• 400 million people live with Hepatitis
• 325 million people are living with chronic viral hepatitis B and C infections worldwide
• 6 -10 million people are newly infected annually
• An estimated 95% of people with hepatitis do not know there are infected

WHAT IS HEPATITIS?

It is an inflammation of the liver, characterized by the presence of inflammatory cells in liver tissue mainly caused by viruses; hence it is also known as Viral Hepatitis. Not all Viral Hepatitis cause long term infections but certain types become chronic, lifelong infections and can lead to serious Liver damage, Cirrhosis and even Liver Cancer.

SYMPTOMS

• Fatigue
• Sudden nausea and vomiting
• Abdominal pain or discomfort on the upper right side
• Clay-colored bowel movements
• Intense itching
• Loss of appetite
• Low-grade fever
• Yellowing of the skin and the whites of your eyes (jaundice)
• Dark urine
• Joint pain

CAUSES

Hepatitis infections are most commonly caused by a group of five known viruses designated A-E.

Other possible causes include:

• Excessive consumption of alcohol
• In some cases, immune system identifies the liver as a foreign object and begins to attack and causes inflammation
• Metabolic disorders

TYPES OF HEPATITIS:

There are three major types of Hepatitis. The symptoms seen for the Hepatitis are similar but the treatment options are determined based on the type of the virus and whether it is acute or chronic.

• Hepatitis A (HAV) - is caused by the Hepatitis A virus and is one of the major causes of food-related infections and illnesses. It appears as an acute infection and doesn't cause chronic liver diseases. Vaccination is available and usually resolved within 2 months of infection.
• Hepatitis B (HBV) - is a chronic Liver inflammation caused by the Hepatitis B virus. It is potentially life-threatening infection leading to severe Liver conditions like Cirrhosis and Liver cancer. Vaccination is available for Hepatitis B.
• Hepatitis C (HCV) - is a long term infection caused by the Hepatitis C virus. People become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. There is no vaccination available for Hepatitis C.

Other Less common types of Hepatitis are:

• Hepatitis D - is caused by the Hepatitis D virus and occurs when a person is infected with Hepatitis B.
• Hepatitis E - is self-limiting liver inflammation caused by the Hepatitis E virus and usually associated with water contamination.
• Autoimmune Hepatitis - is a chronic, autoimmune disease of the Liver that occurs when the body's immune system attacks Liver cells causing the liver to be inflamed. Treatment of Autoimmune Hepatitis involves the prescription of immunosuppressive glucocorticoids.

DIAGNOSIS:

Common tests that help diagnose Hepatitis are:

• Liver function tests (AST and ALT elevated out of proportion to alkaline phosphatase, usually with hyperbilirubinemia)
• Viral serologic testing
• PT/INR measurement
• Ultrasound
• Liver biopsy

TREATMENT
Treatment for Hepatitis is determined based on the type and stage of the viral infection:

• Interferon injections – Most common treatment to manage and slow diseases progression
• Anti-viral Drugs – Early treatment can stop the chronic infection and prevent Liver Cirrhosis
• Liver transplant – If the liver is severely damaged, a liver transplant may be an option

COMPLICATIONS OF HEPATITIS

Hepatitis can progress to further complicated diseases. Some of the most common complications of Chronic Hepatitis are:

• Fibrosis
• Cirrhosis
• Liver cancer
• Liver failure

PREVENTION

Viral Hepatitis can be prevented through hygienic lifestyle and other precautionary measures like:

• Getting Vaccinated
• Safe Blood transfusion
• Safe Injection
• Don't share or re-use sharp objects or syringes

Patients who have recently developed jaundice, excessive sleepiness, irrelevant talk, excessive weakness, itching or other similar symptoms should also consult a liver specialist, as they could have developed an acute form of liver disease sometimes called as hepatitis. Such diseases always need urgent attention of a liver specialist, although most often these are not serious. These liver diseases may be more common after having contaminated food or in a person who is habituated for binge drinking (large amount of alcohol consumed in a short time) or after taking some medicines (especially anti-TB and ayurvedic medicines containing heavy metals).

