and teacher before, after and during treatment, chances are much higher the patient will become an active participant in the process as well.
There are six major strains of HCV, identified genotypes 1 through 6. The genotypes can be broken down more specifically into subtypes (1a, 1b, etc.). Genotypes are important in the diagnosis and treatment of HCV because they indicate how well patients will respond to treatment. HCV is a blood-borne virus, spread primarily through the sharing of needles and paraphernalia used to inject illicit drugs. Other possible, yet less prevalent, modes of transmission include that from infected mother to newborn, sexual transmission, needle sticks in health care workers, tattoos and body piercing. A small amount of those infected with HCV have been by exposure through hemodialysis and transfusion of blood products. Most people with chronic hepatitis C are asymptomatic for the first two decades of infection (Fahey, 2007). Patients who experience symptoms may present with jaundice, abdominal pain, decreased appetite, nausea, dark urine, fatigue and depression. Because HCV is “silent” it is extremely important for high risk individuals to be tested regularly. Blood tests for HCV begin with EIA (enzyme immunoassay) or CIA (enhanced chemiluminescence immunoassay) if positive, the diagnosis should be confirmed with RIBA (recombinant immunoblot assay), a test used to confirm a positive EIA test. If a patient has a positive HCV blood test the next step is to measure the level of ALT (alanine aminotransferase), a liver enzyme in the blood, which indicates inflammation of the liver. Liver biopsy can provide additional information, including extent of fibrosis and cirrhosis, but is no longer a requirement for diagnosis and treatment decisions. Liver biopsies are often recommended for other reasons, usually as a way of determining the extent of the disease (Fahey, 2007). Those at increased risk for contracting HCV include people who have injected drugs at any time, children of mothers infected with HCV, health care workers, and people with tattoos and piercings performed in environments with poor infection control procedures.
There is no vaccine to prevent HCV, making education an extremely important part of preventing the spread of HCV. It is vital that nurses ensure patients’ understanding of the following practices in keeping themselves and others safe from HCV. If patients use intravenous drugs, encourage attending a treatment program and the use of clean needles and other paraphernalia. Do not share items with potential for the presence of blood (e.g. razor, toothbrush). Health care workers use precaution to avoid contact with bodily fluids (e.g. gloves, safety syringes). Follow good health practices when tattooing and body piercing. If infected with HCV never donate blood, organs or tissue.
Hepatitis C is a treatable disease, with many advancements is treatment over the years. Combination therapy is the recommended, and most common, treatment for infected patients. Standard combination therapy with pegylated interferon alpha (peginterferon alpha) and ribavirin has been found to be most effective. Over 50% of patients receiving combination therapy have undetectable HCV in blood tests six months after treatment is completed (Zic, 2005). It is important for patients to know about the medication therapy they receive, as it can be difficult, with many side effects. Interferon alpha is a naturally occurring protein produced by cells after viral infection. The goal of treatment is to eradicate the virus and prevent progression of liver disease before cirrhosis, liver failure, cancer or death occur (Fahey, 2007). Peginterferons are a version of the natural interferon alpha which has been chemically modified to reduce the rate of elimination, therefore increasing the amount of time it is effective (Zic, 2007). Ribavirin is a nucleoside analogue with the ability to act as an inhibitor of the virus, HCV. The mechanism of action of treatment is not yet fully understood and holds no guarantee of success (Fahey, 2007).
Adverse reaction to treatment can vary in intensity, severity, nature and management. It is important to monitor side effects on an individual basis and create a plan for management individually as well. Many patients experience flu-like symptoms early in treatment, these typically lessen as treatment continues. Additional side effects resulting from interferon may include fatigue, hair loss, difficulty focusing, moodiness, and depression. Severe side effects are rare (seen in less than 2% of patients) and include thyroid disease, depression with suicidal ideations, seizures, acute heart or kidney failure, eye and lung problems, hearing loss, and sepsis. In addition ribavirin can cause serious anemia. In treating patients with history of anemia or conditions increasing risk for anemia, such as kidney failure, combination therapy should be avoided until anemia has resolved. Ribavirin causes birth defects and pregnancy should be avoided during treatment. It is imperative to review the product manufacturer information with the patient prior to treatment (National Center, 2006).
Success of treatment of HCV is dependent on patient adherence to the treatment program. Because of the many side effects, frequency of medication administration and patient responsibility to administer the medications, it is not uncommon for patients to discontinue the therapeutic regimen prematurely. The nurse has an important role in encouraging the completion of treatment. After formation of a relationship based on mutual trust and development of a nurse-patient bond the nurse can provide education, empowering the patient to make informed decisions regarding treatment options and other interventions (Zic, 2005) It is important for the nurse to be open and trusting of the information provided by the patient and not be judgmental, as this attitude will be conveyed to the patient. A survey involving nursing care of the HCV infected patient revealed patients discussed issues with the nurse, regarding infection and treatment, that in some cases, they did not address with the physician (Zic, 2005). If a patient offers information they are still using illicit drugs it is imperative the nurse address the issue immediately. Drug users can be offered much support to attain a drug-free status and it is felt to be unethical to offer treatment to patients still using drugs, because of the complications involved with both treatment and drug use (Fahey, 2007).
A number of supports groups exist for the HCV infected patient, along with friends, family members and caregivers. Support groups are an important piece of treatment as they provide a comfortable environment for patients to discuss concerns and hear others, similar to them, share experiences. HCV support groups provide a place for patients to compare challenges of infection and treatment and give suggestions and encouragement to complete treatment (Cormier, 2005).
As more people are diagnosed with viral hepatitis C there is a growing need for nurses in this specialized field. Acknowledging the relationship social support, health promotion and education is the first step in successful treatment of the HCV infected patient. Nurses involved in the care of HCV patients must evaluate and facilitate the need for services to ensure success for the patient.

