The incidence of hepatitis C is falling (Baker, 2000). This is partly because of testing for the presence of the virus in donor blood and in biological agents that are made from blood and injected for various treatments, such as concentrated factor VII for bleeding disorders.
Unfortunately, vaccines are not available. Efforts to develop them continue, but the results are not encouraging. Although the use of gamma globulin has not been specifically tested as prophylaxis against HCV, studies with this preparation several years ago in efforts to prevent posttransfusion hepatitis, which was primarily caused by HCV, were unsuccessful. Since there is no reason to believe that gamma globulin would be helpful, it is not recommended. Tattoos and body piercing have been implicated and should be avoided. The sharing of needles during illicit drug use is now the most common mode of transmission (Achord, 2002).
Presently, there is no vaccine for hepatitis C, but there are vaccines for hepatitis A and B. The CDC recommends these vaccines, particularly the hepatitis A vaccine, for HCV-positive individuals. Becoming infected with hepatitis A virus can be life threatening for someone with HCV infection. In May, the FDA approved a combined hepatitis A and B vaccine called Twinrix, (Bren, 2001).
As discussed briefly in the first parts of this paper, HCV exists in many different forms, called genotypes, confounding researchers in their quest to develop a vaccine effective for all variations. Also, HCV mutates frequently within infected patients, so even if an effective vaccine is developed, it could be rendered useless by a new strain of mutant virus (Henkel, 1999).
A major focus of hepatitis research is development of a cell culture through which scientists can study HCV outside the human body. By understanding how the virus replicates and how it injures cells, researchers may be able to develop ways to control the virus as well as drugs to block it. It is very likely that a vaccine specific to hepatitis C will be developed in the near future. The cost of the research to acquire a vaccine will definitely be justified when you consider all of the demands made upon the healthcare system.
Prognosis
Prognosis is highly variable. With drug etiology, disease may regress completely when offending agent is withdrawn. Cases associated with HBV or HCV tend to progress slowly and are usually relatively resistant to therapy. Autoimmune cases generally improve substantially with treatment. With adequate therapy, patients usually live several years or decades, but hepatocellular failure, cirrhosis, or both eventually develop in many cases (The Merck Manual, 1999).
Treatment
Treatment includes cessation of causative drugs and management of complications (eg, ascites, encephalopathy). Autoimmune hepatitis is best treated by corticosteroids with or without azathioprine. These drugs suppress the inflammatory reaction, perhaps partly by beneficially altering the immune response, and have increased long-term survival.
In most patients, symptoms lessen, biochemical abnormalities largely resolve, and histologic inflammation regresses. However, fibrosis may progress despite apparent clinical and laboratory control, and attempts to discontinue therapy usually lead to relapse; most patients require long-term low-dose maintenance treatment. Drug dosage should be supervised by a specialist.
Therapy for both chronic hepatitis B and C is evolving. Corticosteroids are contraindicated, because viral replication is enhanced. Interferon- is now widely used to suppress viral replication, but overall results are relatively disappointing.
Chronic hepatitis C is treated with a combination of interferon- 3 million IU sc three times weekly plus oral ribavirin 1200 mg daily in two divided doses, which gives better results than interferon alone. This initially suppresses inflammation in about 2/3 of patients. Responders are treated for either 6 or 12 months depending on the specific viral genotype, but most relapse when treatment is stopped; successful long-term disease suppression is only about 30-40% overall. Response depends in part on the viral genotype, viral load, and histologic stage of the disease. Pegylated interferon, a recently developed modification of the drug molecule, will likely replace standard interferon in the near future because it requires injection only once a week and gives marginally better results (The Merck Manual, 1999).
In addition to having limited efficacy, interferon- is expensive, must be given by injection, produces bothersome flu-like side effects in most patients, and induces more serious side effects in a minority of cases. Treatment should be supervised by a specialist. Other antiviral and immunomodulatory drugs against HBV and HCV have been evaluated or are being studied, but no major breakthrough appears imminent.
Liver transplantation has not generally been suitable for end-stage liver disease caused by HBV, because of aggressive disease reference in the graft, but treatment with lamivudine can now help ameliorate this problem. Transplantation for advanced hepatitis C is much more successful; although HCV infection universally recurs, the clinical course is generally indolent, and long-term survival rates are relatively high. In many transplant centers, hepatitis C is now the most common indication for adult liver transplantation.
