COUNSELLING OF PATIENTS WITH VIRAL HEPATITIS by G.Y. Minuk, MD and B.G. Rosser, MD
Problem
Counselling patients with hepatitis B or C viral infections is
often the most difficult aspect of patients management for a number
of reasons. firstly, the natural history of these disorders remains
unclear, particularly with respect to what percent and which
patients will progress to cirrhosis and/or hepatocellular
carcinoma. Secondly, patients often appear with preconceived
notions of their ultimate course based on lay press, radio, and
television accounts of the disease. thirdly, many patients will
have been seen by family practitioners who often counsel patients
based on their recollection of viral hepatitis as it was understood
during their medical school years, concepts that may not have
withstood the test of time. fourthly, the patient's level of
anxiety often impairs or even precludes their ability to understand
and retain much of what has been said. Finally, in a busy office
practice, time is a precious commodity, one that is often deemed
lacking when counselling is required.
Approach
Despite the above limitations, important, useful, and relevant
information can be transmitted to most patients within the final
three to five minutes of the patient visit. for consistency, it is
suggested that the following four aspects of the problem be
discussed:
1) the disease itself, 2) impact of the disease on the patient, 3)
transmission, and 4) family issues.
Counselling patients with hepatitis B or C viral infections is
often the most difficult aspect of patient management for a number
of reasons.
Table 1
Patient Counselling Topics
A. Disease itself
- prevalence
- natural history
- treatment
B. Impact of Disease on Patient
- daily activities
- exercise/rest
- food
- alcohol
- further investigations
C. Transmission
- general
- sexual/intimate
- children
- blood/organ donation
D. Family Screening
- indications
- explanations
The Disease itself
Having established the diagnosis, the first point to make with
the patient is that they are not alone. In the case of HCV, there
are 5 million cases worldwide! This point helps to reassure the
patient that they have not been 'struck by ightening' and avoids
the 'why me' response to the news. It also helps to reassure the
patient that with so many others dealing with the same problem,
presumably much research is being performed and eventually curative
treatment will be identified.
It is also important to emphasize that although the infection
typically lasts for decades, in the majority of cases, chronic HBV
and HCV do not result in a debilitating disease and/or early
mortality. for HBV, it would be reasonable to suggest that 60% of
HBV carriers live a full life and are largely unaware of their
infection other than by virtue of abnormal blood tests. The figure
for HCV carriers are at risk of developing cirrhosis (explained as
extensive scarring of the liver) and liver cancer, years or even
decades down the road. Once again, this information should be
quickly followed with the message that if the results of subsequent
testing suggest that the patient may belong to these high risk
groups, antiviral therapy (of a nonexperimental nature) is
available. The nature of the antiviral therapy, its efficacy and
side effects need not be dealt with at the time of the first visit
as it often remains to be determined whether patients require such
therapy and are candidates for treatment.
Impact of the Disease on the Patient
Many patients' principal concern is whether the disease will
negatively impact on their daily activities, including job
performance. Thus, it is important to state at the outset that very
rarely does chronic viral hepatitis interfere with an individual's
lifestyle or employment. Although fatigue is common in viral
hepatitis, it is difficult to correlate with disease activity
(especially with hepatitis C). correlations between liver tests,
liver histology and symptoms are poor. Cirrhotic patients may feel
fine while less severe degrees of HCV may be associated with sever
fatigue. In addition, fatigue rarely improves during interferon
therapy even despite virologic responses. In the absence of an
advanced state of liver disease, alternative explanations for
fatigue (including but not limited to depressive illness) are
warranted and are required prior to consideration of long-term
disability issues. It should also be mentioned that neither
prolonged bed rest nor strenuous exercise programs will affect the
natural history of the disease and therefore, patients should be
actively encouraged to maintain their normal level of activity.
A similar message should be offered with respect to diet. No
foods exacerbate or improve hepatitis and therefore, regular, well
balanced meals are all that need be recommended. the one
nutritional modification required is that related to alcohol
intake. Because alcohol in moderation is not thought to alter the
natural history of chronic HBV infections, nonalcoholics and
patients without cirrhosis could continue to consume alcohol as
they had previously, as long as that consumption was not excessive.
Drinking to the point of inebriation should be discouraged in all
HBV carriers. alcoholics and patients with cirrhosis should be told
to abstain completely from alcohol consumption. Because alcohol is
thought to enhance HCV viral activity and have an additive effect
on hepatocellular injury, alcohol consumption by HCV carriers
should be limited to no more than one drink/day and as in HBV,
completely avoided in alcoholics and patients with cirrhosis.
A brief outline of what is to transpire during the initial and
subsequent visits is also worth providing. The patient should be
told that on this visit they will have blood tests performed to
document the extent of hepatic inflammation (aminotransferase
values), level of hepatic function (albumin, bilirubin and
prothrombin times), and in the case of HBV, viral activity (HBeAg
and/or HBV-DNA level). Depending on the patient's presentation,
perhaps additional tests to exclude coexisting liver disorders and
systemic infections (such as with HIV) and potential
contraindications to antiviral therapy will need to be performed.
the actual explanation of which liver tests reflect which issue
should be delayed for subsequent visits when a review of what
aminotransferase values, liver function tests, alpha fetoprotein
testing, and viral serology might be better received and retained.