A. Provide education about prevention, exposure and treatment of HCV

I. Difficult to reach and receive follow through from patients/high risk individuals
Many high risk individuals hear stories about how difficult treatment can be and decide not to even attempt seeking diagnosis or treatment as a result. Some were informed that hepatitis treatment was inaccessible if they were currently injecting drugs. Others perceived treatment as inaccessible to those without health insurance. Many state they were likely to accept testing if it were more readily available. Since there seems to be a lack of awareness of locations offering free testing and lack of transportation to the testing and treatments sites, high risk individuals have been deterred from getting tested and treated (Page-Shafer 2002).

II. Low income, under educated, drug addicted patients make education challenging.
There are many factors which hinder education regarding Hepatitis C virus (HCV). It seems that disease specific information is lacking, creating a barrier for preventative health services. This lack of information is evidenced by the injection drug user’s (IDU) perception of low risk for contracting HCV, despite self-reported needle sharing. Because they do not consider themselves to be at risk many IDUs do not get tested. Despite “constant” HIV education many IDUs express little or no exposure to information regarding HCV. HIV and HCV education should be delivered concurrently, as many IDUs report receiving HIV information during drug treatment programs. Drug treatment facilities are prime sites to offer testing and treatment opportunities as well. Limited knowledge of HCV is evidenced during interviews with IDUs.
“Hepatitis has got something to do with HIV, doesn’t it? Your body turns yellow, or some shit like that? No. No. I don’t be around yellow people.” 42-year-old African American woman, lives with
her grandmother. (Lally et al, 2008)
Patients who actually got tested were often confused and frustrated related to lack of information and
education delivered at the time of diagnosis.
“When I was pregnant they said, “You know you have hepatitis C?” And I said, “Yeah, why?”…They said, “It’s no big deal”…so I thought, why should I even bother following up?...Maybe I misinterpreted that…But I did learn…you can get very sick and die from it…The only thing I know of is changing your diet and interferon.” 36-year-old white homeless woman. (Lally et al, 2008)
The most serious barrier is prioritization of obtaining drugs over attention to one’s health. IDUs report that during times when they are actively using they are less likely to get tested, treated or follow up because time is consumed by obtaining and using drugs, interfering with ability to attend to health needs. These barriers are confirmed in statements by drug addicted women.
“When you’re using you just don’t have time for really anything …not your children, not bathing…not eating, not sleeping…not being responsible. It basically consists of money and using. And worrying how to contact your connections. And trying not to get arrested in the process…Users have a 25 hour a day job.” 33-year-old, white, homeless woman (Lally et al, 2008)
“The last thing on my mind is going to get tested…I got to be tested and I know that. But I care about being an addict more than I care about my health.” 23-year-old, African American woman.( Lally et al, 2008)

