Hepatitis B is an infection caused by the hepatitis B virus that invades liver cells to replicate therein and release virions which spread the infection within the organ (Peppa & Maini, 2012). Hepatitis B is transmitted through blood and body fluids. Hence, the infection can be passed on to others through the transfusion of contaminated blood, sharing of needles among intravenous drug users, needlestick or sharps injuries, unprotected sexual intercourse, and from an infected mother to her newborn (Grieve, 2014). To a lesser extent, acupuncture and body piercing using unsterile equipment, and the sharing of toothbrushes and razors can also facilitate transmission.
In 50% of cases, subclinical infection develops and though it eventually resolves without any consequences, the carrier can pass the illness on to others until the virus is cleared completely (Peate & Jones, 2014). In acute hepatitis B, symptoms commonly develop within 60-90 days after viral exposure and resolve within 1-3 months. However, it can develop as early as 45 days and as late as 160 days after exposure (CDC, 2012). Symptoms include fever, flu-like symptoms including headache and malaise, nausea, vomiting, diarrhea, anorexia, weight loss, jaundice, abdominal pain in the upper right side, and dark-colored urine (Grieve, 2014; Peate & Jones, 2014).
The most serious complications especially in chronic infection include liver cirrhosis and decompensation or acute liver failure with progression to hepatic carcinoma highly likely (Peppa & Maini, 2012). Dysfunction in antiviral immune responses is thought to contribute to chronic infection. The first-line treatment for chronic hepatitis B is pharmacologic therapy with peginterferon alfa-2a (Grieve, 2014). Peginterferon enhances the capacity of the immune system to attack the virus and greatly reduce viral titers. However, treatment success is typically 25-50% of cases only (CDC, 2012). Liver transplant is indicated in extensive and irreversible liver damage. In acute cases, treatment consists of supportive therapy.
In the United States, the incidence is 2.1 per 100,000 equivalent to around 6,200 cases with the highest incidence among adults 25-44 years old (Kim, 2009). It is higher among men at 2.7 per 100,000 compared to 1.6 per 100,000 among women. In adults, around 5% of acute and 25% of subclinical infection progress into chronic hepatitis B while it is 30-50% among children (CDC, 2012; Kim, 2009). The prevalence is higher among foreign-born children at 12.8% compared with 1% of U.S.-born children (Wasley et al., 2010). The prevalence is similarly higher among foreign-born adults at 10.3% compared with 3.4% of those born in the U.S. In the U.S., 200-300 Americans die of fulminant or acute hepatitis B annually. Meanwhile, the death rate from liver cirrhosis is 3,000-4,000 each year while mortality from liver cancer is 1000 to 1,500.
Hepatitis B and the Determinants of Health
The determinants of health pertain to the “circumstances in which people grow, live, work, socialize, and form relationships, all of which are shaped by political, social, and economic forces” (Dean & Fenton, 2010, p.1). The factors contributing to susceptibility and increased risk of hepatitis B relate to these determinants. Immigrants who grew up in a country where the disease is endemic and where preventive health care is inadequate are more likely to carry the infection (Dean & Fenton, 2010). They are also less likely to be immunized thus increasing their susceptibility.
In addition, cultural beliefs and health policies in regard to protected sexual intercourse may also perpetuate transmission via this route with infected pregnant women passing on the virus to their newborns. Moreover, the lack of stringent screening policies of blood products increases the risk of hepatitis B among those who receive blood transfusions. In the same way, persons of low socioeconomic status and lack insurance are less likely to seek health care resulting in poorer outcomes. Inadequate nutrition and immunosuppression impair immune functioning. On the other hand, low literacy negatively impacts the understanding of the causes of the disease that influences individual preventive behaviors (Dean & Fenton, 2010).
Further, discrimination and stigma associated with using intravenous drugs, being a male having sex with another male, and incarceration also serve as barriers to adequate health education, preventive and supportive services, and timely treatment (Dean & Fenton, 2010). The practice of sharing razors and toothbrushes among homeless also put them at a greater risk. Insufficient regulation over the practice of body piercing and tattooing and a lack of education on preventing blood-borne infections among those who provide these services also promote disease transmission. In the same manner, alternative medicine practitioners who provide acupuncture therapy similarly need education to ensure they practice infection control. Finally, health care professionals in settings where safety is not a priority will not have the support needed for preventive practices such as sharps injury reduction and the enforcement of policies on the use of personal protective equipment.
The Epidemiologic Triangle and Hepatitis B Infection
The agent is the hepatitis B virus that has an affinity for hepatocytes thus targeting the liver. The virus also employs mechanisms within the cell to evade attack from the immune system that can lead to suboptimal or unsuccessful treatment (Oakes, 2014). The host can be any human being. However, nutrition, immune functioning, and comorbidities affect the host’s response to infection, thus the differential course or time factor of the disease into subclinical, acute, and chronic. Environmental factors include the physical and social environments (Merrill, 2013). For instance, hospitals wherein instruments are not sufficiently sterilized or where health care professionals are not provided adequate protective equipment promote blood-borne infection. Social norms such as the sharing of needles among IV drug users and risky sexual behaviors constitute another type of environment that promotes viral transmission.
Role of the Community Health Nurse
The role of the community health nurse (CHN) includes case management that entails finding cases of the disease, referring patients for treatment, and providing follow-up home visits (Gerber, 2012). There are also nurse practitioners who establish community-based clinics for chronic disease management or specifically cater to patients with chronic hepatitis. The role of CHNs is to bridge patients to primary care providers to ensure treatment compliance and optimum illness management. The CHN also provides health education in schools, workplaces, and various community settings to foster awareness and understanding of the disease, prevent the spread of infection, and promote immunization (Oakes, 2014).
Community health nurses work with partners within and outside the community to remove barriers to preventive and acute care among vulnerable and hard to reach populations (Meadows, 2009) such as men who have sex with men and intravenous drug users. CHNs further provide input during the development of public health programs that address health disparities using an epidemiological approach to collecting and analyzing community health data (Gerber, 2012). Moreover, CHNs provide leadership in the implementation and improvement of such programs.
Concerned National Agencies and Organizations
There are national organizations that address the issue of hepatitis B. The American Association for the Study of Liver Disease (AASLD, 2014)) is a non-profit organization engaging in networking to promote research on various liver diseases including hepatitis B. The AASLD founded the American Liver Foundation as its research, education, and advocacy arm (ALF, 2014). Research is integral in the formation of effective and appropriate treatments and care guidelines. Likewise, public education builds awareness and promotes self-management that reduces the incidence, prevalence, and poor outcomes associated with hepatitis B. Advocacy is also indispensable in putting the issue of disparity to the forefront and ensuring that policies favor the reduction of hepatitis B among vulnerable groups.
Conclusion
Hepatitis B is blood-borne communicable disease affecting the liver. Because of increased exposure to contaminated blood, some segments of the population are at a greater risk of contracting the disease leading to health disparity. The disease can take a subclinical, acute, or chronic course with the latter likely to lead to serious hepatic complications without adequate treatment. There are multiple determinants of infection and patient outcomes that need to be considered when caring for individuals with hepatitis B. In addition, application of the epidemiologic triangle to individuals and groups also assist in developing an appropriate care plan. The role of the community health nurse (CHN) is crucial in disease prevention, acute treatment, and long-term follow-up as well as program and policy development. The CHN can work with national organizations focusing on the disease to improve outcomes in patients with the infection.
References
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