Patients with advanced liver disease such as liver cirrhosis may have symptoms such as jaundice (yellow eyes or urine), blood vomiting, swelling in the feet or abdomen (belly), excessive sleepiness, irrelevant talk, excessive weakness, itching or others. Patients who may have developed such symptoms recently should consult a liver specialist as soon as possible as these symptoms could indicate a serious underlying problem. Depending on their symptoms, their liver specialist may advise them to restrict their liquid and salt intake, take a high protein diet and medicines to keep their bowel movements regular, keep their swelling and other symptoms under control and treat their liver disease. These medicines should be available for about 1 month as their availability may be an issue due to the lockdown.

Patients with very advanced liver disease who need a liver transplant are often under care of a liver specialist and may be waiting for a liver transplant. Regular testing should not be omitted, if required use home collection of blood samples offered by many labs. Most doctors also offer tele-consultation which could be utilized to review your progress with them. If the patient is stable, the transplant should be planned only after the lockdown period. However, in case of an emergency, if the patient’s condition is worsening or if a cadaveric liver is offered to the patient, they should be able to go ahead with the transplant if the donor and the patient are both negative for the COVID infection.

During the COVID-19 pandemic, they should limit their movement in the community and exposure to other sick patients as patients with advanced liver disease may have a weak immune system. As there is currently no proven vaccine to prevent or antiviral medicine to treat this infection, it may be best to avoid it as it may be more difficult for patients with advanced liver disease to fight this infection. Patients may have a lot of free time during the lockdown and should identify productive activities to keep themselves occupied indoors such as pursuing their hobby (painting, reading, etc.). Try to continue indoor exercises such as walking or jogging (in a small area) or using stationary exercise cycle as tolerated by you. Patients and their family members should strictly avoid smoking as it can be dangerous in case of COVID-19 infection. There should be no alcohol intake as it can suddenly worsen a stable liver disease. In case of high-grade fever, dry cough or sputum production, they should be seen immediately and tested for suspected infection by a pulmonologist (lungs specialist) and an infection disease (ID) specialist keeping the liver specialist informed of all progress.

While being treated for the infection, the condition of their liver disease should be closely monitored by a liver specialist.

These profound words make us reflect into the Indian healthcare system. Often decisions may be informed by ideology, economics, political timing, or any number of forces that may have little to do with what people actually need. As leaders around the world grapple with demands to deliver more and better health services, faster and more affordably, it is important to ask whether we are providing services that are appropriate, accessible, safe, clinically effective, and satisfying to the people using services and those delivering them.

To understand and achieve this, we need to ask the Five Rights: Are we delivering the Right Care, by the Right Provider, at the Right Time, in the Right Place, and at the Right Cost?

Deploying Nurses to Bridge the Gap

Speaking at the ICN Congress in Singapore in 2019, WHO’s Dr. Tedros Ghebreyesus said, “We simply cannot achieve universal health coverage and the health-related targets in the SDGs (Sustainable Development Goals) unless we empower and equip nurses and midwives, and harness their power.” His powerful words talk about a solution to bridge the gap. Nurses have solutions and can be utilized more effectively to help resolve the big challenges in health systems. However we must educate, regulate, deploy, support and reward them to lead that change.

Experts suggest that well-educated nurses deployed in the right numbers offer positive health outcomes across many settings, including morbidity and mortality outcomes. Nurse-led models of care have proven their clinical efficacy, satisfaction to the public, and cost-effectiveness when compared to traditional models. For example, nurse prescribing in the UK, the Royal College of Nursing found improvements in patient care such as timelier access to medicines and treatment, increased flexibility for patients who would otherwise have had to see a doctor, improved service efficiency that allows physicians to care for complex patients, diversion of avoidable emergency and hospital admissions, and better access to more streamlined and patient-centred care.

Thus, nurses’ leadership should be prominent in implementing the solutions for sound healthcare structure.

The Next Steps

In repeated polls in Canada and the USA over the past 20 years, nurses nearly always come out on top of the list of professionals most trusted by the public. This outcome is the result of

• Decades of hard work by professional associations
• Development of standards of practice
• Strong nursing education including a space for them to opt for advanced practices
• Strict nursing regulation

A model like this would revolutionize India’s healthcare system along with giver affordable and targeted care for individual patients. The way forward should place higher priority on public health, health promotion and wellness, and the prevention of illnesses and injuries. And for nurses to work hand-in-hand with top tier health care systems to effectively help deliver the right care in the right place and right time at reasonable costs.

