For Nursing Students

1. Hepatitis-B

2. What is Hepatitis?
• “Hepatitis” means inflammation of the
liver.
• The liver is a vital organ that processes
nutrients, filters the blood, and fights
infections.
• When the liver is inflamed or
damaged, its function can be affected.

3. Hepatic Physiology
Liver:
• Weight: 1.5kg (1-2.3kg) & receive 1500 blood/minutes
• Largest solid organ in the body
• Performs over 500 chemical processes
• Produces over 160 different proteins
• Makes clotting factors for the blood
• Stores & releases sugar as glycogen
• Metabolizes, detoxifies, synthesizes
• Secrete about 500 ml bile/day

4. Functions of liver
• Synthesis of plasma proteins
• Synthesis of vitamin A
• Production of heat
• Metabolism of alcohol
• Conversion of glucose to glycogen for storage
• Storage of fat soluble vitamins: A,D,E, K, iron,
copper, some water soluble vitamins e.g.
riboflavine, niacin, pyridoxine, folic acid and
vitamin B12

5. Functions of liver……………….
• Desaturation of fat
• Deamination of amino acids
• Transamination: removing the nitrogenous
portion of amino acids and adding it to other
carbohydrate molecules forming new non-
essential amino acids
• Breakdown of erythrocytes
• Detoxification of drugs
• Inactivation of hormones
• Secretion of bile to excrete bilirubin

6. General Concepts
• Hepatitis = 'inflammation of the
liver'.
• Six medically important viruses
are commonly described as
“hepatitis viruses”:
HAV,HBV,HCV,HDV,HEV,HGV

7. Table 24.12

8. Hepatitis-B

9. Hepatitis B In the World
• Half worlds population: high risk of HBV
• 400 million people are chronically infected.
Most are unaware of their infection.
• 10-30 million will become infected each
year.
• An estimated 1 million people die each year
from hepatitis B and its complications.
• Approximately 2 people die each minute
from hepatitis B.
• 10th Leading cause of death in worldwide.

10. • The WHO estimates the global
burden of disease from occupational
exposure to be 40% of the hepatitis B
and C infections and 2.5% of the HIV
infections among HCWs as
attributable to exposures at work,
While 90% of the occupational
exposures occur in the developing
world.

11. • The prevalence of HBV and HCV worldwide
vary by region, ranging from 0.5 to 10% for
hepatitis B and from 1 to 4% for hepatitis C.
• The risks of transmission of infection from an
infected patient to the HCW following a NSI
are (CDC Report):
Hepatitis-B : 3–10%
Hepatitis-C : 3%
HIV : 0.3%

12. Determinants of NSIs include:
• Overuse of injections and unnecessary sharps
• Lack of supplies: disposable syringes, safer needle
devices, and sharps-disposal containers
• Lack of access to and failure to use sharps containers
immediately after injection
• Inadequate or short staffing
• Recapping of needles after use
• Lack of engineering controls such as safer needle
devices
• Passing instruments from hand to hand in the
operating suite
• Lack of awareness of hazard and lack of training

13. In Nepal, there are about 3,15,000
people infected with chronic Hepatitis-B.
According to the annual report
2009/2010 of Nepal Blood Transfusion
Service, Hepatitis B was detected
among 596 people and Hepatitis C was
detected among 438 across the country.
HBV is about 100 times more infectious
than HIV.

14. • Acute Hepatitis B refers to the first 6
months, after someone is exposed to
the Hepatitis B virus.
• Some people are able to fight the
infection and clear the virus for others,
the infection remains and leads to a
“chronic,” or lifelong, illness.

15. Why is Hepatitis B such a concern?
• Hepatitis-B is the world’s most common blood-
borne viral infection.
• Approximately 10% of people who get
Hepatitis B infections will become lifelong
carriers of the disease even though they no
longer have symptoms.
• Hepatitis B carriers have a higher risk of
developing liver cancer (about 25% chronic
hepatitis patient develop liver disease).

16. How serious is Hepatitis B?
• Over time, approximately 15%–25% of people
with chronic Hepatitis B develop serious liver
problems, including liver damage, cirrhosis,
liver failure, and even liver cancer.
• Every year more than 6,00,000 people
worldwide die from Hepatitis B-related liver
disease.

17. 3. HBV: Modes of Transmission
 Parenteral - IV drug abusers, health workers are
at increased risk.
 Sexual - sex workers and homosexuals are
particular at risk.
 Perinatal(Vertical) - mother(HBeAg+) →infant.

