Disease Sensitive Counselling& Care - Do’s and Don’ts

  • Do encourage “liver good life” - diet, attitude, vaccination, education
  • Do vaccinate all partners and relatives
  • Do support patients on treatment for any constant side effects
  • Do assume 80% of presenting infections were from childhood or healthcare
  • Do inform the liver specialist when issuinglong term prescriptions
  • Do mention 21 units of alcohol creates cirrhosis
  • Do mention obesity doubles the risk of serious liver disease
  • Do explain to patients with healthy livers that they may not need treatment
  • Do not assume injecting drug use or sexual risks
  • Do audit high risk occupations and endemic origins for cause of infection
  • Do not call Hep C sexual only transfusable, encourage kissing and hugging
  • Do try substituting, “maternity infections” for “mother to child infections”
  • Do encourage “premiership blood hygiene” not separate kitchens/W.C.
  • Do not say chronic carrier sayhepatitis b positive
  • Do download a “Just Diagnosed Pack” for every diagnosis.

Do try and use simple terms for HBV results

HBeAg
HBV DNA(high)
HBsAg
Anti-HBc Igm
Anti HBs/HBe
100 anti pml / Got it –replicating
Got it –replicating
Got it
Fighting it
Cleared
Immunised / (often high risk yet quickly manageable)
(often high risk yet quickly manageable)
(often low risk and often left untreated)
(acute 6 month window period)
(immune for life)
(immune may need boosters)

The Hepatitis Pre-Test Discussion

Should ask for informed consent for testing by the patient after explaining:

The value of knowing liver status and diagnosing a carcinogen early

Assessment of Infection Risks and or Symptoms that need testing

Explanation of risks for HBV/HCV being common

Information about confidentiality and the notification process.

It may be necessary, to assess if support is needed for a test result, e.g. with children, the mentally ill and the elderly, and to reduce infection risks, e.g. vaccination/safer injecting practice.

The Hepatitis Post-Test Discussion

The test result should be given in a manner that is confidential and sensitive.

An Understanding of HCV / HBV’s Disease Journey. With HCV explanation that is not a sex disease is advised

Liver Friendly lifestyle, explanation as to how HCV/HBV kills with pills or alcohol

The Basics of both HBV Vaccination and Blood hygiene precautions, people need to use plasters and bleach spills. HBV also requires safer sex as the virus can bein sexual fluids

Medical Referral to a liver specialist, and a source of disease printed information such as the Hep C Trust or Hep B Positive provide

Assessment of mental state - people diagnosed with hepatitis can react very differently; many find the emotional shock more harmful than the virus. It is important to make sure they are able to understand and learn quickly what hepatitis is and is not.

On Occasion it is necessarytoarrange education, rehabilitation or psychological counseling or therapy.

STOP

CAUTION

USE

BECAUSE

Hepatitis B Vaccination(ata glance) Schedule

Source patient.co.uk/doctor/Hepatitis-B-Vaccination-and-Hepatitis-B-Prevention.htm

  • The course of immunisation involves 3 injections over 6 months. Day 1, 30 and 180
  • The Usual Adult Accelerated course is over 21 days,Day 1, 7, 21, boosted at 1 year. It can be used in the immunocompromised, but check their CD count does not drop.
  • An accelerated course on Day 1, Day 30 and Day 60 boosted at 1 year is given to babies of half strength dosage
  • 25% of UK babies are born into UK Endemic Communities, WHO and the BMA recommends prompt vaccination for them.

The vaccine should be given into the deltoid region or anterior thigh in babies. It is less effective if given into the buttock. It is quite possible that a course may give lifelong immunity,but for health professionals one further booster at 5 years* is recommended. Antibody titres should be tested 1 to 4 months after the primary course.

  • A titre above 100 mIU/ml is regarded as adequate. Around 10-15% of adults fail to respond to three doses of vaccine or respond poorly.
  • Poor responders with titres of 10 to 100 mIU/ml should have a booster and those with a titre below 10 mIU/ml should repeat the course.
  • Those over 40 years old, are obese or who smoke are more likely to fail to respond.
  • Alcoholics are also reported as having lower seroconversion rates, particularly those with advanced liver disease.
  • Patients who are immunosuppressed or on renal dialysis may also respond less well and require larger or more doses of vaccine.
  • Failure to gain antibody after 2 complete courses should not be seen as necessarily meaning no immunity, as immunity is largely cell-mediated rather than by antibody.
  • Post-exposure prophylaxis (PEP) involves giving hepatitis B vaccine and possibly immunoglobulin too if required within 48 hours.
  • Of a thousand people vaccinated and having no boosters 3 became infected after 10-15 years. 5 years is chosen due to safety, health staff are not suddenly “at risk” after 5 years.