According to data recorded by the World Health Organization (WHO) in 2016, with an estimated 40 million people suffering from chronic Hepatitis B and six to 12 million people are infected with Hepatitis C, Hepatitis or inflammation of the liver has become one of the pressing public health concerns in India. Not just that, viral Hepatitis caused by Hepatitis Viruses especially B and C results in a whopping economic and social burden on the affected individuals and their families. Hepatitis is an inflammation of the liver. The condition can be self-limiting or progress to fibrosis (scarring), cirrhosis or liver cancer.

There are mainly two categories of viral hepatitis:

1. Hepatitis A and E

2. Hepatitis C and B

CAUSES OF HEPATITIS:

Hepatitis A:

Hepatitis A is a viral illness causing liver swelling or inflammation. It is passed on when an uninfected person consumes food or water that has been contaminated with the feces of an infected person. Most infections are passed on through close personal contact with an infected household member. It is usually a self-limiting illness causing symptoms like mild fever, body ache, fatigue, yellow discolouration of eyes and urine and sometimes itching. The symptoms can last for a few weeks and the jaundice gradually subsides without any long term complications. It does not need any specific treatment. The treatment includes supportive care and good nutritious diet. In rare cases it can cause a serious condition called acute liver failure which includes hampered blood clotting and drowsiness. Acute liver failure needs immediate hospitalisation, ICU care and may need an urgent liver transplantation in some cases.

Hence prevention is the best approach.Eating well cooked fresh, warm hygienic food and good personal hygiene including hand washing before eating food are the most important preventive steps.A vaccine is also available for prevention of Hepatitis A.

Hepatitis E:

It is similar to Hepatitis A but can be more severe. It can particularly cause severe disease including Acute Liver Failure in pregnant women. There is no vaccine available as of now for Hepatitis as of now. Hence strict precautions as outlined in section for Hepatitis A need to be followed for prevention.

Hepatitis B:

Hepatitis B is a viral illness affecting the liver. Unlike Hepatitis A and E, it more often than not remains in the liver of the infected individuals for a long time. In most cases it just stays in the liver without causing injury or damage. Such individuals are called inactive carriers. But in some patients, the virus causes liver injury which can progress to fibrosis (scarring), cirrhosis (permanent structural liver damage) and even liver cancer. It is important to identify whether a particular patient is an inactive carrier or has active disease. This can be done by a doctor by clinically examining and reviewing certain test reports. Hence it is important to consult a doctor and get yourself evaluated. Effective treatment is available for Hepatitis B and is needed usually over a long term. Hepatitis B can be transmitted through contact with body fluids like semen, vaginal fluids, and blood. It can pass from a mother to a new-born during delivery, during blood transfusion, sharing needles and having unprotected sex.

An effective vaccine is available for Hepatitis B and is now included in the universal vaccination schedule for children

Hepatitis C:

The mode of transmission of Hepatitis C is similar to Hepatitis B and it also causes a chronic liver illness that can progress to cirrhosis and liver cancer. Very effective oral medications are now available for CURE of Hepatitis C and have to be taken for a finite duration of 3-6 months. It is important to identify the patients of Hepatitis C in early stage of the disease and treat them before permanent damage has occurred in the liver.

Take note of these symptoms:

Fatigue, nausea and vomiting, abdominal pain or discomfort, loss of appetite, dark urine, joint pain, yellowing of the skin, sore muscles, itchy skin, and joint pain are some of the common symptoms that one may exhibit. Once you notice the symptoms, immediately consult your doctor who will suggest a proper line of treatment.

Take-home message:

Hepatitis A and E can be prevented using simple measures. It is important to get tested for Hepatitis B and C. If negative, vaccine for Hepatitis B needs to be taken. If positive, consult doctor immediately for effective and timely treatment.

The first case of COVID-19 in India, was reported on 30 January 2020. As numbers kept on increasing, on 24 March, the Prime Minister ordered a nationwide lockdown for 21 days, affecting the entire 1.3 billion population of India. On 14 April, the PM extended the nationwide lockdown till 3 May which was followed by two-week extensions starting 3 and 17 May.

