THE WORLD has become a smaller place: You can fly to another continent in hours, and fresh produce grown in one country is eaten in another. These are just two factors that have hastened the spread of viral hepatitis around the world in recent years. In this article, I'll review the major types of viral hepatitis and discuss new treatments that can help a patient cope with acute and chronic disease.

In the beginning
Despite their individual differences, all hepatitis viruses have similar effects on the liver. Symptoms may include right upper quadrant abdominal pain, anorexia, dark-colored urine, diarrhea, nausea and vomiting, fatigue, jaundice, and joint pain. For characteristic changes in lab values, see How hepatitis affects lab values .

Some patients infected with a hepatitis virus are asymptomatic. For example, about 30% of patients with positive hepatitis B titers and 80% of those with positive hepatitis C titers don't recall experiencing symptoms. Children are commonly asymptomatic regardless of virus type.

Hepatitis viruses are classified according to mode of transmission. The enteric viruses, hepatitis A and E, are primarily transmitted via the fecal-oral route. Recent outbreaks of hepatitis A have been attributed to tainted produce and poor sanitation practices by infected food service workers. Although the fecal-oral route is the primary mode of transmission, enteric hepatitis viruses also may be transmitted by blood or sexual activity.

The other hepatitis viruses—B, C, D, G, and the recently identified transfusion-transmissible disease—are transmitted via blood and body fluid . People at risk for these infections include those with multiple sexual partners, day care and health care workers, people suffering needle-stick injuries from improperly disposed medical waste, people using recreational drugs, and people receiving tattoos and piercings. Even seemingly innocent behaviors, such as sharing a toothbrush or a razor, can lead to contact with tainted blood.

In the past, blood transfusion was a significant mode of transmission. But today, donor blood is screened for these viruses and tainted blood is discarded.

New hepatitis viruses are still being identified. One, called transfusion-transmissible virus, has been identified in children who've received blood transfusions. This hepatitis variant is considered a chronic but benign infection. No treatment is considered necessary, and widespread screening isn't needed.

When caring for any patient with hepatitis, protect yourself by avoiding exposure to the patient's blood and body fluids. Now let's look more closely at each type of hepatitis, from A to G and beyond.
Hepatitis A: The news maker
Recent outbreaks of hepatitis A, an RNA virus, have been attributed to tainted raw produce. In 2003, an outbreak near Pittsburgh, Pa., killed 3 people and sickened nearly 700. The virus was traced to green onions served in one restaurant. (See “Calming the Panic over Hepatitis A” in the June issue of Nursing2004. )

Human or animal feces in the soil, tainted water used for irrigation or food preparation, or food handled by infected persons all have the potential to contaminate the food we eat. Seafood may be tainted when improperly treated sewage is released into waterways.

However, foodborne or waterborne infection account for only about 3% of all cases of hepatitis A. In most cases, the cause is unknown. When the cause can be determined, it's usually contact with an infected person.

The virus incubates for about 4 weeks before symptoms appear. During this time, and for 7 to 10 days after symptoms appear, the patient is infectious. Up to 20% of patients become ill enough to require hospitalization, but fewer than 1% die. Most patients recover without treatment and become immune to future bouts of hepatitis A.

However, hepatitis A infection may have a longer-lasting impact on health than once believed. A study found that hepatitis A seropositivity is an independent risk factor for coronary artery disease (CAD), raising the possibility that hepatitis A plays a role in CAD development.

The most important defense against infection is good hand hygiene. If your patient is planning to travel in an area where hepatitis A is endemic, warn her to eat only cooked produce and meat and to use bottled or boiled water for drinking and toothbrushing. Also remind her not to put ice in beverages unless she's sure it was made from boiled or bottled water.

After sanitary precautions, the next best protection against hepatitis A is vaccination. A multidose vaccine combining hepatitis A and B protection is available. A single-dose hepatitis A vaccine on the horizon may improve patient compliance with completing the recommended vaccination schedule.