18. How is Hepatitis B NOT spread?
• Hepatitis B is not spread through
breastfeeding, sharing eating utensils,
hugging, kissing, holding hands, coughing,
or sneezing.
• Unlike some forms of hepatitis, Hepatitis-B
is also not spread by contaminated food or
water.

19. Risk Groups
• Have multiple sex partners
• Have STIs
• MSM
• IVDUs: Sharing needles
• Live with a person who has Hepatitis B
• On hemodialysis
• Are exposed to blood on the job

20. Risk Groups……………………..
• Sharing a needle during ear piercing, body
piercing or tattoos.
• Accidentally pricking with a used needle.
• Sharing tooth brushes, razors, or other personal
items
• Cleaning cuts or open sores of an infected
person
• have an open cut on skin.

21. Concentration of Hepatitis B Virus
in Various Body Fluids
Low/Not
High Moderate Detectable
blood semen urine
serum vaginal fluid feces
wound exudates saliva sweat
tears
Breast milk

22. Hepatitis-B virus (HBV)
HBV is a Hepadna virus.
An extremely resistant strain capable of
withstanding extreme temperatures and
humidity.
It can survive when stored for 15 years at
-20°C, for 24 months at -80°C, for 6
months at room temperatures, and for 7
days at 44°C.
Able to survive in dried blood for >1 week.

23. Properties of HBV
• a member of the hepadna virus group
• Circular partially double-stranded
DNA viruses
• Replication involves a reverse
transcriptase.
RNA Virus: RNA-Protein
DNA Virus: DNA-RNA-Protein

24. HBV
DNA RNA PROTEIN
Reverse transcriptase
24

25. HBV : Structure

26. WBC: N/E/B/L/M (WBC Engulf antigen)
Lymphocytes: produced & mature in stem cells in bone
marrow, regulate immune system, kill cells that bear specific
target antigen.
-B: produce antibodies against the pathogen and are
dependent on T-cells for the information of pathogen.
produced in stem cells in bone marrow and travel to mature in thymus gland.
-T:
T=helper (CD4):recognize virus and stimulate B-cell to actively fight infection.
T=Suppressor (CD8): Suppress T & B cell after control of infection.
T= Cytotoxic (killer): recognize virus infected cells and Kill them directly.
26

27. 5. Pathogenesis & Immunity
• Virus enters hepatocytes via blood
• Immune response (cytotoxic T cell) to viral
antigens expressed on hepatocyte cell surface
responsible for clinical syndrome
• 5 % become chronic carriers (HBsAg> 6 months)
• Higher rate of hepatocellular cancer in chronic
carriers, especially those who are “e” antigen
positive
• Hepatitis B surface antibody likely confers
lifelong immunity (IgG anti-HBs)

28. Animation or Video

29. Four stages in the viral life cycle
Stage I: Immune Tolerance
• The duration of this stage for healthy adults is
approximately 2-4 weeks and represents the
incubation period.
• For newborns, the duration of this period
often is decades.
• Active viral replication is known to continue
despite little or no elevation in the
aminotransferase levels and no symptoms of
illness.

30. Stage II: Immuno response
• Inflammatory reaction: natural defense of
body.
• The immune system attack the hepatitis-
B infected cells in the liver and start to
clear the infection from body.
• This phase lasts in few weeks if infected
cells clears, other wise last for years if not
clear infected cells.

31. Stage III: Viral clearance:
• Known as seroconversion because body
produce anti-body against surface antigen “e”
of the HBV.
• In this phase HBV stop reproducing it self.
• In the host can target the infected hepatocytes
and the HBV Viral replication no longer occurs.
• HBeAb can be detected.
• The HBV DNA levels are lower or undetectable,
and aminotransferase levels are within the
reference range.
• HBsAg still is present.

32. Stage IV: Immunity to Hepatitis-B
• When full antibody is produced and clear HBV
from body.
• Hepatitis-B genetic material (DNA) usually
disappears.
• Most of the individual develop life long
immunity and 10% enter in stage II & III again
and become chronic carrier.
• They infect others, and chronic liver damage.

34. Incubation
• Viral incubation ranges from 45-180
days.
• Symptoms begin an average of 90
days (range: 60–150 days) after
exposure to HBV.

