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Information

Synonym/Acronym

Hepatitis A antibody: HAV, hepatitis B antigen and antibodies: HBV (HBeAg, HBeAb, HBcAb, HBsAb, HBsAg), hepatitis C antibody: HCV, hepatitis D antibody: HDV (delta hepatitis), hepatitis E antibody: HEV.

Rationale

To test blood for the presence of antibodies that would indicate a past or current hepatitis infection.

Patient Preparation

There are no food, fluid, activity, or medication restrictions unless by medical direction.

Normal Findings

Method: Enzyme immunoassay for HAV, HBV, HDV, HEV; polymerase chain reaction (PCR) may also be used where indicated. Negative.

(Method: Enzyme immunoassay, chemiluminescent immunoassay, branched chain DNA [bDNA], Nucleic Acid Amplification Testing [NAAT], PCR, recombinant immunoblot assay [RIBA], viral RNA RT [reverse transcription] PCR) for HCV. Negative.

Critical Findings and Potential Interventions

Specific infectious organisms are required to be reported to local, state, and national departments of health. Lists of specific organisms may vary among facilities. State health departments provide information regarding reportable diseases, which can be accessed at each state health department Web site. The CDC provides information regarding national notifiable diseases at https://ndc.services.cdc.gov/search-results-year/.

Overview

Study type: Blood collected in a gold-, red-, or red/gray-top tube for HAV, HBV, HCV, HDV, or HEV enzyme immunoassay and chemiluminescent immunoassay; related body system: Digestive and Immune systems. Blood collected in lavender-top [EDTA] or white-top [PPT EDTA] tubes for HCV molecular testing of viral DNA or RNA.

Hepatitis is a term used to describe inflammation of the liver. There are a variety of causes of hepatitis that include exposure to hepatotoxic substances such as alcohol or drugs or infection by a hepatitis virus. The resulting illness can range from a mild, self-limiting condition to a life-threatening disease. The disease may present as an acute illness or develop into a chronic condition. This study reviews the viral sources of hepatitis infections.

Vaccination against hepatitis A and hepatitis B can be administered to infants, children, and adults; there is also a combination Hep A/Hep B vaccine for adults. It is not known how long immunization against hepatitis A lasts, but studies have shown it to be effective for at least 10 yr. The hepatitis B vaccine provides lifelong immunity for most people.

HAV:The hepatitis A virus (HAV) is classified as a picornavirus. Its primary mode of transmission is by the fecal-oral route under conditions of poor personal hygiene or inadequate sanitation. The incubation period is about 28 days, with a range of 15 to 50 days. Onset is usually abrupt, with the acute disease lasting about 1 wk. Therapy is supportive, and there is no development of chronic or carrier states. Assays for total (immunoglobulin G [IgG] and immunoglobulin M [IgM]) hepatitis A antibody and IgM-specific hepatitis A antibody assist in differentiating recent infection from prior exposure. If results from the IgM-specific or from both assays are positive, recent infection is suspected. If the IgM-specific test results are negative and the total antibody test results are positive, past infection is indicated. The clinically significant assay—IgM-specific antibody—is often the only test requested. Jaundice occurs in 70% to 80% of adult cases of HAV infection and in 70% of pediatric cases.

HBV:The hepatitis B virus (HBV) is classified as a double-stranded DNA retrovirus of the Hepadnaviridae family. Its primary modes of transmission are parenteral, perinatal, and sexual contact. Serological profiles vary with different scenarios (i.e., asymptomatic infection, acute/resolved infection, coinfection, and chronic carrier state). The formation and detectability of markers is also dose dependent. The following description refers to HBV infection that becomes resolved. The incubation period is generally 6 to 16 wk. The hepatitis B surface antigen (HBsAg) is the first marker to appear after infection. It is detectable 8 to 12 wk after exposure and often precedes symptoms. At about the time liver enzymes fall back to normal levels, the HBsAg titer has fallen to nondetectable levels. If the HBsAg remains detectable after 6 mo, the patient will likely become a chronic carrier who can transmit the virus. Hepatitis Be antigen (HBeAg) appears in the serum 10 to 12 wk after exposure. HBeAg can be found in the serum of patients with acute or chronic HBV infection and is a sign of active viral replication and infectivity. Levels of hepatitis Be antibody (HBeAb) appear about 14 wk after exposure, suggesting resolution of the infection and reduction of the patient’s ability to transmit the disease. The more quickly HBeAg disappears, the shorter the acute phase of the infection. IgM-specific hepatitis B core antibody (HBcAb) appears 6 to 14 wk after exposure to HBsAg and continues to be detectable either until the infection is resolved or over the life span of patients who are in a chronic carrier state. In some cases, HBcAb may be the only detectable marker; hence, its lone appearance has sometimes been referred to as the core window. HBcAb is not an indicator of recovery or immunity; however, it does indicate current or previous infection. Hepatitis B surface antibody (HBsAb) appears 2 to 16 wk after HBsAg disappears. Appearance of HBsAb represents clinical recovery and immunity to the virus.