For short-term protection from the virus, hepatitis A immune globulin can be administered 2 weeks before or after exposure.

Hepatitis B: Blood and beyond
This double-shelled DNA virus has been isolated in all body tissues and fluids and can live for up to 72 hours on surfaces that look clean. The virus can be spread perinatally and during sexual contact with an infected person; other risk factors include needle sharing during recreational intravenous (I.V.) drug use, acupuncture, hemodialysis (because of possible equipment contamination and the patient's decreased immune response), tattooing, and ear and body piercing. Health care and public safety workers are at high risk for contracting hepatitis B from sharps injuries with contaminated equipment and from other exposures to infected body fluid.

The virus incubates for 30 to 180 days. Anyone who's been exposed to infected body fluids should be evaluated by his primary care provider for hepatitis B virus. Anyone diagnosed with hepatitis B infection should be evaluated for liver disease and for human immunodeficiency virus (HIV) infection.

Before symptoms appear, the patient will have increased hepatitis B surface antigens and increased liver function test results. After symptoms appear, the body produces immunoglobulins to the antigens; antigens and viral DNA in the patient's blood indicate that he's infectious.

Vaccination has dramatically reduced the rate of new hepatitis B infections. The three-dose vaccination series is recommended for health care and public safety workers, children under age 18, international travelers, recreational drug users, men who have sexual relations with other men, patients with clotting disorders or liver disease, and anyone sharing a household with an infected person.

An estimated 1.25 million Americans are chronically infected with hepatitis B. Infection is more likely to become chronic if acquired early in life. Chronic carriers of hepatitis B may be asymptomatic.

Treatment for chronic hepatitis B may include interferon, lamivudine, or famciclovir. Treatment for hepatitis B usually lasts 4 to 12 months. Some genotypes of hepatitis B respond to treatment better than others.

Hepatitis C: Quick-change artist
Hepatitis C, an enveloped RNA virus, mutates rapidly to create multiple variants that respond differently to treatment. Consequently, this virus has foiled vaccine development. The disease can remain asymptomatic for years, but 70% of those infected eventually develop chronic liver disease. An estimated 3.9 million Americans have been infected with hepatitis C; 2.7 million have chronic liver disease from the infection.

Those at high risk for exposure to hepatitis C include health care and public safety workers and recreational I.V. drug users. Factors increasing a person's risk include receiving clotting factors before 1987 or blood or solid organs before 1992, undergoing hemodialysis, having multiple sexual partners, and getting tattoos or piercings. Infants born to infected mothers are at some risk: The rate of disease transmission is about 5%. Hepatitis C virus also has been detected in breast milk, but large studies have shown that transmission via this route is possible only if the patient's viral titers are high and she's experiencing hepatitis symptoms.

The virus incubates for 14 to 180 days. Within the first few weeks after exposure, hepatitis C RNA can be found in the blood although the patient may be asymptomatic for years. Patients eventually produce anti–hepatitis C antibodies, usually within 6 months. Diagnosis is made by testing for viral RNA or antibodies via enzyme-linked immunosorbent assay.

New hope for patients with hepatitis C comes from peginterferon alfa-2a and ribavirin (Pegasys/Copegus). This form of interferon, which is given with ribavirin, has been dramatically more effective than the previous interferon and ribavirin combination therapy. In a recent study, 62% of patients with hepatitis C genotypes 2 and 3 achieved a sustained virologic response with the new combination therapy, compared with 12% of patients on the older combination. In addition, 29% of patients with genotype 1, considered the hardest strain to treat, achieved a sustained virologic response.

Prevention strategies for health care professionals include using safety engineered sharps, limiting contact with blood and body fluids, and properly sterilizing multiuse equipment. As appropriate, teach patients to avoid needle sharing and to use only single-use needles and ink for tattooing and properly sterilized instruments for body piercing.