However, the initial visit is the most appropriate time to explain
to patients that hepatitis merely refers to inflammation of the
liver in the same way that arthritis reflects inflamed joints,
tonsilitis is a name for inflamed tonsils, and etc. In their
particular instance, the hepatitis (or inflammation of their liver)
is a result of a viral infection whereas in others, the hepatitis
may be the result of alcohol abuse, drug toxicity, immunologic
disorders, and etc. As mentioned earlier, cirrhosis of the liver
might be best described as extensive scarring of the liver
resulting from prolonged and severe hepatitis. If it is the
physician's practice to arrange for an ultrasound examination of
thee abdomen some-time following the initial visit, the purpose of
this 'radar' examination of the liver can be explained in terms of
the need to ensure that the liver disease is not more advanced than
what the blood tests might indicate (no evidence of portal
hypertension), and in the case of patients suspected of having
cirrhosis, to document that there are no space-occupying lesions
present within the liver. the final aspect of counselling that
relates to the patient's own course is the possibility that a liver
biopsy may be required if the blood test results suggest there is
active inflammation and treatment would otherwise be appropriate.
once again, details regarding the biopsy procedure should be
delayed until the next visit when a clearer picture exists
regarding whether the procedure is warranted.
Transmission
Both HBV and HCV carriers should be instructed to dispose of
blood-soaked materials themselves and not pass the task on to
others. For example, if the patient has a nosebleed or cuts his or
herself shaving, the tissues used to control the bleeding should be
discarded by the patient. Open wounds should be covered and
instruments that may be contaminated by blood such as razor blades
and/or toothbrushes should be confined to the patient's own
personal use. There is no need to segregate eating utensils, cups,
bowls, etc. Reassure the HBV carrier that sexual/intimate contact
can be resumed once their partner has been provided with the
appropriate immunoprophylaxis (HBIG and vaccine). Until then,
condoms should be employed in mutually monogamous relationships,
and in all cases where additional sexual partners are involved. At
the present time, immunoprophylaxis or vaccination for HCV does not
exist and the rate of transmission by sexual contact is considered
sufficiently low that condoms are not advocated (within monogamous
relationships). The point can be made that recent estimates suggest
that the average couple having an average frequency of sexual
activity would have to reside together for in excess of 600 years
prior to the susceptible partner acquiring the HCV infection from
the index case. However, intercourse during menses and anal
intercourse should be discouraged to minimize the potential for
transmission. Reassurance is also appropriate for female HBV
carriers who are either pregnant or planning to have children. They
should be told that the risk of intrauterine transmission is low
(approximately 5-10%) and that immunoprophylaxis given at birth is
at least 95% effective in preventing postnatal transmission. As a
result, breast feeding and other intimate contact between mother
and child should be encouraged where appropriate. Female HCV
carriers have an even lower risk of maternal-infant transmission
(less than 5%) and those infants who are infected may not develop
chronic liver disease as frequently as do adults although only
preliminary data exist on this particular issue. Details regarding
testing of the newborn for HBV and HCV infection can be delayed to
subsequent appointments when the carrier is either pregnant or
planning a pregnancy. finally, both HBV and HCV carriers should be
told not to donate blood. Organ donations from HBV carriers are not
permitted but certain centres will accept organ donations from HCV
carriers.
Many patients' principal concern is whether the disease will
negatively impact on their daily activities, including job
performance.
Family Issues
Having established the diagnosis of either a chronic HBV or HCV
infection, the patient should be told that it is important for
other members of the household (in the case of HBV), and where
appropriate, individuals who had shared intravenous drugs
(regardless of the equipment used/shared and whether the index case
is an HBV or HCV carrier) and sexual contacts of HBV carriers be
notified and encouraged to see their family physicians regarding
further testing. Such revelations can often cause family and
interpersonal upheaval and it is therefore important to stress to
the patient that there are a number of means by which an individual
can acquire viral hepatitis and in a significant percent ( 15-40% )
no clear source can be identified. This allows the patient to
select their own explanation as to how they might have acquired the
infection when speaking to their spouse, partners, family members,
etc., without having to divulge previously unknown high-risk
activities and dispel preconceived notions held by those
individuals.
Summary
In summary, counselling patients with chronic viral hepatitis B
or C infections can be a difficult and awkward aspect of patient
management. For that reason, it is often help to fill the void, a
clear, concise, and frank account of the issues involved (disease,
patient, prevention, and family) delivered in a caring and
compassionate manner can go a long way to enlisting the trust and
confidence of the patient for what is often the more difficult
times that lie ahead.
Source: http://www.hepnet.com/update10.html
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