Onset of HBV infection is usually insidious. Most infected children and half of infected adults are asymptomatic. During the acute phase of infection, symptoms range from mild to severe. Chronicity decreases with age. HBsAg and HBcAb tests are used to screen donated blood before transfusion. HBsAg testing is often part of the routine prenatal screen. Vaccination of infants, children, and young adults is becoming a standard of care and in some cases a requirement.

HCV:The hepatitis C virus (HCV) causes the majority of bloodborne non-A/non-B hepatitis cases. There are six main genotypes, or strains, of the virus, and 50 subtypes of the virus have been identified. It is possible to be infected with more than one genotype at a time. The virus is a flavivirus and contains a single-stranded RNA core. Its primary modes of transmission are parenteral, perinatal, and sexual contact. The incubation period varies widely, from 2 to 52 wk. Onset is insidious, and the risk of chronic liver disease after infection is high. On average, antibodies to hepatitis C are detectable in infected individuals within 4 to 10 wk of infection by enzyme immunoassay screening methods and as early as 2 to 3 wk of infection by PCR methods. Once infected with HCV, 75% to 85% of patients will become chronic carriers. Infected individuals and carriers have a high frequency of chronic liver diseases such as cirrhosis and chronic active hepatitis, and they have a higher risk of developing hepatocellular cancer.

The transmission of hepatitis C by blood transfusion has decreased dramatically since it became part of the routine screening panel for blood donors. The possibility of prenatal transmission exists, especially in the presence of HIV coinfection. Therefore, this test is often included in prenatal testing packages. The test sequence begins with a qualitative immunoassay screening test for viral antibodies. Indeterminate or suspected false-positive results may be confirmed by the RIBA assay, which also detects viral antibodies. NAAT is the method used to document the presence of ongoing infection. Viral genotype testing is used to identify HCV RNA by RT PCR. Hepatitis C antibody testing should not be repeated on a patient who previously tested positive as the antibody will remain present and will therefore provide no clinical benefit; genotype and viral load testing (bDNA or RT PCR) are used to select and guide therapeutic interventions.

GenotypeGeographic Prevalence
Genotype 1North America (found throughout the world but in the United States represents 70%–75% of all cases of hepatitis C)
Genotype 2Worldwide
Genotype 3Worldwide
Genotype 4Northern Africa
Genotype 5South Africa
Genotype 6Asia

Molecular technologies are another approach to testing various specimen types; there are now numerous applications in the areas of pathogen identification (e.g., HCV), disease identification (e.g., oncology), and treatment development. Next-generation sequencing (NGS) is a category of molecular testing used to sequence DNA fragments. NGS technology is capable of sequencing DNA fragments from pathogenic organisms across a range in size from small sequences (single-nucleotide polymorphisms) to large sequences (thousands or billions). Multiplex assays are another type of molecular testing designed to simultaneously sequence DNA fragments from multiple pathogens to help identify mixed populations of infectious agents. The indications for NGS have expanded significantly, and it is now an important tool in the diagnosis/identification of pathogenic organisms. NGS also provides a means and/or the potential to perform prognostic epidemiologic studies, lineage tracing (cell lines), discovery of genetic variants with drug resistance mutations, development of individualized therapeutic regimens, and development of preventive measures (e.g., vaccines).

HDV:Symptoms of hepatitis D virus (HDV) infection are similar but often more severe than those of hepatitis B virus (HBV) infection. As with HBV, the primary modes of HDV transmission are parenteral, perinatal, and sexual contact. The virus contains a single-stranded RNA core. Replication of this virus requires the presence of the hepatitis B outer coat. Therefore, HDV infection can occur only with hepatitis B coinfection or superinfection. Onset is abrupt, after an incubation period of 3 to 13 wk. Because of its dependence on HBV, prevention can be accomplished by using the same pre-exposure and postexposure protective measures used for HBV.