Hepatitis D: Not a solitary traveler
An incomplete RNA virus, hepatitis D depends on hepatitis B envelope proteins to reproduce. As a coinfection with hepatitis B, hepatitis D may lead to potentially fatal fulminant hepatitis (see Fulminant hepatitis: Trouble's brewing ). Endemic to Mediterranean regions, hepatitis D is transmitted in the same ways as hepatitis B and can be prevented by hepatitis B vaccination.

The virus is identified by the presence in serum of intrahepatic delta antigens or antibodies in chronic disease. Treatment with interferon alfa-2b may help patients with hepatitis D/hepatitis B coinfection.

Hepatitis E: In the water and a lot more
Responsible for large disease outbreaks in Southeast and Central Asia, the Middle East, Africa, and Mexico, hepatitis E is a single-stranded RNA virus rarely seen in the United States. Diagnosis of this enteric virus is made by ruling out other hepatitis viruses in a patient with active, symptomatic hepatitis.

Symptoms occur 15 to 60 days after exposure, with the incubation period ranging from 2 to 9 weeks. Children usually are asymptomatic; the severity of illness increases with age. Although the illness generally is self-limiting and benign, up to 3% of patients die, usually from dehydration. Up to 25% of pregnant women who become infected die. Treatment with immune globulin can minimize symptoms, but Western preparations of immune globulin aren't effective against this virus.

Good hand hygiene, boiling drinking water, avoiding ice made from contaminated water, and thoroughly cooking meat and produce can help prevent the virus from spreading. Travelers should avoid raw foods or prepare their own using a pure water supply.

Hepatitis F: “F” is for false
A few cases of hepatitis that didn't quite fit the A, B, C, D, or E profile were identified in the early 1980s and labeled “hepatitis F” in 1994. These viruses have now been identified as variants of hepatitis C. The “hepatitis F” label isn't currently used for any virus.

Hepatitis G: Growing in prominence
The latest virus to be named is hepatitis G, a single-stranded, enveloped RNA virus similar to hepatitis C. As with hepatitis B and C, this virus is transmitted by blood and body fluids and can probably be found in all body tissues. Two variants of hepatitis G have been identified, and researchers are working to identify other suspected variants. Identified in blood samples from around the world, hepatitis G is diagnosed by seroconversion or detection of hepatitis G RNA in blood or liver tissue.

The long-term effects of hepatitis G aren't known. Public health reports include patients who developed flulike symptoms for a limited period and recovered (although they were still seropositive) and patients who developed fulminant hepatitis and died.

After recovery, patients may have persistent viremia lasting several years, but coinfection with other hepatitis viruses doesn't seem to worsen their condition. Production of cytokines in people with hepatitis G has been reported to slow the progression of HIV coinfection to acquired immunodeficiency syndrome (AIDS).

No vaccine has been developed against hepatitis G. Current treatment is supportive and focused on symptom management and reducing hepatitis G titers. Some patients benefit from interferon treatment.

Caring for your patient
Nursing care is aimed at encouraging healing, preventing complications, and supporting the patient. Encourage him to perform activities of daily living to the best of his ability, pausing to rest frequently throughout the day.

Because nausea may increase during the day, administer antiemetic medications as ordered. Advise the patient to eat a hearty breakfast and then smaller, frequent meals of high-calorie, nutrient-dense, low-fat foods throughout the day. To avoid stressing the liver, which detoxifies ammonia (a by-product of protein digestion), tell him to limit his protein consumption.

Monitor the patient for fluid and electrolyte imbalances and weigh him daily. Report abnormal electrolyte levels and weight gain of more than 2 pounds (0.9 kg) in one day. Administer I.V. fluids as ordered to prevent dehydration and correct electrolyte imbalances.

Monitor the patient's clotting studies and administer vitamin K if his international normalized ratio is elevated. Teach the patient to avoid alcohol during acute illness and for 6 months after recovery. He should also avoid substances that may affect liver function, such as some herbs and medications.