The demand for liver transplantation is therefore increasing largely due to the increased incidence of HCV. It is without no doubt that this will continue to grow rapidly in the years to come. Of course, liver donations are not too many compared to those who need liver transplants. And so a question of who should have liver transplants arises. There will be a problem of who should get liver transplants first.
The United States has policies for this. Revised policy in the United States for the allocation of donated cadaver livers now distributes available organs depending on medical urgency rather than regional location. The new policy is aimed at making donated livers available to people at greatest risk of imminent death. Those with the most urgent need, often with a life expectancy of less than one week, are considered status one. The next most urgent group is status two A, followed by status two B and status three (Howard, 2003).
Previously, donated livers were offered to a person with a status one rating who resided in the locale where the organ was donated. If no match was found, it was offered to someone with a status two or three rating in the same local area. With revised allocation guidelines, a donated liver still will be offered to a person with a status one rating in the location it was donated, but if no match is found, it will be offered to someone with a status one rating in the larger UNOS region before being offered locally to someone with a status two or three rating. The revised policy is expected to increase the number of transplantations performed for people who have a status one rating by up to 80% and cut waiting time in half (Howard, 2003)
The goal of treatment is sustained response--meaning that the virus is not measurable in the blood after drug therapy is completed. Those who continue to have measurable levels of the virus after treatment are considered non-responders. Relapsers "clear" the virus during therapy or shortly thereafter, but the virus returns after therapy ends (Bren, 2001).
Evaluation of the safety of clinical practice in my workplace
Health care professionals are among those that are at high risk for hepatitis C. Treating and having to take care of people who are infected with the hepatitis C virus poses a great risk for health care professionals. Safety measures have therefore to be examined within health care institutions. So far, within my workplace, standard operating procedure regarding care of patients infected with HCV have been strictly followed, as well as the handling of specimen from HCV carriers. Personal hygiene can also help prevent the spread of hepatitis. Unnecessary transfusions should be also avoided in order to minimize incidence of hepatitis.
Preventing transmission from healthcare workers to patients has been controversial. Although transmission has been documented, it is rare and limited to case reports. Up to half of the reports were confounded by other factors like contamination of patients' narcotics used for healthcare workers' surreptitious habit of IV drug use. The calculated risk for HCV transmission from an RNA-positive surgeon to a patient during an invasive procedure is 0.00018%, which was roughly comparable to the chance of acquiring HCV by transfusion in the United States in the year 2000. It is recommended in some countries (Berklan, 2000) that no HCV-infected healthcare professional be restricted from his or her work. Despite this recommendation, some health departments have required HCV-infected physicians to obtain informed consent before performing surgery on their patients (Pearlman, 2004).
Healthcare organizations should treat hepatitis C in the same manner that they treat HIV or AIDS. Recommendations should include strict adherence to worldwide admitted precautions and education on hepatitis C for all healthcare workers. This education should include emphasizing the importance of reporting all percutaneous sticks. Presently, healthcare workers are screened only if there is a known exposure to hepatitis C (Dillman, 1999). Because hepatitis C is insidious in nature, testing should be done for both the source patient and the healthcare worker, regardless of known status. If a healthcare worker is identified as being positive, counseling and treatment for hepatitis C should be offered.
The value of prevention is skyrocketing. It should be noted that many individuals with the disease are unaware they are infected with HCV because symptoms often do not appear until serious liver damage has already occurred. Therefore, many individuals go through their lives not knowing they have the virus, such wasted time could have been used to start treating the individual infected. Also, given the fact that there is no vaccine yet against hepatitis C, an awareness campaign is indeed a necessity. The chances for individuals getting the infection are increased with the lack of a vaccine against the virus.
Hepatitis C awareness campaigns should be made not only for work environments but for the general public as well. Programs on awareness would put individuals at a concern over prevention of hepatitis C. An awareness campaign is needed which should be focused on raising hepatitis C awareness in the minds of the general public, elected officials, and policy-makers.