Blood tests and Investigations for Liver Function

Some of the standard or routine blood tests that your doctor will order to check “liver function” are in reality only able to detect liver damage. These tests may not be sensitive enough to accurately reflect whether your liver is functioning at its optimum level. These tests will usually be abnormal in significant liver disease or liver distress; however, they can still give normal readings in some cases of mild liver disease. This is why imaging tests of the liver and gallbladder, such as ultrasound scans or CAT scans or MRI scans are important. These imaging tests can determine the degree of liver disease and if there are any tumours, cysts, gallstones or fatty accumulations which change the texture of the liver.

Healthy ranges for Blood tests for Liver Function

ALT0 - 45 U/L

GGT0 - 45 U/L

AST0 - 45 U/L

ALP30 - 120 U/L

BILIRUBIN0 - 20 U/L or 0.174 to 1.04 mg/dL

ALBUMIN38 – 55g/L or 3.8 to 5.5g/dL

AFP20 – 32g/L or 2 to 3.2g/dL

  • ALT (alanine aminotransferase), is elevated showing inflammation of the liver.
  • GGT (gamma glutamyl transpeptidase) is elevated in those who use alcohol or toxins.
  • AST (aspartate aminotransferase) is elevated in heart, muscle and liver diseases.
  • ALP (alkaline phosphatase) is elevated in many types of liver and non liver disease.
  • BILIRUBIN is elevated, patient may have a yellow colour skin and eyes, jaundice.
  • ALBUMIN falling levels of blood albumin show deteriorating liver function.
  • AFP (Globulin protein). Elevated usually mean excessive inflammation in the liver and/or immune system. Very high levels may be seen in some types of cancers.

Ultrasound scans of the liver

Ultrasound scans are very useful to detect changes in the liver. Damage to liver cells by fat, toxins or infections etc, causes inflammation, which can lead to hard scar tissue or fibrosis. A liver that has developed widespread fibrosis is firmer, and if the condition progresses to cirrhosis, the liver can become almost rock-hard. Detected early, fibrosis of the liver can in many cases be reversed. Scarring and fibrosis is scored 1 to level 6 or mild, medium and high.

Liver Biopsy - This is the procedure where a needle is inserted through the abdominal wall into the liver to remove a tiny sample of the liver tissue. The pathologist is able to see if the liver cells are healthy, if there is a lot of scar tissue destroying the liver architecture. Liver biopsy is considered to be an accurate way to determine if your liver tissue looks healthy, fatty or inflamed, or if you have cirrhosis.

Don’t forget to ask those at risk

Birth in endemic areas and injecting drug useare the key risks.

Remember to test extended family groups, 75% of infections are accounted for by the blue risks alone. All risk assessments by EASOL and ELPA.

High risk groups for Hepatitis B / High risk groups for Hepatitis C
  • Migrants from areas with medium or high prevalence
  • People who received injections, blood products or surgery in high prevalence nations
  • People who received NHS transfusions or surgery before1992
  • People who inject street drugs, including steroids
  • Unvaccinated workers who come into contact with blood
  • Newborns of HBV infected mothers
  • Patients on chemotherapy or immunosuppressant’s
  • People with persistently elevated liver enzymes
  • People with liver cirrhosis or fibrosis
  • People with liver cancer
  • Families who have a infected member
  • People who have been imprisoned
  • People who have haemodialysis
  • People with HIV or HCV
  • Men who have sex with men
  • People who have many sexual partners
  • People who do not wear plasters
/
  • Migrants from areas with medium or high prevalence
  • People who received injections, blood products or surgery in high prevalence nations
  • People who received NHS transfusions or surgery pre1992
  • People who inject street drugs, including steroids
  • Unvaccinated workers who come into contact with blood
  • Newborns of HCV infected mothers
  • Patients on chemotherapy or immunosuppressant’s
  • People with persistently elevated liver enzymes
  • People with liver cirrhosis or fibrosis
  • People with liver cancer
  • Families who have a infected member
  • People who have been imprisoned
  • People who have haemodialysis
  • People with HIV or HBV
  • Men who have sex with men
  • People who do not wear plasters

