Hepatitis B immune globulin (HBIG) provides passive immunity to hepatitis B and is indicated for people exposed to HBV who have never had hepatitis B and have never received hepatitis B vaccine. Specific indications for postexposure vaccine with HBIG include: (1) inadvertent exposure to HBAg-positive blood through percutaneous (needlestick) or transmucosal (splashes in contact with mucous membrane) routes, (2) sexual contact with people positive for HBAg, and (3) prenatal exposure (babies born to HBV-infected mothers should receive HBIG within 12 hours of delivery).
HBIG, which provides passive immunity, is prepared from plasma selected for high titer of anti-HBs. Prompt immunization with HBIG (within hours to a few days after exposure to hepatitis B) increases the likelihood of protection. Both active and passive immunization are recommended for people exposed to hepatitis B through sexual contact or through percutaneous or transmucosal routes. If HBIG and hepatitis B vaccine are administered at the same time, separate sites and separate syringes should be used.
Prophylaxis with high doses of HBIG started at the time of liver transplantation and continued indefinitely improves survival by thwarting recurrence of hepatitis B (Bacon & Di Bisceglie, 2000). There has been no evidence that HIV infection can be transmitted by HBIG. • Gerontologic Considerations The elderly patient who contracts hepatitis B has serious risk of sever liver cell necrosis or fulminant hepatic failure, particularly if other illnesses are present. The patient is seriously ill and the prognosis is poor, so efforts should be undertaken to eliminate other factors (eg, medications, alcohol) that may affect liver function.
F. Medical Management The goals are minimize infectivity, normalize liver inflammation, and decrease symptoms. Of all the agents that have been used to treat chronic type B viral hepatitis, alpha interferon as the single modality of therapy offers the most promise. This regimen of 5 million units daily or 10 million units three times weekly for 4 to 6 months results in remission of disease in approximately one third of patients (Befeler & Di Bisceglie, 2000). The long-term benefits of this treatment are being assessed.
Interferon must be administered by injection and has significant side effects, including fever, chills, anorexia, nausea, myalgias, and fatigue. Late side effects are more serious and may necessitate dosage reduction or discontinuation. These include bone marrow suppression, thyroid dysfunction, alopecia, and bacterial infections. Two antiviral agents (lamivudine [Epvir] and adefovir [Hepseral] oral nucleoside analogs, have been approved for use in chronic hepatitis B in the United States.
Viral resistance may be and issue with these agents and studies of their effectiveness alone and in combination with other therapies are ongoing (Befeler & Di Bisceglie, 2000). Bed rest may be recommended, regardless of other treatment, until the symptoms of hepatitis have subdued. Activities are restricted until the hepatic enlargement and elevated levels of serum bilirubin and liver enzymes have disappeared. Gradually increased activity is then allowed.
Adequate nutrition should be maintained: proteins are restricted when the liver’s ability to metabolized protein by products is impaired, as demonstrated by symptoms. Measures to control the dyspeptic symptoms and general malaise include the use of antacids and antiemetics, but all medications should be avoided if vomiting occurs. If vomiting persists, the patient may require hospitalization and fluid therapy. Because of the mode of transmission, the patient is evaluated for other bloodborne diseases (eg, HIV infection). G. Nursing Management
Convalescence may be prolonged with complex symptomatic recovery sometimes requiring 3 to 4 months or longer. During this stage, gradual resumption of physical activity is encouraged after jaundice has resolved. The nurse identifies psychosocial issues and concerns, particularly the effects of separation from family and friends if the patient is hospitalized during the acute and infective stages. Even if not hospitalized, the patient will be unable to work and must avoid sexual contact. Planning is required to minimize alterations in sensory perception.
Planning that includes the family helps to decrease their fears and anxieties about the spread of the disease. H. Teaching Patients Self-care. Because of the prolonged period of convalescence, the patient and family must be prepared for home care. Provision for adequate rest and nutrition must be ensured. The nurse informs family members and friends who have had intimate contact with the patient about the risks of contracting hepatitis B and makes arrangements for them to receive hepatitis B vaccine or hepatitis B immune globulin as prescribed.
Those at risk must be aware of the early signs of hepatitis B and of ways to reduce risk to themselves by avoiding all modes of transmission. Patients with all forms of the hepatitis should avoid drinking alcohol. IV. Conclusion Follow-up visits by a home care nurse may be needed to assess the patients’ progress and answer family members’ questions about disease transmission. A home visit also permits assessment of the patient’s physical and psychological status and the patient and family’s understands of the importance of adequate rest and nutrition.
The nurse also reinforces previous instructions. Because if the risk of transmission through sexual intercourse, strategies to prevent exchange of body fluids are advised, such as abstinence of keeping follow-up appointments and participating in other health promotion activities and recommended health screenings.
Reference:
1. Bacon, B. R. , & Di Bisceglie, A. M. (Eds. ) (2000). Liver disease, pp. 345-358. New York: Churchill Livingstone. 2. Befeler, A. S. , & Di Bisceglie, A. M. (2000). Hepatitis B. Infectious Disease Clinics of North America, 14(3), 617-632.3. Centers for Disease Control and Prevention (CDC). (1999). Prevention of hepatitis A through active or passive immunizations: Recommendations of the Advisory Committee on Immunization Practice (ACIP). MMWR: Morbidity and Mortality Weekly report, 48 (RR-12), 1-37. 4. Centers for Disease Control and Prevention (CDC). (2002). Sexually transmitted diseases treatment guidelines 2002. MMWR: Morbidity and Mortality Weekly report, 51 (RR-6), 1-84. 5. Koff, R. S. (2001). Hepatitis vaccines. Infectious Disease Clinics of North America, 15 (1), 83-93.