Because of the lockdown, there was a significant reduction in the number of transplants. In fact, the transplant program stopped during nationwide lockdown. There were no living donor transplants and there were 5 cases of brain-stem death identified in Mumbai during this period, but none could become donors due to practical problems. These include scarce resources (e.g., beds, operating theatres, medics, and nurses) and a logistical difficulty in ensuring clean and microbiologically safe pathways within hospitals for transplant patients.

As regards, kidney transplant procedures, there was fear among doctors that SARS-CoV-2 infection could be missed in both donors and recipients who are asymptomatic owing to the sensitivity issues with the RT-PCR test. Additionally, in the immediate postoperative period and after hospital discharge, transplanted patients have increased susceptibility to SARS-CoV-2 infection owing to induction therapy and immunosuppressive treatment. Because of this even the patients were reluctant for transplant and particularly kidney transplant patients because they have an alternative in the form of dialysis. Beginning June 1, the lockdown was released. By this time, with better understanding of COVID-19 and availability of antiviral and anti-inflammatory drugs the recovery rate of COVID-19 steadily improved.

Timely case identification” and “proper clinical management”. The recovery rate has been steadily increasing. In my opinion, with proper evaluation of recipient and donor which includes epidemiologic history, clinical history, throat swab for RT PCR and HRCT chest and with proper care in the hospital, kidney transplantation can be performed in the current situation. It is important to discuss with the patient that despite taking all precautionary measures, a small risk of covid infection remains and a dedicated consent form would help patients make well informed decisions. The significant decline in kidney transplantation is due to uncertainty regarding the risk of developing COVID-19 infection and its impact on recipients and also because these patients have an alternative in the form of dialysis.

Nurses are part of one of the biggest segments of the healthcare industry and they play an extremely important role. The right caring for a patient post-treatment is crucial for their recovery, and nurses are well aware of that. They ensure that they provide the patients with everything they need, right from caring to counselling, to ensure their good health and speedy recovery. However, even after knowing everything about health and healthcare, most of these caring angels fail to take care of their own health. 

The healthcare industry is one of the most hazardous environments to work in. Nurses in this industry are constantly exposed to a complex variety of health and safety hazards in the course of their work. Hazards range from biological exposure to disease-causing organisms such as tuberculosis and human immunodeficiency virus (HIV); exposure to chemicals such as glutaraldehyde and ethylene dioxide; risks of needle-stick injuries causing HIV, hepatitis, etc; Long working hours causing musculoskeletal issues; moving heavy patients that may lead to physical discomfort; and prolonged shift work causes stress and adds to the health issues.

In a report published by the WHO, the disease burden caused by percutaneous sharps injuries among healthcare workers was found to be three million per year. Maximum cases of hepatitis B, hepatitis C and HIV among healthcare workers were reported to be due to needle stick injuries. It is very unfortunate that approximately 1000 healthcare workers die annually from occupational HIV, which can and should have been prevented. Despite having the resources and the knowledge, almost 80% of healthcare workers remain unimmunized (against Hepatitis B) in many parts of the world.

In addition to this, nurses have a higher risk of non-communicable diseases such as diabetes, hypertension, and cardiovascular diseases as well. Many nurses are forced to lead an unhealthy lifestyle due to their long shift hours, busy-paced work, and the stress of maintaining a work-life balance. With so many responsibilities, it becomes easy to understand how self-care becomes their last priority.

Maintaining the health of the nurses became all the more difficult during the pandemic with the extreme workload, minimal information about the virus, and the fear of contracting the disease. Therefore, we made certain provisions in the hospital itself. We provided all our nurses and staff members with vitamin C supplements and adequate protein to ensure their immunity is boosted, we gave them constant reminders to drink water and gave them enough breaks between shifts to rest and destress. Bio breaks were given to use the washroom and return with fresh PPEs keeping in mind menstrual hygiene and prevention of UTIs and renal calculi. We also checked their weight regularly to make sure they are well-nourished and also are regularly screened for COVID-19 so that if infected, they can be treated on time. The nurses who had turned positive were provided free and best care to recover.

