• 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.