Epidemiology: Hepatitis B T Ob
Grand Canyon University: NRS-427v
January 19th, 2014

There are a large number of scientific discoveries that have come about serendipitously. Dr. Baruch Blumberg may say that this was the case when he discovered the Hepatitis B Virus. Dr. Blumberg and his colleagues discovered the Hepatitis B virus in 1967, developed the blood test that is used to diagnose the virus and in 1969, invented the first Hepatitis B vaccine. In 1976, Dr. Blumberg was honored with the Nobel Prize in Medicine for his discovery (HepB Foundation, 2013)
Hepatitis B is caused by the Hepatitis B virus (HBV). A blood test called Hepatitis B surface antigen (HBsAg) is used to find the presence of the virus in the blood. When serum comes back with a positive HBsAg result it is indicative of active HBV infection that can be passed on to others (Mast & Weinbaum, 2009). Determining immunity to HBV can be done by the Hepatitis B surface antigen (anti-HBs) blood test. Having antibodies can mean prior HBV infection from which the person has recovered or that the person has received the vaccine. A positive anti-HBs test also means that the person is protected by the vaccine or their natural immunity and cannot become infected or infect others. Determining whether a person has had or currently has an active HBV infection can be done by the Hepatitis B core antigen (anti-HBc) blood test. A positive anti-HBc test indicates the person can have a chronic infection and is also infectious (Mayo Clinic, 2013) Additional tests to gauge severity of the infection and liver health include: liver function tests (LFTs) and Hepatitis B DNA (HBV DNA). HBV DNA detects how much virus is present (viral load), which monitors how well anti-viral therapy is working (CDC, 2012).
“The epidemiology triangle is used to analyze the natural history of a disease. A change in any of the factors represented in this triangle (the person, the causative agent, environment) has the potential to change the balance of health (Maurer & Smith, 2013).”
Hepatitis B is transmitted by a person coming in contact with an infected person’s blood or bodily fluids. HBsAg has been detected in multiple body fluids, but only semen, saliva and serum have been found capable of infecting another person. Additionally, a mother who is known to have the virus can pass it to her newborn during delivery. When the mother’s HBV infection is known, the newborn can receive vaccination to help prevent infection. For adults, the primary sources of HBV infection are percutaneous exposure to blood and sexual contact. Percutaneous transmission can occur through receiving a blood transfusion, organ/tissue transplant or sharing needles during injection-drug use. Health care workers are at risk due to frequent exposure to blood/needles (Mast & Weinbaum, 2009).
Therefore, the relationship of HBV and the epidemiologic triangle is as follows: the causative agent is the virus, the environment is typically either skin punctured during unsafe drug-injecting practices and/or unsafe sexual practices between infected individuals. Finally, the third side of the triangle is the susceptible person, one that has not been vaccinated against HBV or is immuno-compromised.
The average time from exposure to detection of HBsAg is thirty days (Mast & Weinbaum, 2009) but signs and symptoms can appear up to three months after a person has been infected and vary with age; they can also range from mild to severe. Most children under age five and newly infected immuno-suppressed adults can be asymptomatic. When present, signs and symptoms can mimic flu-like symptoms and can include: fatigue/weakness, fever, abdominal pain, dark urine, joint/muscle pain, headache, poor appetite, nausea/vomiting and jaundice (After other symptoms have begun to dissipate is when jaundice may begin to be evident) (CDC, 2013).
Treatment of HBV will vary and depend on whether infection is acute or chronic. HBV treatment is prescribed and monitored by specialist hospital/clinic, nurse and doctor teams in the field. In acute HBV infection, treatment may be aimed at managing and decreasing symptoms while allowing the person’s immune system to fight the infection. Follow-up tests can ensure the virus has left the body (Mayo Clinic, 2013). In cases of chronic HBV infection, anti-viral medications may be prescribed. The ideal aim of treatment is clearance of HBV infection, however this is not always possible. Therefore, the usual aim is to achieve long-term suppression of HBV deoxyribonucleic acid (DNA) replication. This lowers inflammation in the liver and thus prevents HBV complications, such as: progression of liver disease, leading to liver cirrhosis (scarring of the liver) and development of primary liver cancer (Jack & Cooper, 2013). Another extreme complication of HBV is liver failure, where the liver’s vital functions shut down and a liver transplant becomes necessary to sustain life (Mayo Clinic, 2013).
Taking precautions against HBV infection is the best mode of defense. The Hepatitis B vaccine is recommended for all at-risk individuals, starting at infancy. It is given as a series of three-to-four injections over a period of six months (Mayo Clinic, 2013).
“The CDC estimates that approximately 38,000 people are infected with HBV yearly and the number of people living with chronic HBV is between 800,000 to 1.4 million. Vaccination of infants and adolescents has dramatically reduced new cases of HBV in persons less than nineteen years of age (Mauer & Smith, 2013). “
The demographic of interest for HBV transmission and disease includes those who fall within the following criteria, anyone that is: living with an HBV-infected person; having sex with an HBV-infected person; a man having sex with men; an intravenous drug-user; on kidney dialysis; immuno-suppressed or on anti-rejection medications after organ transplant; pregnant; or anyone with unexplained, abnormal liver enzyme tests.
The role of the community health (CH) nurse emphasizes support and ensures that the patient is aware of all treatment options available. This is crucial to increase compliance with the treatment option that is chosen. The CH nurse delivers ongoing health education on the benefits of compliance with the prescribed medication regimen and follow up with scheduled appointments with their MD or clinic. Education also targets any factors that may affect recovery, such as obesity and/or alcohol intake as these will precipitate the worsening of liver disease. The CH nurse is also aware of psychosocial factors such as work-related stress and family dynamics.
The CH nurse closely follows patients who are receiving anti-viral treatment to monitor tolerance of medications, adequate symptom control and potential side effects. Patients with HBV taking anti-viral treatments are at risk of the virus re-emerging if medications are missed or not taken as prescribed. The CH nurse is a liaison between patient and prescribing team. A recent study from China showed that continuous community nursing care led to increase in patient compliance with HBV treatment and improve their quality of life (Jack & Cooper, 2013). The CH nurse collects data that is reported back to the team regarding symptom management, medication side effects, testing, vaccinations, the need for sick notes required for the patient’s school/employer, as well as the patient’s support system contacts and sexual partners (Jack & Cooper, 2013). CH nurses also follow up with patients not undergoing treatment for HBV to monitor lab tests and emerging signs and symptoms. Patients in the immune-tolerant state of infection that are HBeAg-positive with a high viral load and normal ALT are advised to monitor ALT every six months (Jack & Cooper, 2013).
“Scientific evidence shows that genetic predisposition and risk behaviors only partially explain why some people become sick and other do not. Many chronic and infections diseases cluster in population that experience constraints to good health that can be social and economic. These constraints are knows as Social Determinants of Health (SDH) and they determine the extent to which a person possesses the physical, social and personal resources to identify and achieve personal goals, satisfy needs, cope with the environment and achieve optimal health (Dean & Fenton, 2013).”
SDH play a part in the spread of Hepatitis B and affect the recovery of anyone affected by the virus that is in less than favorable SDH. If a person’s socioeconomic status affects their access to care of education regarding their care, they will not be able to choose and follow a treatment plan that will get them well. The goal of any organization should be to focus on making the necessary socioeconomic, cultural and environmental changes in policies to incorporate or integrate adult HBV vaccination services and education services into established programs. Thus, arming CH nurses and other health workers with the necessary tools to give those affected with the disease the best chance at healing and survival.
The Hepatitis B Foundation is the only national, non-profit organization solely dedicated to improving the quality of life of those whose life is affected by HBV worldwide. Their goal is to find a cure. The Foundation contributes to resolving or reducing the impact of Hepatitis B through promoting disease awareness, funding focused research, supporting treatment initiatives and immunizations. They are a primary source of information for patients and families, the medical/scientific community and the general public (HepB foundation, 2013).