35. C/F of Acute Hepatitis B
A. Symptoms:
1. Pre-icteric Phase/ prodromal stage: 3–9 days
- Lethargy, Chills, headache, malaise
- Anorexia, distaste, nausea, vomiting,
diarrhoea
- Upper abdominal pain
- Arthralgia, skin rashes and poly arthritis.
Examination: fever with relative bradycardia +
enlarged tender liver

36. 2. Icteric Phase: 2-4 w
• Increase Jaundice with decrease fever &
improvement of general condition
• Constitutional symptoms diminishes
• Dark- colored urine due to bilirubinuria
• Clay- colored urine due to cholestasis
• Loss of weight
• Pruritus as a result of elevated serum bile
acid/salt

37. 3. Post-icteric Phase (recovery phase)
• Disappearance of jaundice
• Urine and stool color become normal
• Appetite improve
• GI symptoms disappears
Complete recovery of liver may take up
to 6 months

38. B. Signs
• Jaundice
• Tender hepatomegaly
• Spleenomegaly (10%)
• Enlarged cervical lymph node

39. Symptoms of Chronic Hepatitis B
• Many people with chronic Hepatitis-B do not
have symptoms and do not know they are
infected.
• Even though a person has no symptoms, the
virus can still be detected in the blood.
• Symptoms of chronic Hepatitis-B can take up to
30 years to develop.
• Damage to the liver can silently occur during
this time. When symptoms do appear, they are
similar to acute infection and can be a sign of
advanced liver disease.

41. Diagnostic strategy
• History & Physical examination
• Jaundice
• RUQ tenderness +- Hepatomegaly
• Liver function tests
• HBs Ag in serum:
– Presence of HBsAg

43. The following tests are done to help diagnose
and monitor people with hepatitis B:
1. HBsAg: Hepatitis-B surface antigen. A positive result means you
have an active infection.
2. Anti-HBsAg: anti-body to surface antigen. No need Rx.
3. Anti-HBc: anti-body to core-antigen.
4. HBeAg: Hepatitis Be antigen- pre-core region of the HBV
genome.
5. Anti-HBeAg: anti-body to e-antigen.
6. Virological Markers: HBV DNA
7. Biochemical marker: alanine aminotransferase (ALT)
8. Histological markers: liver biopsy.

44. Patterns of Abnormal
• Elevations in ALT & AST only: suggests cellular
injury
• Elevations in Alk Phos & Bilirubin: suggests
cholestasis or obstruction.
• Mixed pattern: ALT, AST, AP & Bili: probably
the most common scenario

45. Patterns of Abnormal
• Consider degree of elevation: Very high ALT
and AST usually only come from a couple of
sources:
- Acute viral hepatitis (A,B,C)
- Acetominophen toxicity / overdose
- “Shock Liver”; cardiac or surgical event?

46. Management: Approach
1. Clinical suspension: S/S, jaundice etc
2. Serology (with HCV): HBsAg +ve -Repeat
3. Counselling: explain prognosis- Ca lung, HCV, HIV,
Cirrhosis, precautions
4. Stable patient: send viral load
5. HBe - +ve, = Acute infections
6. Liver biopsy: shows stage of liver damage
7. Rx: Lamivadine/Interferon + vitamins + symptomatic Rx
-Drugs: Increase dose to decrease viral load
- Duration: 6months to 2 years or life long, depends on viral load

47. Management
• No specific treatment
• Sever patient needs admission
• Bed rest
• Diet: ND with slight fat restriction, glucose &
fruit juice beneficial, anti-emetic, ORS
• Avoid: sedative & hypnotics if possible
• Educate patient about preventive measures
• Anti-viral drugs: if available

48. Management
Three main drugs:
1. Interferon: expensive, very effective
2. Lamivudine: less expensive, not very effective
3. Adefovir Dipivoxil
Newer drugs:
1. Entecavir
2. Telbivudine
3. Clevudine
4. Emtricitabine
5. Pegylated alpha interferon

49. Interferon alfa
• Had been mainstay for therapy
• Subcutaneous injection three times per week for 3
months or longer
• 30% of patients who could tolerated regime had a
successful response
– Seroconverted to HBe antibodies
– Normalization of LFTs
• Multiple side effects
– Fever, myalgia, thrombocytopenia, depression
• Contraindicated in very advanced liver disease

50. 9. HBV PEP: Exposure to diagnosed HB Pt.
exposed within 48 hours of the incident/
neonates whose mothers are HBsAg and
HBeAg positive.
Is previously vaccinated or not
= yes – 3 dose, complete
= Not sure/not complete: check for anti-
HBsAg
if anti-HBsAg Positive: no need vaccination

