The Silent Epidemic

More than 4 million Americans are infected with viral hepatitis.¹ Hepatitis B and hepatitis C are now more common than human immunodeficiency virus (HIV), and deaths from viral hepatitis outnumber those caused by HIV.¹ Unfortunately, many Americans are unaware they are infected. It is estimated that 30% of those with hepatitis B infection and 75% of those with hepatitis C infection^1,2

WHAT IS HEPATITIS?

Hepatitis is an inflammation of the liver, which can be caused by a viral infection, as well as alcohol abuse, use of specific drugs, certain diseases, and some toxins. The most common viruses in the hepatitis family are A, B, and C.

Hepatitis A is an acute infection of the intestines that is typically cured with basic treatment. Hepatitis B virus (HBV) and hepatitis C virus (HCV) are bloodborne, acute infections but they can remain viable in the body, causing longterm health problems. Vaccines are available to prevent hepatitis A and HBV.³ Post-exposure prophylaxis is also available for HBV.

Chronic HBV infection affects between 800,000 and 1.4 million people in the United States.³ However, since the introduction of the HBV vaccine in 1982, the rate of new acute HBV cases has significantly declined.³ While acute HBV has specific symptoms, such as fever, fatigue, and vomiting, chronic HBV infection can remain asymptomatic for up to 20 years.³ Approximately one-quarter of those infected with chronic HBV will develop cirrhosis or liver cancer.³ Chronic HBV can be treated with antiviral drugs, which may reduce the virus’ ability to damage the liver.

The incidence of HCV is growing rapidly and chronic infection has serious health consequences, including death. A twofold increase in deaths related to HCV infection is expected by 2019.² Most people infected with acute HCV go on to develop chronic infection. Although acute hepatitis infection may produce flu-like symptoms 6 weeks to 7 weeks after exposure, many people with hepatitis C infection never present with any symptoms.⁴ Chronic infection typically lasts a lifetime and causes chronic liver disease, cirrhosis, and liver cancer. It is the most common cause of liver transplantation in the US.⁴  Chronic HCV infection is treated with antiviral drugs. The federal Food and Drug Administration has approved two new drugs—Victrelis and Incivek—for the treatment of HCV. The new drugs can be added to standard antiviral drug regimens and are designed to reduce the ability of HCV to replicate, creating a sustained viral response against the virus.⁵ Research has shown that the drugs increased the creation of a sustained viral response, which doesn’t eliminate the virus completely, but significantly reduces the likelihood that complications from the virus will ensue among patients who had not received treatment for HCV by 23% to 75%.⁵

DENTAL IMPLICATIONS

Individuals at risk of HBV or HCV infection should be tested (Table 1 provides a list of risk factors).^1,3,4,6,7 Because so many Americans with HCV are baby boomers (born between 1945 and 1965), the US Centers for Disease Control and Prevention is considering recommending one-time testing for this population. Educating patients about the risks of viral hepatitis infection and encouraging testing, if appropriate, can help prevent damage from undiagnosed, untreated infection. Dental professionals not protected from HBV by immunization

or past infection who are involved in an occupational exposure should be tested for HBV by a qualified health care provider. The CDC also recommends that all health care providers receive the HBV vaccination and have a titer test 2 months to 3 months after completing the three-dose series to ensure they are protected. If the source patient has HCV, then a qualified health care provider should perform appropriate testing and determine the need for treatment and follow-up care, depending on seroconversion. Following standard infection control procedures is the key to limiting the risk of HBV and HCV exposure in the dental setting. Special precautions for treating patients with viral hepatitis infection are not required.

CONCLUSION

Viral hepatitis infection poses a significant public health threat. Dental hygienists can contribute to the solution by educating their patients about hepatitis infection and recommending testing if necessary. Preventing transmission in the dental practice is also part of the solution. By remaining vigilant in all infection control protocols, including the wearing of personal protective equipment, adequate barrier protection and surface disinfection, and appropriate sterilization processes and monitoring, the risk of hepatitis virus transmission is mitigated.

Table 1. Risk Factors for Viral Hepatitis^1,3,4,6,7

• Born outside of the United States,particularly Asia and Africa
• Born between 1945 and 1965
• Injection drug use (even one time)
• Recipients of blood transfusion or organdonation before 1992
• Received tattoo or body piercing withunsterile instruments
• Health care workers with needlestickinjuries
• Those with HIV infection
• Those undergoing hemodialysis
• Children of infected mothers
• Sexual contact with an infected person
• Men who have sexual contact with othermen
• Those with multiple sexual partners
• Blood contact with an infected person
• Sharing personal care items, such astoothbrushes and razors, with an infectedperson
• Travel to areas with high rates ofhepatitis infection

REFERENCES

1. Institute of Medicine. Hepatitis and liver cancer: a National Strategy for Prevention and control of Hepatitis B and C.Washington, DC: National Academies Press; 2010.
2. Rein DB, Wittenborn JS, Weinbaum CM, Sabin M, Smith BD, Lesesne SB. Forecasting the morbidity and mortality associated with prevalent cases of pre-cirrhotic chronic hepatitis C in theUnited States. Dig Liver Dis. 2011;43:66–72.
3. Centers for Disease Control and Prevention.Overview of hepatitis B. Available at:www.cdc.gov/hepatitis/B/bFAQ.htm. accessed April 26, 2012.
4. Centers for Disease Control and Prevention.Overview of hepatitis C. Available at:www.cdc.gov/hepatitis/C/index.htm. Accessed April 26, 2012.
5. Jesudian AB, Gambarin-Gelwan M, Jacobson IM.Advances in the treatment of hepatitis C virus infection. Gastroenterol Hepatol (NY).2012;8:91–101.
6. Weinbaum CM, Williams I, Mast EE, et al.Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep.2008;57(RR-8):1–20.
7. Armstrong GL, Wasley A, Simard EP, McQuillanGM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States,1999 through 2002. Ann Intern Med.2006;144:705–714.

From Dimensions of Dental Hygiene. May 2012; 10(5): 40, 42-43.