The ABCDE'S of Hepatitis
Did you know there are five types of hepatitis? Here is a valuable primer for the dental assistant about these viruses.
Why is it important to know about hepatitis in dental practice? Understanding the various kinds of hepatitis viruses and how they are transmitted can assist the dental team in providing proper care, as well as serve a reminder of the importance of using proper infection control. For example, the only reported case of patient-to-patient transmission of hepatitis B virus (HBV) that occurred in a dental office was linked to improper or incomplete removal of blood on patient items.1
In this rare case, a patient with no traditional risk factors for disease was reported by his or her physician to the state health department after being diagnosed with HBV. An epidemiologic investigation found that this patient had undergone oral surgery immediately after another patient who had also been reported to the health department with hepatitis B. Confirmation of the transmission of HBV from patient-to-patient was confirmed by molecular epidemiology in the laboratory. While the staff was vaccinated and always used standard infection control procedures, outbreak investigators concluded that the transmission of hepatitis B occurred through improper cleaning of blood on items used in the care of both patients.1
This case highlights the need for vigilance in using proper infection control procedures every time for every patient in the dental office, which has been emphasized since the very first Centers for Disease Control and Prevention (CDC) infection control guidelines were released in 1986.2 However, before the widespread use of routine dental infection control practices for each patient, the largest number of cases of hepatitis B transmitted from any healthcare worker to a patient was transmitted from an ungloved oral surgeon to 55 of his patients. This occurred before the HBV vaccination and glove use was standard operating procedure in dental practices.3 In another outbreak investigation, hepatitis B was transmitted to patients by an oral surgeon who had not been vaccinated against it.4
Today's infection control procedures require continued monitoring and quality assurance, along with adherence. It is critical that a comprehensive infection control plan is in place to ensure that infection control lapses do not occur. A review of these procedures can be found on the CDC's website under current infection control guidelines, which were last updated in 2003.3 A few key principles for how to process items used in dental patient care are outlined below.
These are basic principles for preventing HBV, along with other hepatitides and other infectious disease. Along with using new personal protective equipment such as gloves, masks, and eyewear for each patient visit, proper procedures for all of the items used in the patient visit are emphasized. Properly sterilizing and decontaminating instruments and other objects used in the visit is important for patient's, as well as the dental healthcare worker's safety. In general, classification of these items as shown in Table 1 is useful to determine how to properly process them after each patient visit.
Using these basic principles for assessing how to process dental items will prevent the transmission of HBV as well as other hepatitides. We know that HBV is one of the viruses of the hepatitides that is most readily transmitted by the smallest amount of blood or saliva containing blood. However, there are also other hepatitides that are important to understand, some of which are bloodborne and some of which are not. Hepatitis B represents the worst-case scenario for transmission, because only a tiny amount of blood can transmit this disease.
Most of these liver infections present with the classic common symptoms of fever, jaundice (yellowing of skin), and, sometimes, even yellow sclera of the eye. Each of the hepatitides has different risk factors and different modes of transmission.
What are the Hepatitides?
Generally, hepatitis A, B, C, D, and E are the hepatitides. While linked with a similar name, each are quite different. For hepatitis A, B, C, D, and E, each has a distinct virus that causes disease. Vaccination can protect against hepatitis A and B infection. However, there is no vaccination against hepatitis C, D, and E, further reinforcing the need to use standard infection control practices for every patient to protect you, your fellow staff members, and your patients.
In general, hepatitis means inflammation of the liver, as well as referring to a group of infections caused by different viruses that affect the liver. Nearly 80,000 new infections occur each year.5 About 1 million Americans are living with chronic hepatitis B infection.5 A total of 4.4 million Americans are estimated to be living with chronic hepatitis of any kind; the majority of them do not know that they are affected.5
The most common types are hepatitis A, hepatitis B, and hepatitis C, while hepatitis D and E are less common.5,6 The leading cause of liver cancer is viral hepatitis. Chronic liver infection occurs with hepatitis B and C, while hepatitis A, D and E may be transient.
What is Hepatitis A?
Hepatitis A is caused by infection with the hepatitis A virus (HAV). It is transmitted through a fecal–oral route, either from close personal contact with an infected person or from consuming contaminated water or food. Bloodborne transmission is rare, and transmission by saliva has not been shown. Hepatitis A does not result in chronic liver infection or disease. Relapse occurs in 10% to 15% of patients, usually within the first 6 months after initial infection.6
In the United States, nearly half of all reported HAV cases have no specific risk factor identified.5 Among adults with identified risk factors, the majority of cases are among men who have sex with other men, persons who use illegal drugs, and international travelers.5
Because transmission of HAV during sexual activity probably occurs because of fecal–oral contact, measures typically used to prevent the transmission of other STDs (eg, the use of condoms) do not prevent HAV transmission. In addition, efforts to promote good personal hygiene have not been successful in interrupting outbreaks of hepatitis A. Vaccination is the most effective means of preventing HAV transmission among persons at risk for infection. Hepatitis A vaccination is recommended for all children at age 1, for persons who are at increased risk for infection, for persons who are at increased risk for complications from hepatitis A, and for any person wishing to obtain immunity. Immunity is present with one initial dose and a follow-up dose at 5 to 8 years after the initial vaccination. This vaccine is recommended for international travelers, especially those to Asia.
What is Hepatitis B?