Liver Illnesses at 30 years undiagnosed with HBV/HCV

The percentages of long term HBV/HCV patients aillments are from published studies

  • Gall stones, 17%Cirrhosis, 25%
  • Fibrosis, 35%Liver failure,10%
  • Liver Cancer, 10%Poor LFT’s,40%

Overview of Illnesses Linked with Viral Hepatitis-central.com 2009

The hepatitis B/C virus mainly affects the liver, but other illnesses are associated with it. These mainly affect the skin, eyes, joints, immune system, nervous system and kidneys. Some of these conditions– Cryoglobulinemia, for example – are somewhat more common and well-documented, while others are infrequent or their association with hepatitis has not yet been proven. Several studies have found that between 70-74% of patients experience non liver conditions.

  • Common highlights conditions that have called the helpline twice in one day,
  • Speech marks highlight common patient or counselor statements.

Daily “HBV & HCV can affect the skin.” “Cause painful and wearying conditions.”

Common Peripheral Neuropathy Increased Sjogren‟s syndrome

Common Pruritus 15 Increased Lichen myxoedematosus

Common Arthralgia Increased Vitiligo

Common Fatigue Increased Porphyria Cutanea Tarda

Common Fibromyalgia Increased Thyroid Disease hyperthyroidism

Common Arthritis poly and monooligoarthritis. Mooren Corneal Ulceration

Common Persistently high ALTs 40%Paresthesia

Spider NeviCluster Headache Rare Lichen Planus

Weekly “HBV & HCV affects the veins, kidneys and blood and their many functions”.

Increased ThrombocytopeniaIncreased Immune Thrombocytopenic

Increased Systemic LupusIncreased Vasculitis

Increased Insulin Resistance Rare Hypertrophic Cardiomyopathy

Raynaud‟s SyndromeNeutropenia

Rare DiabetesRare Behcet‟s Disease

Common CryoglobulinemiaRare Cerebral Vasculitis

Membranoproliferative GlomerulonephritisIncreased Membranous Nephropathy

Monthly “HBV & HCV can affect the lungs.” & “HBV & HCV can cause non liver cancers.”

Increased Waldenstrom Macroglobulinemia Multiple Myeloma

Increased Non-Hodgkin‟s LymphomasKidney Cancer 0.6%

Asthma Idiopathic pulmonary fibrosis

Chronic Obstructive Pulmonary DiseaseBile duct and NHL Cancer 1%

It is important to remember that the vast majority of people with hepatitis may never experience the more severe types of these non liver illnesses above. The great shame is so often these conditions are treated without any thought they may be Hepatitis driven by General Practitioners and Hospital Specialists as well as support groups and patients.

Helpline Callers commonly have many of the above ailments plus cirrhosis, fibrosis.

Factors below Non Diagnosis occurred in 85% of Deaths*

Hepatitis, Alcohol and Binge Drinking

  • Alcohol is approximately two to four times more destructive to the liver of a person with viral hepatitis. 60% of those drinking 21 units were cirrhotic after 5 years.
  • Alcohol abuse is often fatal to the undiagnosed.
  • One helpline caller had quintupled his ALT score with a weekend binge.

Hepatitis, Prescriptions and Binge Medicating, 3 hospitalised callers in 1 day due to this

The following list is a guide to medicines used to treat many medical conditions. The list does not include all medicines that may affect the liver systems. If a medicine you are taking is not listed here, check with your doctor. One helpline caller noted an ALT score of 625 after 3 months of paracetamol.

  • Acetaminophen Paracetamol Antacids
  • Antibiotics Anticholinergics
  • AnticonvulsantsAntihypertensives
  • Antituberculins Calcium channel blockers
  • Chlorpromazine Colchicine
  • Iron Laxatives
  • Nitrates Nonsteroidal-anti-inflammatory
  • Potassium chloride Quinidine
  • Theophylline Vitamins

Hepatitis, Obesity, Diet and Binge Eating

While not as yet totally defined, many factors influence the rate of disease progression. Diet likely plays an important role in this process, as all foods and beverages that we ingest must pass through the liver to be metabolized. In particular obesity and fatty liver disease can further damage the liver.