Elected officials and policy makers are specifically mentioned as target populations for hepatitis C awareness since they are the ones who are more in the position to create programs that will further strengthen the awareness campaign. They are in a very good position to implement measures that will help individuals lessen their chances of contacting the deadly virus.
The impact of hepatitis C on societies is staggering. Billions are estimated as being spent on the disease worldwide (Henkel, 1999). This includes billions spent on treatment which would have been preventable if only there was a vaccine or individuals are more aware of the infection. If such a trend would continue, allocations for other medical concerns would therefore lessen in favor of the infectious disease, which does not sound very good. Continued research and awareness campaigns therefore have to be done in order to lessen the staggering costs of the disease management and prevention. This of course is only secondary to the aim of helping millions of individuals that are infected with the disease.
In summary, with no vaccine and no effective post-exposure prophylaxis against the hepatitis C virus, best efforts at fighting the silent dragon should be directed toward counseling HCV-infected patients and those at risk of developing infection. Adequate sterilization of medical and surgical instruments and equipment, consistent use of personal protective equipment during patient care, and use of safety devices for venous access should be routine practice for all health care providers. In addition, promotion of community programs for safe injection practices and testing for people in high-risk categories could be a focus with measurable outcomes for all of society.
Conclusion
Hepatitis C is dangerous not only because of the damage it inflicts, but because people may be asymptomatic for years before they realize they are suffering from incurable liver disease. It almost exclusively is spread by dirty needles. Currently there is little hope for treatment of hepatitis C. A drug called Interferon Alpha-2B (inferferon is an immunity substance naturally present in small amounts in the body) has proven somewhat successful in combating the virus, but only in about 15 to 20 percent of the cases. While scientists are conducting research to find more-powerful antidotes, the best hope of curbing the spread of the virus continues to lie mainly in prevention. Health care institutions also have to be aware of the specific measures needed to be able to avoid and prevent infection with the hepatitis C virus. Further programs are needed for populations to educate them of the severity of the disease and its complications.
Hepatitis C infection is therefore a major public health problem throughout the world as can be seen by its effects on the body and the society in general. Yet for all its severity, it is largely preventable. Prevention can happen through awareness campaigns, rigorous efforts to protect blood supplies usually in health care environments, and major education and intervention programs for such at-risk populations as recreational intravenous drug users.
Unfortunately, vaccines are not available. Efforts to develop them continue, but the results are not encouraging. Although the use of gamma globulin has not been specifically tested as prophylaxis against HCV, studies with this preparation several years ago in efforts to prevent posttransfusion hepatitis, which was primarily caused by HCV, were unsuccessful. Since there is no reason to believe that gamma globulin would be helpful, it is not recommended. Tattoos and body piercing have been implicated and should be avoided. The sharing of needles during illicit drug use is now the most common mode of transmission (Achord, 2002).
Presently, there is no vaccine for hepatitis C, but there are vaccines for hepatitis A and B. The CDC recommends these vaccines, particularly the hepatitis A vaccine, for HCV-positive individuals. Becoming infected with hepatitis A virus can be life threatening for someone with HCV infection. In May, the FDA approved a combined hepatitis A and B vaccine called Twinrix, (Bren, 2001).
As discussed briefly in the first parts of this paper, HCV exists in many different forms, called genotypes, confounding researchers in their quest to develop a vaccine effective for all variations. Also, HCV mutates frequently within infected patients, so even if an effective vaccine is developed, it could be rendered useless by a new strain of mutant virus (Henkel, 1999).
A major focus of hepatitis research is development of a cell culture through which scientists can study HCV outside the human body. By understanding how the virus replicates and how it injures cells, researchers may be able to develop ways to control the virus as well as drugs to block it. It is very likely that a vaccine specific to hepatitis C will be developed in the near future. The cost of the research to acquire a vaccine will definitely be justified when you consider all of the demands made upon the healthcare system.
Prognosis
Prognosis is highly variable. With drug etiology, disease may regress completely when offending agent is withdrawn. Cases associated with HBV or HCV tend to progress slowly and are usually relatively resistant to therapy. Autoimmune cases generally improve substantially with treatment. With adequate therapy, patients usually live several years or decades, but hepatocellular failure, cirrhosis, or both eventually develop in many cases (The Merck Manual, 1999).