51. Post-exposure management
Post-exposure prophylaxis (PEP) involves
giving hepatitis B vaccine and possibly
immunoglobulin too if required.
– Immunoglobulin is given at a different site and it
does not reduce the immune response to the
vaccine.
– If the status of the source is unknown assume
infection.
– It should be given within 48 hours and certainly no
later than 7 days after exposure.
– On site: clean wound with soap-water

52. Prevention
• Universal/Standard Precautions: maintain
• Vaccination
- highly effective recombinant vaccines
• Hepatitis B Immunoglobulin (HBIG)
-exposed within 48 hours of the incident/ neonates
whose mothers are HBsAg and HBeAg positive.
• Other measures
-screening of blood donors, blood and body fluid
precautions.
Drinking alcohol can make your liver disease worse.

53. Universal Precautions:
The general Principles of Infection Prevention and
Control (STANDARD PRECAUTIONS) CDC guidelines:
Achieving optimum hand hygiene.
Using personal protective equipment.
Safe handling and disposal of sharps.
Managing blood & bodily fluids.
Decontaminating equipments.
Managing accidents.
Good communication.
Training / education.
Consider all the patients are infected: blood & body fluids

54. New CDC guideline
recommends frequent use of
alcohol-based handrubs
New recommendations are
shown on the following slides

55. When should you wash your
hands with soap and water?
Wash your hands with plain or antimicrobial soap
and water if :
• your hands are visibly soiled (dirty)
• hands are visibly contaminated with
blood or body fluids
• before eating
• after using the toilet

56. When should you use an
Alcohol Based Handrub ?
If hands are not soiled or contaminated with blood or
body fluids, use an alcohol-based handrub :
• before direct contact with patients
• after direct contact with a patient’s skin
• after having contact with body fluids, wounds or
broken skin
• after touching equipment or furniture near the
patient
• after removing gloves
• after handwash with soap and water

57. Tips on how to
wash your hands effectively
• Wet hands first with water – not hot
• Apply 3 to 5 ml of soap to hands
• Rub hands together for at least 15
seconds
• Cover all surfaces of the hands
and fingers
• Rinse with water and Dry
• Use paper towel to turn off tap

58. Tips on how to use an
alcohol handrub
• Take 1.5 to 3 ml of an alcohol gel / rinse in the palm
• Rub hands together x 10-15 seconds
• Cover all surfaces of your hands and fingers
• Include areas around / under fingernails
• Continue rubbing hands together until alcohol dries
It takes around 10 -15 seconds of rubbing
for the hands to dry

59. Some more tips on how to use
an alcohol-based handrub
• If after cleaning your hands 8 to 10 times with
an alcohol based handrub, you feel a “build-up”
of emollients on your hands, wash your hands
with soap and water
• After cleaning your hands with an alcohol based
handrub make sure the hands are totally dry
before putting on gloves.

60. Chemicals used in Hospital
– Chlorine (Boric acid power): 14 gm / lit.
– Cidex (glutraldehyde) – 2%
– Savlon: 1% ,2% ,5%
– Betadine: 2.5% , 5% , 7.5%
– Phenol (mob): 2%
– Formalin: 40%, (10% biopsy).
– Spirit – 70%
– Carbolic aid. 2%
– H2O2 = 30%

61. –Skin: spirit dry 2 min (Min 30 sec)
(contact period)
–Thermometer-clean - 70% alcohol.
–Cheattle forceps: autoclave and
dry.
–Blood stained linen: 1% sodi. Hyp. –
30 min.

62. Hepatitis B Vaccine
• Hepatitis B vaccine is the best protection.
• For adults, the Hepatitis B vaccine is given
as a series of 3 shots over a period of 6
months (0-30-180 days) (0-1-6 Months)
• The entire series is needed for long-term
protection.
• Booster doses are not currently
recommended.

63. VACCINE RECOMMENDATIONS
• Hepatitis B vaccine available since 1982
• Routine vaccination of 0-18 year olds
• Vaccination of risk groups of all ages
• As of December 2006, 164 countries vaccinate
infants against hepatitis B during national
immunization programmes - a major increase
compared with 31 countries in 1992, the year
that the World Health Assembly passed a
resolution to recommend global vaccination
against hepatitis B.

64. Complications of Hepatitis
1. Fibrosis
• scarring of the liver. The liver is damaged by
constant inflammation and creates the scar
tissue to repair itself. Unfortunately, this scar
tissue keeps the liver from working as it once
did. When the fibrosis becomes extensive, it
is called cirrhosis.