Fat and Hepatitis. Fatty fried foods are very hard for the liver do digest, they frequently cause pain to longer term patients, they are also complicit in creating fatty liver so should be taken rarely

Iron and Hepatitis. The liver plays an important role in the metabolism of iron since it is the primary organ in the body that stores this metal. The average diet contains about 10- 20 mg of iron. Only about 10% of this iron is eliminated from the body. Patients with chronic hepatitis sometimes have difficulty excreting iron from the body. This can overload of iron in the liver, blood, and other organs. Excess iron can be very damaging to the liver. Studies suggest that high iron levels reduce the response rate of patients with hepatitis C to interferon. Thus, patients with chronic hepatitis whose serum iron level is elevated, or who have cirrhosis, should avoid taking iron supplements and restrict the iron rich foods in their diet, such as red meats, liver, and cereals fortified with iron.

Protein and Hepatitis. Adequate protein intake is important to build and maintain muscle mass and to assist in healing and repair. Protein intake should be between about 60 – 120 grams a day in patients with hepatitis, unless encephalopathy occurs. Encephalopathy is an altered mental status. It has been shown that restriction of the diet of animal protein and maintaining a total vegetarian diet, helps reverse this condition and improve mental capacity. Advanced scarring of the liver or cirrhosis can lead to fluid in the abdomen referred to as ascites.

Salt and Hepatitis. Patients with hepatitis who have ascites must be on salt restricted diets. Every gram of sodium consumed results in the accumulation of 200 ml of fluid. The lower the salt, the better this fluid accumulation is controlled. While often difficult, sodium intake should be restricted to 1000mg each day, and preferably to 500 mg per day. For example, one teaspoon of table salt - 2,325 mg of sodium! Most fast food restaurants are a no no. Meats, especially red meats, are high in sodium a vegetarian diet may often become necessary. Patients with hepatitis without ascites are advised not to overindulge in salt intake, although their restrictions need not be as severe.

Helpline Reports 1st June to 1st November 2011. (8 and 1)

The Palette of HBV Treatments – for Patients to Use with Specialists

The goals and aims of HBV treatment are to lower infectivity and slow liver damage. This is because no drug is effective at removing the virus. Hepatitis B HBsAG on your test result means you are infected but you are a low infection risk and HBeAG means you are infected and the virus is replicating and you are a high infection risk. Treatment of chronic infection may be necessary to reduce the risk of cirrhosis and liver cancer also. Chronically infected individuals with persistently elevated ALT’s, a marker of liver damage, and high e antigen or just HBV viral loads are candidates for therapy.

Several medicines treat hepatitis B. If you do not need to start treatment immediately, you will be monitored over time to know when hepatitis becomes more active. Once you start treatment, you will have regular blood tests to see how well the treatment is working and to detect side effects or drug resistance. Monitoring will continue after finishing treatment to detect signs that the infection has come back. Each patient may have a different set of needs or treatments according to the factors and their individual health, further these medicines evolve and improve rapidly, being on a trial is quite normal in this field of medicine.

Lamivudine — Lamivudine is effective in decreasing hepatitis B virus activity and ongoing liver inflammation. It is safe in patients with liver failure and long-term treatment can decrease the risk of liver failure and liver cancer. (See "Lamivudine monotherapy for chronic hepatitis B virus infection".)Lamivudine is taken by mouth, usually at a dosage of 100 mg/day. The major problem with lamivudine is that a resistant form of hepatitis B virus (referred to as a YMDD mutant) frequently develops in people who take lamivudine long term. Other medicines are less likely to cause resistance.

Adefovir — Adefovir is an alternative initial choice for people who have detectable hepatitis B virus activity and ongoing liver inflammation. An advantage of adefovir compared to lamivudine is that resistance to adefovir is less likely to develop. In addition, adefovir can suppress lamivudine-resistant HBV. (See "Adefovir dipivoxil in the treatment of chronic hepatitis B virus infection".)Adefovir is taken by mouth, at a dosage of 10 mg/day, for at least one year. Most patients will need long-term treatment to maintain control of the hepatitis B virus. Adefovir is a weak antiviral medicine, and resistance does occur over time. Other medicines are more potent.