Apart from that, we also arranged several diversions such as poster competitions, counselling events to take care of nurses’ grievances, and several other provisions were made to ensure that the mental health of the nurses was also taken care of.  

I agree that nursing is a noble profession and that you are expected to keep your patients as the top priority, but it is equally important to take care of yourself because you can look after your patients only when you are fit and healthy. Set aside some time for exercise, take care of your nourishment, take vitamin C and protein supplements to boost your immunity, get enough rest and sleep, practice meditation to maintain good mental health, report to a physician in your hospital if you are feeling uneasy or unwell, ask for help whenever you feel overwhelmed by work and lastly, give yourself the priority and importance you need and deserve.

With the COVID-19 pandemic, we are living through a world crisis that we have never seen in nearly a hundred years.

The enormous scale of the crisis and the impact it has created had already caused a lot of fear, uncertainty and anxiety across the globe. The frontline workers were always at the risk of contracting the virus, despite which they have served us and took care of millions worldwide. When the pandemic started no one knew about it precisely and we were in the same boat too. All the employees and nurses were timorous and terrified but when we gathered them with respective managers and conducted meetings to explain their duty, they came forward. We had taken the initiatives to train them and counsel them about how they have to take care of the patients in the given scenario.

The acceptance of a situation where we had to stand for one another was the utmost priority which the nurses developed. Those times were so hard as there was no transportation for anyone to go to their homes respectively which was a matter of concern. But, we being nurses were only concerned about our duty and responsibility.

Generally, the ICU care unit had always seen the hardest goodbyes and warmest welcomes, but Covid-19 ICU care units were no less of a greater chore. We were running aisles to get the patients what they needed on time each moment. This reminds me of the most challenging day in the covid ICU critical care unit. This was the time when covid cases peaked up, we were accommodating 40-45 patients all at once. Suddenly, we received a call from the emergency room that there were three patients that had to be admitted as early as possible. We panicked as soon as this news was received. They were on mobile ventilators and they had to come all the way to the hospital.

We had assigned two nurses who took care of these covid patients, as our first priority were always them, we were making arrangements for them for a hassle-free admittance. We received the call about their arrival post at 5 pm in the evening and these critical patients arrived at 7 pm. They were in miserable conditions, one patient was unconscious and the other two had major respiratory problems. I remember how their saturation levels were at 80 and it was terrifying to see three patients at once with such ailments.

The doctors along with nurses were on the duty trying to do whatever we could to bring them to normalcy. As the three of them had different conditions, looking after them was a challenge. The frontline leaders faced great difficulty to get the nurses from normal ICU to covid care unit. Arranging manpower was a task for the assistant nursing superintendent. Even though there were such circumstances the nurses always came front to help the patients which were overwhelming.

Nurses are known for their patience levels and self-composed nature, needless to say, that day we experienced it. The nurses were so composed and patient with those patients who happened to recover in later stages. There was less equipment for them so, we immediately contacted the biomedical engineers to provide us with the necessary equipment. They did a very commendable job in coordinating with us at such times.

There is an on-call list for emergencies where the nurses wait at their respective hostels. If there is any need, they attend as soon as possible. Such arrangements play a major role at times where it is the matter of life and death. Post that day, we have taken good care of the mentioned patients and they recovered pretty well.

This experience has been great learning for the nurses as they have dealt with such situations, they are now ready for anything. They have no fear of treating any patient with any kind of ailments. Currently, we have 12 covid patients admitted and the nursing staff is dealing with them extremely responsibly. As they are competent to handle patients, the nurses are getting opportunities in other countries mainly, the Gulf countries and the UK where they are looking for such skilled manforce.

I am very much proud that after such experiences, our nurses are getting the opportunity to excel in their careers. After the patients recovered, their smiles are what we look up to and feel proud of. Even though time has passed such memories stay with us impacting and leave us with great learnings.

I believe that a pandemic had to come to make the world realise what nurses are capable of doing anything and 2020 was the year for nurses. As the patients struggle for their life, we can handle any situation now as we demonstrate care, team spirit and utmost unity. The most challenging day had been the most memorable one too in the times of covid.