B. Administer pharmaceutical treatment with regular visits to monitor effectiveness of treatment

I. Lack of health insurance/financial resources to fund Hepatitis C treatment programs
Injection drug users (IDU) are a medically underserved population, nationally, and confront many barriers to accessing medical services. Lack of regular medical care and low to non-existent levels of insurance coverage represent significant obstacles. Because IDUs access to and utilization of medical care is inconsistent, current medical complaints often override infectious disease detection, diagnosis and education during instances when care is sought. (Lally et al, 2008) Once diagnosed payment for treatment remains a huge concern to patients.
"I though of [treatment] a lot. I've got to go to the doctor…Oh my God, I don't know how much it's going to cost. Let me see if I can get medical first, and then I'll go." 31-year-old white woman, stays with brother (Lally et al, 2008).
Patients on Medicaid are significantly more likely to be treated for HCV than patients with only Medicare coverage or private/commercial insurance. Patients with Medicaid are more likely to seek and follow through with treatment because Medicaid pays the total cost of prescription medications including interferon-based combination treatments. Medicare alone does not cover the total cost of medications resulting in large out of pocket expenses for patients (Narasimhan et al, 2006). Free, federally funded HIV testing and counseling is much more accessible through local agencies and health departments than for Hepatitis C, services which would seem to fit hand in hand.

II. Difficult to follow up for continued treatment and monitoring for many reasons, including, lack of transportation, accurate and stable contact information, mental illness and patient priorities other than health care follow up
Common reasons for non-treatment include minimal/mild disease on biopsy (38%), noncompliance (31%) , patient refusal (22%) and significant psychiatric problems (8%) (Narasimhan et al, 2006). A study reveals very low income is the strongest correlating group of HCV infected patients. Four California counties participated in the study which revealed 60% of those infected earn a monthly household income of less than $999 and only 7% earning over $3000 per month. 90% had not earned a college degree and 41% did not complete high school. 62% of those infected with HCV were single, 54% having more than 5 sex partners and 45% diagnosed with an STD other than HCV (Page-Shafer et al 2002). Lack of education and financial resources make continuation of treatment and monitoring very challenging for healthcare professionals.
Many patients indicate that a lack of transportation hinder their ability to receive testing, results, treatment and monitoring.
"Transportation…would help a heck of a lot because people are out here catching buses and they're [drug] sick. Who wants to go out there in the snow, rain, sleet, whatever, even when they're not sick?...I haven't been making appointments because I don't have a ride out there. And I'm not going to get on no bus and all that shit when I don't feel good." 43-year-old CapeVerdian woman, homeless (Lally et al, 2008)


References

Lally et al (2008). A qualitative study among injection drug using women in Rhode Island: attitudes toward tesing, treatment, and vaccination for hepatitis and HCV. AIDS Patient Care and STDs. 22(1). 53- 63. Retrieved May 9, 2008 from Academic Search Premier.
Narasimhan, G. et al (2006). Treatment rates in patients with chronic hepatitis C after liver biopsy. Journal of Viral Hepatitis. 13. 783-786. Retrieved May 4, 2008 from Academic Search Premier.
Page-Shafer, K. et al (2002). Hepatitis C virus infection in young, low-income women: The role of sexually transmitted infection as a potential cofactor for HCV infection. American Journal of Public Health. 93(4). 670-676. Retrieved May 4, 2008 from Academic Search Premier.
Cormier, M. (2005). The role or hepatitis C support groups. Gastroenterology Nursing,
28(3), S4-S9.
Fahey, S. (2007). Developing a nursing service for patients with hepatitis C. Nursing
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National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. (2006,
December 8) Viral hepatitis C. Retrieved February 16, 2008 from http://www.cdc.gov/nchhstp/.
Zic, I. (2005). Peginterferon alpha/ribavirin comination therapy for the treatment of hepatitis C infection. Gastroenterology Nursing, 28(4), 317-328.