Treatment
Treatment includes cessation of causative drugs and management of complications (eg, ascites, encephalopathy). Autoimmune hepatitis is best treated by corticosteroids with or without azathioprine. These drugs suppress the inflammatory reaction, perhaps partly by beneficially altering the immune response, and have increased long-term survival.
In most patients, symptoms lessen, biochemical abnormalities largely resolve, and histologic inflammation regresses. However, fibrosis may progress despite apparent clinical and laboratory control, and attempts to discontinue therapy usually lead to relapse; most patients require long-term low-dose maintenance treatment. Drug dosage should be supervised by a specialist.
Therapy for both chronic hepatitis B and C is evolving. Corticosteroids are contraindicated, because viral replication is enhanced. Interferon- is now widely used to suppress viral replication, but overall results are relatively disappointing.
Chronic hepatitis C is treated with a combination of interferon- 3 million IU sc three times weekly plus oral ribavirin 1200 mg daily in two divided doses, which gives better results than interferon alone. This initially suppresses inflammation in about 2/3 of patients. Responders are treated for either 6 or 12 months depending on the specific viral genotype, but most relapse when treatment is stopped; successful long-term disease suppression is only about 30-40% overall. Response depends in part on the viral genotype, viral load, and histologic stage of the disease. Pegylated interferon, a recently developed modification of the drug molecule, will likely replace standard interferon in the near future because it requires injection only once a week and gives marginally better results (The Merck Manual, 1999).
In addition to having limited efficacy, interferon- is expensive, must be given by injection, produces bothersome flu-like side effects in most patients, and induces more serious side effects in a minority of cases. Treatment should be supervised by a specialist. Other antiviral and immunomodulatory drugs against HBV and HCV have been evaluated or are being studied, but no major breakthrough appears imminent.
Liver transplantation has not generally been suitable for end-stage liver disease caused by HBV, because of aggressive disease reference in the graft, but treatment with lamivudine can now help ameliorate this problem. Transplantation for advanced hepatitis C is much more successful; although HCV infection universally recurs, the clinical course is generally indolent, and long-term survival rates are relatively high. In many transplant centers, hepatitis C is now the most common indication for adult liver transplantation.
The demand for liver transplantation is therefore increasing largely due to the increased incidence of HCV. It is without no doubt that this will continue to grow rapidly in the years to come. Of course, liver donations are not too many compared to those who need liver transplants. And so a question of who should have liver transplants arises. There will be a problem of who should get liver transplants first.
The United States has policies for this. Revised policy in the United States for the allocation of donated cadaver livers now distributes available organs depending on medical urgency rather than regional location. The new policy is aimed at making donated livers available to people at greatest risk of imminent death. Those with the most urgent need, often with a life expectancy of less than one week, are considered status one. The next most urgent group is status two A, followed by status two B and status three (Howard, 2003).
Previously, donated livers were offered to a person with a status one rating who resided in the locale where the organ was donated. If no match was found, it was offered to someone with a status two or three rating in the same local area. With revised allocation guidelines, a donated liver still will be offered to a person with a status one rating in the location it was donated, but if no match is found, it will be offered to someone with a status one rating in the larger UNOS region before being offered locally to someone with a status two or three rating. The revised policy is expected to increase the number of transplantations performed for people who have a status one rating by up to 80% and cut waiting time in half (Howard, 2003)
The goal of treatment is sustained response--meaning that the virus is not measurable in the blood after drug therapy is completed. Those who continue to have measurable levels of the virus after treatment are considered non-responders. Relapsers "clear" the virus during therapy or shortly thereafter, but the virus returns after therapy ends (Bren, 2001).
Evaluation of the safety of clinical practice in my workplace
Health care professionals are among those that are at high risk for hepatitis C. Treating and having to take care of people who are infected with the hepatitis C virus poses a great risk for health care professionals. Safety measures have therefore to be examined within health care institutions. So far, within my workplace, standard operating procedure regarding care of patients infected with HCV have been strictly followed, as well as the handling of specimen from HCV carriers. Personal hygiene can also help prevent the spread of hepatitis. Unnecessary transfusions should be also avoided in order to minimize incidence of hepatitis.