Living with chronic hepatitis
Someone with chronic hepatitis infection may live for many years with his disease. Teaching him about the disease can help him lengthen his life, avoid complications, and slow disease progression. Encourage him to make healthful lifestyle choices, including sticking to a low-fat diet and limiting red meats; avoiding alcohol, tobacco, and illicit drugs; exercising regularly; managing stress; and getting enough rest.

Explain that changes in protein synthesis influence hormone production and regulation. A female patient may notice shorter or skipped menses initially; as liver damage increases in severity and clotting factors diminish, menses may become heavy and prolonged. Her breasts may become pendulous because of decreased estrogen. Men may develop breast tissue because of hepatitis-related inability to produce testosterone.

A women being treated with immune globulins or ribavirin should use two types of birth control simultaneously because these drugs may cause birth defects. Warn her that oral contraceptives may be ineffective because of changes in protein synthesis and hormone production during hepatitis therapy. She should use condoms, spermicidal foam or jelly, or a diaphragm if abstinence isn't possible.

Intercourse during menses increases the risk of transmitting hepatitis to an uninfected partner. Tell the patient to dispose of used sanitary supplies in containers with tight lids or to double-bag them in plastic bags.

Provide emotional support. A patient who feels helpless, anxious, or guilty may engage in risky behavior. Depression, which may be linked to concerns about the illness, can also be related to changes in body chemistry or adverse drug reactions. Encourage the patient to discuss emotional and social problems with his primary care provider, who can explore possible causes and offer treatments.

The patient's fear of infecting others may lead him to isolate himself at a time when he most needs support from friends and family. Let him talk about his fears, answer his questions, provide information, and help him explore appropriate coping behaviors. Refer him to a hepatitis support group and, if appropriate, to support groups such as Alcoholics Anonymous or Narcotics Anonymous. Encourage him to see his health care provider regularly for monitoring and follow-up testing.

Hope for the future
As a nurse, you can help patients understand how to prevent hepatitis transmission, follow prescribed treatments, and learn to live with chronic infection.

How hepatitis affects lab values
* Serum aspartate aminotransferase—increases in prodromal stage
* Serum alanine aminotransferase—increases in prodromal stage
* Serum alkaline phosphatase—increases in prodromal stage
* White blood cell counts—transient neutropenia and lymphopenia, followed by lymphocytosis
* Serum bilirubin—rises in acute disease and may remain elevated as the disease becomes chronic. The liver can't conjugate bilirubin, resulting in clay-colored stools and decreased urobilinogen.
* Prothrombin time (PT)—increases as liver damage increases. A PT of 3 seconds or more indicates severe liver damage. The patient is at increased risk for bleeding because of decreased fibrinogen production. If esophageal varices develop, the patient is at risk for life-threatening hemorrhage.
* Albumin—decreases in liver disease, leading to muscle atrophy
* Globulin—decreases in liver disease, putting the patient at increased risk for infection
* Gamma-aminobutyric acid and ammonia—rise as the liver becomes less efficient, leading to hepatic encephalopathy
Fulminant hepatitis: Trouble's brewing
A rare but serious complication of hepatitis is fulminant hepatitis, or sudden and severe liver dysfunction leading to massive hepatocellular necrosis. Viral hepatitis is a common cause of this complication, which can lead to hepatic encephalopathy and death if not treated. Because fulminant hepatitis has a poor prognosis, liver transplantation is the treatment of choice.

Signs and symptoms of fulminant hepatitis include jaundice, an enlarged and tender liver during the acute inflammatory stage, liver function tests consistent with severe liver failure, decreased hemoglobin and hematocrit levels, prolonged clotting times, and blood in the patient's stool.

Intervene rapidly to treat acute liver failure and support the patient. Maintain adequate perfusion and oxygenation. Administer sedatives and mannitol as ordered to maintain normal intracranial pressure. Monitor for fluid and electrolyte imbalances and maintain normal blood glucose levels and body temperature. If ordered, give neomycin and lactulose to reduce ammonia levels. The patient may need inotropes for circulatory support. If liver transplant is indicated, prepare the patient for transplant.