HEV:The hepatitis E virus (HEV) is classified as a single-stranded RNA hepevirus with five separate genotypes. HEV is a major cause of enteric non-A hepatitis worldwide; about 20% of the U.S. population demonstrates presence of IgG antibody. Its primary mode of transmission is the fecal-oral route under conditions of poor personal hygiene or inadequate sanitation. The incubation period is about 28 days. IgM and IgG are detectable within 1 mo after infection. Onset is usually abrupt, with the acute disease lasting several weeks. Therapy is supportive, and patients usually recover, although the disease is quite debilitating during the acute phase. Hepatitis E infection can occasionally develop into a severe liver disease and may cause chronic infection in organ transplant or other immunocompromised patients. Assays for total (IgG and IgM) hepatitis E antibody and IgM-specific hepatitis E antibody help differentiate recent infection from prior exposure. If results from the IgM-specific or from both assays are positive, recent infection is suspected. If the IgM-specific test results are negative and the total antibody test results are positive, past infection is indicated. IgM remains detectable for about 2 mo; IgG levels persist for months to years after recovery.

Indications

Interfering Factors

N/A

Potential Medical Diagnosis: Clinical Significance of Results

Positive Findings in

  • Individuals with current viral hepatitis infection
  • Individuals with past or chronic viral hepatitis infection

Nursing Implications, Nursing Process, Clinical Judgement

Potential Nursing Problems: Assessment & Nursing Diagnosis

ProblemsSigns and Symptoms
Activity (related to inadequate nutrient metabolism, increased basal metabolic rate associated with viral infection)Verbal report of weakness; inability to tolerate activity; shortness of breath with activity; altered heart rate, blood pressure, and respiratory rate with activity
Infection: HAV, HEV (related to crowded living conditions with poor sanitation; poor personal hygiene; fecal-oral exposure; exposure to contaminated water, milk, food; raw shellfish); HBV, HCV, or HDV (related to unprotected sex, exposure to blood and body fluids of an infected person, sharing needles with an infected person)Fever, fatigue; loss of appetite, jaundice, nausea and vomiting, dark-colored urine, abdominal pain, stool that is clay colored, joint pain; it is possible to be infected and have no symptoms
Nutrition(insufficient—related to the inability to adequately store or metabolize foods, lack of appetite, refusal to eat, nausea and vomiting)Unintended weight loss; pale, dry skin; dry mucous membranes; documented inadequate caloric intake; subcutaneous tissue loss; hair pulls out easily; paresthesias

Before the Study: Planning and Implementation

Teaching the Patient What to Expect

  • Discuss how this test can assist in detecting, evaluating, and monitoring hepatitis infection.
  • Explain that a blood sample is needed for the test.

Potential Nursing Actions

  • Obtain a history of IV drug use, high-risk sexual activity, and occupational exposure.

Safety Considerations

  • Follow recommended precautions to decrease risk of staff exposure associated with blood, body fluids, and needle sticks.

After the Study: Implementation & Evaluation Potential Nursing Actions

Avoiding Complications

  • Counsel the patient and significant contacts, as appropriate, that hepatitis B immune globulin (HBIG) immunization is available (for HBV and HDV) and is in fact required in many places as part of childhood immunization and employee health programs. Vaccination regulations vary by state.
  • Parents may choose to sign a waiver preventing their newborns from receiving the vaccine; they may choose not to vaccinate on the basis of philosophical, religious, or medical reasons.

Treatment Considerations

  • Victims of sexual assault, including children and older adults, may be at risk for developing hepatitis.
  • Discuss how disease transmission occurs and provide education on how to avoid reinfection and to prevent ongoing medical problems.
  • Discuss chronic infection in organ transplant or other patients who are immunocompromised.
  • Stress the importance of hand hygiene to prevent viral transmission.
  • Provide access to counseling services.
  • Provide a nonjudgmental, nonthreatening atmosphere for a discussion, during which the risks of sexually transmitted infections are explained. It is also important to discuss the problems that the patient may experience (e.g., guilt, depression, anger).

Infection

  • The best treatment for infection is adequate rest, good nutrition, and adequate fluid intake.
  • It is important to recommend both family and significant others receive the hepatitis vaccination.
  • Explain that alcohol should be avoided to decrease risk of liver damage
  • Over-the-counter medication should be checked with the health-care provider (HCP) before taking to ensure there is no risk to the liver. Explain that jaundice can last several months.
  • Prevention and early treatment are key components of hepatitis therapeutic strategies. Immune globulin can be given before HAV exposure (in the case of individuals who may be traveling to a location where the disease is endemic) or after exposure, during the incubation period. Prophylaxis is most effective when administered 2 wk after exposure.

Hepatitis A

  • Hepatitis A does not have a specific treatment.
  • The best course of action is to treat the symptoms, such as nausea and fatigue.
  • Adequate diet and rest are very important to a full recovery.
  • Dietary intake can be improved by snacking and eating several small, high-caloric meals a day.
  • Dehydration can be prevented by drinking plenty of fluids such as water, juice, or milk.
  • Discuss prevention strategies such as abstaining from sexual activity with infected partners, vigorous handwashing after toileting and changing diapers, and abstaining from food prepared by infected individuals.