References
Centers for Disease Control and Prevention (CDC), 2013. http://www.cdc.gov/hepatitis/HBV/HBVfaq.htm

Centers for Disease Control and Prevention (CDC), 2012. Updated CDC recommendations for the management of hepatitis B virus-infected health care providers and students http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6103a1.htm

Dean, Hazel D, Fenton, Kevin A, MD, PhD, FFPH. Perspective public health reports 2013. Supplement3/Volume 1285: Integrating a social determinants of health approach into public health practice: A five-year perspective of actions implemented by CDC’s national center for HIV/AIDS, viral hepatitis, STD, and TB prevention. http://www.publichealthreports.org/issueopen.cfm?articleID=3041

Hepatitis B Foundation, The. 2013. Retrieved from: http://www.hepb.org , http://www.hepb.org/about/Blumberg.htm

Jack, K., Cooper, J., & Ryder, S. (2013). Hepatitis B virus part 2: treatment options and the role of the specialist nurse. Gastrointestinal Nursing, 11(4), 33-40.

Mast, E., Weinbaum, C., Fiore, A., Alter, M., Bell, B., Finelli, L., & ... Ward, J. (2009). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part II: immunization of adults. MMWR: Morbidity & Mortality Weekly Report, 55(RR-16), 1-33.

Maurer, F & Smith, C. Community/Public Health Nursing Practice, 2013 [VitalSouce bookshelf version]. Retrieved from http://pageburstls.elsevier.com/books/978-1-4557-0762-1/id/B9781455707621000075_s0090

Mayo Clinic, 2013. http://www.mayoclinic.org/diseases-conditions/hepatitis- b/basics/definition/CON-20022210