Preventing transmission from healthcare workers to patients has been controversial. Although transmission has been documented, it is rare and limited to case reports. Up to half of the reports were confounded by other factors like contamination of patients' narcotics used for healthcare workers' surreptitious habit of IV drug use. The calculated risk for HCV transmission from an RNA-positive surgeon to a patient during an invasive procedure is 0.00018%, which was roughly comparable to the chance of acquiring HCV by transfusion in the United States in the year 2000. It is recommended in some countries (Berklan, 2000) that no HCV-infected healthcare professional be restricted from his or her work. Despite this recommendation, some health departments have required HCV-infected physicians to obtain informed consent before performing surgery on their patients (Pearlman, 2004).
Healthcare organizations should treat hepatitis C in the same manner that they treat HIV or AIDS. Recommendations should include strict adherence to worldwide admitted precautions and education on hepatitis C for all healthcare workers. This education should include emphasizing the importance of reporting all percutaneous sticks. Presently, healthcare workers are screened only if there is a known exposure to hepatitis C (Dillman, 1999). Because hepatitis C is insidious in nature, testing should be done for both the source patient and the healthcare worker, regardless of known status. If a healthcare worker is identified as being positive, counseling and treatment for hepatitis C should be offered.
The value of prevention is skyrocketing. It should be noted that many individuals with the disease are unaware they are infected with HCV because symptoms often do not appear until serious liver damage has already occurred. Therefore, many individuals go through their lives not knowing they have the virus, such wasted time could have been used to start treating the individual infected. Also, given the fact that there is no vaccine yet against hepatitis C, an awareness campaign is indeed a necessity. The chances for individuals getting the infection are increased with the lack of a vaccine against the virus.
Hepatitis C awareness campaigns should be made not only for work environments but for the general public as well. Programs on awareness would put individuals at a concern over prevention of hepatitis C. An awareness campaign is needed which should be focused on raising hepatitis C awareness in the minds of the general public, elected officials, and policy-makers.
Elected officials and policy makers are specifically mentioned as target populations for hepatitis C awareness since they are the ones who are more in the position to create programs that will further strengthen the awareness campaign. They are in a very good position to implement measures that will help individuals lessen their chances of contacting the deadly virus.
The impact of hepatitis C on societies is staggering. Billions are estimated as being spent on the disease worldwide (Henkel, 1999). This includes billions spent on treatment which would have been preventable if only there was a vaccine or individuals are more aware of the infection. If such a trend would continue, allocations for other medical concerns would therefore lessen in favor of the infectious disease, which does not sound very good. Continued research and awareness campaigns therefore have to be done in order to lessen the staggering costs of the disease management and prevention. This of course is only secondary to the aim of helping millions of individuals that are infected with the disease.
In summary, with no vaccine and no effective post-exposure prophylaxis against the hepatitis C virus, best efforts at fighting the silent dragon should be directed toward counseling HCV-infected patients and those at risk of developing infection. Adequate sterilization of medical and surgical instruments and equipment, consistent use of personal protective equipment during patient care, and use of safety devices for venous access should be routine practice for all health care providers. In addition, promotion of community programs for safe injection practices and testing for people in high-risk categories could be a focus with measurable outcomes for all of society.
Conclusion
Hepatitis C is dangerous not only because of the damage it inflicts, but because people may be asymptomatic for years before they realize they are suffering from incurable liver disease. It almost exclusively is spread by dirty needles. Currently there is little hope for treatment of hepatitis C. A drug called Interferon Alpha-2B (inferferon is an immunity substance naturally present in small amounts in the body) has proven somewhat successful in combating the virus, but only in about 15 to 20 percent of the cases. While scientists are conducting research to find more-powerful antidotes, the best hope of curbing the spread of the virus continues to lie mainly in prevention. Health care institutions also have to be aware of the specific measures needed to be able to avoid and prevent infection with the hepatitis C virus. Further programs are needed for populations to educate them of the severity of the disease and its complications.
Hepatitis C infection is therefore a major public health problem throughout the world as can be seen by its effects on the body and the society in general. Yet for all its severity, it is largely preventable. Prevention can happen through awareness campaigns, rigorous efforts to protect blood supplies usually in health care environments, and major education and intervention programs for such at-risk populations as recreational intravenous drug users.
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