Unlike hepatitis A, which is transmitted primarily by the fecal—oral route, hepatitis B is transmitted primarily through blood (percutaneous and permucosal). HBV has been found in blood, saliva,, semen, and vaginal secretions and can be transmitted through mucous membranes and breaks in the skin. HBV is also transferred from carrier mothers to their babies, especially in areas with a high incidence (ie, Southeast Asia). The infection is usually not via the umbilical vein, but from the mother at the time of birth and during close contact afterward. HBV has a long incubation period.
It replies in the liver and remains in the serum for relatively long periods, allowing transmission of the virus. Those at risk for developing hepatitis B include surgeons, clinical laboratory workers, dentists, nurses, and respiratory therapists. Staff and patients in hemodialysis and oncology units and sexually active homosexual and bisexual men and injection drug users are also at increased risk. Screening of blood donors has greatly reduced the occurrence of hepatitis B after blood transfusion. Most people (>90%) who contract hepatitis B infections will develop antibodies and recover spontaneously in 6 months.
The mortality rate from hepatitis B has been reported to be as high as 10%. Another 10% of patients who have hepatitis B progress to a carrier state or develop chronic hepatitis with persistent HBV infection and hepatocellular injury and inflammation. It remains a major cause of cirrhosis and hepatocellular carcinoma worldwide This paper scrutinizes and defines the history, signs and symptoms, environment, family history, treatment, patient teaching, and nursing interventions and application to nursing of hepatitis B.
II. Discussion A. Clinical Manifestations Clinically, the disease closely resembles hepatitis A, but the incubation period is much longer (1 to 6 months). Signs and symptoms of hepatitis B may be insidious and variable. Fever and respiratory symptoms are rare: some patients have arthralgias and rashes. The patient may have loss of appetite, dyspepsia, abdominal pain, generalized aching, malaise, and weakness. Jaundice may or may not be evident. If jaundice occurs, light-colored stools and dark urine accompany it.
The liver may be tender and enlarged to 12 to 14 cm vertically. The spleen is enlarged and palpable in a few patients; the posterior cervical lymph nodes may also be enlarged. Subclinical episodes also occur frequently. B. Assessment and Diagnostic Findings HBV is a DNA virus composed of the following antigenic particles: • HBcAg—hepatitis B core antigen (antigenic material in an inner core • HBsAg—hepatitis B surface antigen (antigenic material on surface of HBV) • HBeAG—an independent protein circulating in the blood • HBxAg—gene product of X gene of HBV/ DNA
Each antigen elicits its specific antibody and is a marker for different stages of the disease process: • Anti-HBc—antibody to core antigen or HBV; persists during the acute phase of illness; may indicate continuing HBV in the liver. • Anti-HBs—antibody to surface determinants on HBV; detected during the late convalescence; usually indicates recovery and developments of immunity. • Anti—HBe—antibody to hepatitis B e-antigen; usually signifies reduced infectivity. • Anti—HBxAG—antibody to the hepatitis B x-antigen; may indicate ongoing replication of HBV
HBsAg appears in the circulation in 80% to 90% of infected patients 1 to 10 weeks after exposure to HBV and 2 to 8 weeks before the onset of symptoms or an increase in transferase (transaminase) levels. Patients with HBsAg that persists for 6 or more months after acute infection are considered HBsAg carriers (Befeler & Di Bisceglie, 2000). HBeAg is the next antigen of HBV to appear in the serum. It usually appears within a week of the appearance of HbsAg and before changes in aminotransferase levels, disappearing from the serum within 2 weeks.
HBV DNA, detected by polymerase chain reaction testing, appears in the serum at about the same time as HBeAg. HBcAg is not always detected in the serum in HBV infection. About 15% of American adults are positive for anti-HBs, which indicate that they have had hepatitis B. Anti-HBs may be positive in as many as two thirds of IV/injection drug users. C. Prevention The goals of prevention are to interrupt the chain of transmission, to protect people at high risk with active immunization through the use of hepatitis B vaccine, and to use passive immunization for unprotected people exposed to HBV.
• Preventing Transmission Continued screening of blood donors for the presence of hepatitis B antigens will further decrease the risk of transmission by blood transfusion. The use of disposable syringes, needles, and lancets and the introduction of needleless IV administration systems reduce the risk of spreading this infection from one patient to another or to health care personnel during the collection of blood samples or the administration of parenteral therapy. Good personal hygiene is fundamental to infection control.
In the clinical laboratory, work areas should be disinfected daily. Gloves are worn when handling all blood and body fluid as well as HBAg-positive specimens, or when there is potential exposure to blood (blood drawing) or to patients’ secretions. Eating and smoking are prohibited in the laboratory and in other areas exposed to secretions, blood, or blood products. Patient education regarding the nature of the disease, its infectiousness, and prognosis is a critical factor in preventing transmission and protecting contacts. D. Active Immunization: Hepatitis B Vaccine
Active immunization is recommended for individuals at high risk for hepatitis B (eg, health care personnel and hemodialysis patients). In addition, individuals with hepatitis C andhepatitis C and other chronic liver disease should receive the vaccine (CDC, 1999). A yeast-recombinant hepatitis B vaccine (Recombivax HB) is used to provide active immunity. Long-term studies of healthy adults and children indicate that immunologic memory remains intact for at least 5 to 10 years, although antibody levels may become low or undetectable.
Measurable levels of antibodies may not be essential for protection. In those with normal immune systems, booster does are not generally required. The CDC (2002) does not recommend booster doses may be revisited if reports of hepatitis B increase or an increased prevalence of the carrier state develops, indicating that protection is declining. A hepatitis B vaccine prepared from plasma of humans chronically infected with HBV is used only rarely and in patients who are immunodeficiency or allergic to recombinant yeast-derived vaccines.
Both forms of the hepatitis B vaccine are administered intramuscularly in three doses, the second and third doses 1 and 6 months after the first dose. The third dose is very important in producing prolonged immunity. Hepatitis B vaccination should be administered to adults in the deltoid muscle. Antibody response may be measured by anti-HBs levels 1 to 3 months after completing the basic course of vaccine, but this testing is not routine and not currently recommended. Individuals who fail to respond may benefit from one to three additional doses (Koff, 2001).
People at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. Health care workers who have had frequent contact with blood are screened for anti-HBs to determine whether immunity is already present from previous exposure. The vaccine produces active immunity to HBV in 90% of healthy people (Koff, 2001). It does not provide protection to those already exposed to HBV and provides no protection against other types of viral hepatitis.
Side effects of immunization are infrequent; soreness and redness at the injection site are the most common complaints. Because hepatitis B infection is frequently transmitted sexually, hepatitis B vaccination is recommended for all unvaccinated persons being evaluated for a sexually transmitted disease (STD). It is also recommended for those with a history of an STD, persons with multiple sex partners, those who have sex with injection drug users and sexually active men who have sex with other men (CDC, 2002).