Hepatitis B

  • HBIG vaccination should be given immediately after situations in which there is a potential for HBV exposure (e.g., accidental needle stick, perinatal period, sexual contact) for temporary, passive protection.
  • Immune globulin can be given before exposure (in the case of individuals who may be traveling to a location where the disease is endemic) or after exposure, during the incubation period.
  • Interferon alpha-2b may be useful in the treatment of hepatitis B. Antiviral drugs used to treat hepatitis B include adefovir, entecavir, interferon alpha-2b, lamivudine, pegylated interferon, telbivudine, tenofovir alafenamide, and tenofovir disoproxil.
  • The specific course of treatment is decided through discussions between the patient and HCP.

Hepatitis C

  • Antiviral drugs used to treat hepatitis C include boceprevir, daclatasvir, glecaprevir/pibrentasvir, interferon alpha-2b, ledipasvir/sofosbuvir, peginterferon, ribavirin, simeprevir, sofosbuvir, telaprevir, and velpatasvir.
  • The specific course of treatment is decided through discussions between the patient and HCP.
  • Therapeutic interventions are based on factors that include the type of virus identified, the patient’s complete health history (including any history of liver disease, kidney disease, HIV coinfection, and previous treatment), and the patient’s response to treatment.
  • The average treatment is over a period of 12 wk but may extend over a period of 1 yr, and it may be financially prohibitive for some patients.
  • Prevention strategies include abstinence from illicit drug use, unprotected sex with multiple partners or an individual where health status is uncertain, and obtaining a tattoo where the cleanliness of the equipment cannot be verified.

Hepatitis D

  • Hepatitis D has limited options as far as treatment.
  • This virus only occurs in those already infected with hepatits B.
  • Pegylated interferon alpha is the only drug found to be effective in treating hepatitis D.
  • Duration of therapy is not clear, but it is estimated to be more than a year.
  • The prevention strategy is for those not infected with hepatitis B to receive a hepatitis B vaccination.

Hepatitis E

  • Hepatitis E is not treated with specific interventions in most situations, as it will eventually run its course.
  • Immunosuppressed patients can be given the antiviral ribavirin or interferon with some positive effect.
  • Hospitalization may be considered for pregnant women who are symptomatic.
  • Prevention strategies include maintaining adequate sanitation with good clean drinking water and abstaining from raw venison and pork.

Safety Considerations

Activity

  • There are several assessment and intervention techniques that can assist in managing altered activity tolerance.
  • Assess current level of activity and activity tolerance.
  • Assist in setting realistic activity goals.
  • Trend vital signs, including orthostatic blood pressure, with activity; monitor for oxygen desaturation and administer oxygen as necessary.
  • Collaborate with physical therapy to support activity, pace activities to match energy stores, and collaborate with the patient to establish activity goals.
  • Assist with self-care and encourage long, uninterrupted periods of rest.
  • Introduce the use of assistive devices as needed.
  • Fatigue can be common with hepatitis.
  • Some interventions to address fatigue are to pace activities to preserve energy stores.
  • Identify what aggravates and decreases fatigue.
  • Assess for physiologic factors such as anemia.
  • Observe for emotional factors such as depression, which can contribute to the presence of fatigue.
  • Fall and injury risk precautions should be put in place.

Nutritional Considerations

  • Adequate nutrition is important with all forms of hepatitis.
  • Generally, the best recommendation is to eat a well-balanced diet. Encourage cultural home foods.
  • Dietary recommendations will vary depending on the condition and its severity.
  • Valuable areas of inquiry are nutritional history, current eating habits, and attitude toward eating.
  • Assess for the presence of ascites and nausea.
  • Some potential strategies to address nutrition concerns are to monitor weight daily and administer ordered vitamins and antiemetics for nausea.
  • Monitor nutritional laboratory values such as Alb, serum electrolytes, Hgb, RBC count, transferrin, and WBC count.
  • Explain the importance of providing an adequate daily fluid intake of at least 4 L.
  • Eliminate alcohol from the diet.
  • Generally, small, frequent meals high in carbohydrates and low in fat will provide the required energy while not burdening the inflamed liver.
  • There are some specific instances when hepatitis can affect the diet.
  • Treatment with interferon, which may result in side effects such as loss of appetite, soreness in the mouth and throat, nausea and vomiting.
  • Disease progression that results in further deterioration of health may result in loss of appetite or fatigue such that significant malnourishment occurs.
  • Presence of additional medical conditions such as diabetes, hypercholesterolemia, hypertension, or kidney disease with specific dietary restrictions may also negatively impact adequacy of nutrition.

Clinical Judgement

  • Consider how to convey that failure to adhere to therapeutic recommendations can have severe health consequences.

Follow-Up and Desired Outcomes