Hepatitis B is caused by HBV, a bloodborne virus, which is transmitted by percutaneous (ie, puncture through the skin) or mucosal contact with infectious blood or body fluids (eg, semen, saliva). Risks for Hepatitis B include:
- Unprotected sex
- Born to an infected mother
- Unsterilized tattoos or piercings
- An accidental needlestick from a needle that was used on an infected person
- Using a contaminated person's razor or toothbrush
- Sharing drug needles with an infected person
HBV is not spread through food or water, sharing eating utensils, breastfeeding, hugging, kissing, hand holding, coughing, or sneezing. HBV is extremely hardy, and can survive outside the body and still be capable of causing infection.5 Because it is bloodborne, it is a proven occupational hazard to dental healthcare workers.6-8 Standard precautions should be followed to prevent infection. While gloves are worn, any blood or dried blood should be cleaned and then disinfected using a 1:10 dilution of household bleach to water.
Hepatitis B has a variety of symptoms for active infection for up to 6 months. While infants and immunosuppressed persons do not have active symptoms, fever, nausea, extreme fatigue, and jaundice are common symptoms. Persons for whom HBV infection persists have chronic HBV infection, and a subset of these develop cirrhosis or liver cancers.5 The incubation period is very long—an average of 120 days and even 160 days after exposure.5,6 For acute infection, no medication is available; treatment is supportive.
For chronic infection, several antiviral drugs are available. Persons with chronic HBV infection require medical evaluation and regular monitoring to determine whether disease is progressing and to identify liver damage or cancer.
All dental assistants and all dental healthcare workers should be vaccinated against hepatitis B.7,8 Three doses of the vaccine and a booster about 10 years after the initial three doses is sufficient to produce immunity.
What is Hepatitis C?
Hepatitis C virus (HCV) causes hepatitis C, which is transmitted through contact with an infected person's blood. Common risk facts are similar to hepatitis B, such as:
- Unprotected sex
- Born to an infected mother
- Unsterilized tattoos or piercings
- An accidental needlestick from a needle that was used on an infected person
- Using a contaminated person's razor or toothbrush
Hepatitis C is diagnosed through blood tests of a confirmed positive test for HCV RNA or for antibody to HCV. These tests also show whether there is chronic hepatitis C or another type of hepatitis. Often, a liver biopsy is done if chronic hepatitis C is suspected. There is no vaccination against hepatitis C. Outbreaks have been traced to injecting syringes used on multiple patients in ambulatory healthcare or spa settings.5
Chronic hepatitis C is most often treated with the drug combination peginterferon and ribavirin, which attacks the hepatitis C virus. Treatment lasts from 24 to 48 weeks. If chronic infection does not resolve, a liver transplant may be necessary.
What is Hepatitis D?
Hepatitis D, is also known as delta hepatitis, is caused by infection with the hepatitis D virus (HDV) and is different from the other four hepatitis viruses. This type of hepatitis is relatively rare in the United States, and can be either acute with active symptoms, or chronic. Prior infection with HBV is necessary for the HDV to replicate, so infection occurs only among people who were previously infected with the HBV. Like hepatitis B, HDV is transmitted through percutaneous or mucosal contact with infectious blood. The virus is transmitted either by coinfection with HBV or as superinfection in people with HBV infection. There is no vaccine against hepatitis D, but vaccination against hepatitis B is effective at preventing hepatitis D infection.
What is Hepatitis E
Hepatitis E virus (HEV) causes hepatitis E and is the most recently discovered hepatitis. Like hepatitis A, it is transmitted by the fecal–oral route, from water or food that is contaminated by stool, or from the ingestion of raw or uncooked shellfish. Person-to-person transmission is uncommon. There is no evidence for sexual transmission or for transmission by blood transfusion.
Following a transient hepatitis, hepatitis E usually resolves and is followed by recovery. Generally, patients who report hepatitis E do not shed the virus after this initial illness and chronic liver infection does not occur. However, hepatitis E that occurs in pregnancy can be much more severe, with a mortality rate of 20%. No available therapy is capable of altering the course of acute infection.
Because cases of hepatitis E are not clinically distinguishable from other types of acute viral hepatitis, diagnosis is made by blood tests that detect elevated antibody levels of specific antibodies to hepatitis E. While studies to find a vaccine are ongoing, there are no commercially available vaccines exist for the prevention of hepatitis E, nor is there any remedy available for pre- or post-exposure prophylaxis.
Summary
Proper infection control will protect you and your patients from acquiring or transmitting hepatitis. Additional precautions are outlined by the CDC.7,8 Your practice's infection control manual should include: infection control guidelines; post-exposure prophylaxis procedures for a needlestick occurrence; vaccination records for all staff, and disinfection and sterilization processes for various equipment.
References
1. Redd JT, Baumbach J, Kohn W, et al. Patient-to-patient transmission of hepatitis B virus associated with oral surgery. J Infect Dis. 2007;195(9):1311-1314.
2. Scarlett MI, Bond W, Corbin SJ, et al. Recommended Infection Control Practices for Dentistry. MMWR Recomm Rep. 1986;35:237-242.
3. Rimland D, Parkin WE, Miller GB, Schrack WD. Hepatitis B outbreak traced to an oral surgeon. N Engl J Med. 1977;296(17):953-958.
4. Centers for Disease Control and Prevention. Outbreak of hepatitis B associated with an oral surgeon—New Hampshire. MMWR Morb Mortal Wkly Rep. 1987;36(9):132-133.
5. Centers for Disease Control and Prevention. Viral hepatitis facts. Available at: www.cdc.gov/hepatitis/. Accessed April 15, 2011.
6. Palenik CJ. Alphabet soup: The various hepatitis viruses. Contemporary Dental Assisting. Jan/Feb 2007;22-25.
7. Centers for Disease Control and Prevention. Recommended infection control practices for dentistry. MMWR. 1993;42(RR-8):33-47.
8. Sehulster L, Chinn RY, et al. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2003;52(RR-10):1-42.
Disclosure
Dr. Scarlett has received financial compensation from the Centers for Disease Control and Prevention.
About the Author
Margaret Scarlett, DMD
Scarlett Consulting International
Atlanta, Georgia