65. 2. Cirrhosis of the Liver
Extensive fibrosis is called cirrhosis. Hepatitis C and
alcoholic hepatitis are two very common causes of
cirrhosis, though there are many others.
3. Cancer of the Liver
Hepatocellular carcinoma is a type of cancer that affects
the liver cells.
4. Liver Failure
Liver failure is a serious, but uncommon, complication
of hepatitis
5. Glomerulonephritis
Glomerulonephritis is a complicated disorder of the
kidneys caused by inflammation and is seen in chronic
hepatitis B and hepatitis C infections.

66. 6. Cryoglobulinemia
Abnormal cluster of a kind of protein that
blocks small blood vessels leading to
circulation problems.
7. Hepatic Encephalopathy
Severe loss of liver function, such as liver
failure, can lead to inflammation in the brain
called encephalopathy. This causes mental
problems, like confusion, and can lead to
coma. Advanced hepatic encephalopathy is a
serious condition and is usually fatal.

67. 8. Portal Hypertension
One of the liver's important jobs is to filter blood.
However, cirrhosis and other problems can interfere
with the liver's portal circulation system. When this
portal system is blocked, blood can't return to the liver
from the digestive system and pressure increases,
called portal hypertension. This is a serious
complication and can be fatal.
9. Porphyria
Porphyria is a group of diseases caused by problems
processing important chemicals in the body called
porphyrins. One type, called porphyria cutanea tara,
leads to blistering of the hands and face and is a rare
complication of chronic hepatitis C infection.

68. 10. Viral Co-Infection
A person who is infected with both the
hepatitis B and the HIV viruses is said to have
a HBV/HIV Co-infection.
Approximately 10% of the HIV-infected
population worldwide is infected with
hepatitis B. This figure may approach 20% in
Southeast Asia, and 5% in North America and
Western Europe. ( I found 30% HB+ve)

70. Precautions
• Practice safe sex: use condoms during sex
• Do not share toothbrushes, razors or other
personal items
• Do not share needles, syringes or other
injecting equipment
• Do not donate blood, sperm, organs or any
other tissues
• Be careful about blood contact

71. Nursing Care Plan
The symptoms of acute hepatitis B infection
include:
• Loss of appetite
• Feeling tired
• Muscle and joint aches
• Low-grade fever
• Abdominal pain
• Yellowish discoloration of the skin
• Tea- or cola-colored urine

72. • Grayish or clay-colored stools: A few people
develop a severe form of hepatitis B known as
fulminant hepatitis.
• This form of the disease appears rapidly and
can cause death.
Its symptoms include:
• Mental confusion, hallucinations, or
extreme sleepiness
• Jaundice
• Noticeable swelling of the abdomen
• Sudden collapse

74. Hepatitis-B: Summary
• HBV: Blood, semen, saliva, vaginal
secretions
• Highly contagious; sexually transmitted
• 90-95% self limited over 6 months
• Chronic infection: >6 months
• Nurses must be careful about it:
vaccination and PEP is important

75. Thank you

76. Clinical outcomes of Hepatitis B infections
Figure 66-11. Clinical outcomes of acute hepatitis B infection. (Redrawn from White DO, Fenner F:
Medical virology, ed 3, New York, 1986, Academic Press
From Murray et. al., Medical Microbiology 5 th edition, 2005, Chapter 62, published by Mosby Philadelphia,,

77. Acute Hepatitis B Virus Infection with Recovery
Typical Serologic Course
Symptoms
HBeAg anti-HBe
Total anti-HBc
Titre
HBsAg IgM anti-HBc anti-HBs
0 4 8 12 16 20 24 28 32 36 52 100
Weeks after Exposure

78. Interferon therapy
Indication:
1. Detectable markers of HBV replication ALT >2
times
Dose:
• 5 MU(s/c) daily or10 MU(s/c) three times/ week
X16 wks
Contraindication:
• ALT normal or <2 times
• Immunocompromised
• Decompensated disease
• Childhood acquisition

79. Complications of interferon therapy
• Flulike syndrome
• Bone marrow suppression
• Emotional liability
• Autoimmune thyroiditis
• Alopecia
• Rashes

80. Lamivudine
• Dose:
• 100 mg OD X 12 month or till seroconversion
Hbe Ag sero conversion 16-20% at 1 year
Adefovir Dipivoxil
Dose:
• 10 mg OD X ≥48 wks
• Complication: Nephrotoxicity