Jarrod McMaugh takes a look at chronic viral hepatitis, the subtypes and stigma surrounding the conditions

Chronic Viral Hepatitis affects close to half a million Australians, and is responsible for approximately 1000 deaths per year. Despite the availability of new treatments, close to 80% of people living with chronic viral hepatitis are not engaged in care.

Pharmacists have a role to play in increasing awareness of the availability of treatments, and have a responsibility to understand how stigma and language can affect the experience of people living with a chronic condition.

Hepatitis – general features

Hepatitis is the term used to describe any condition that causes inflammation of the liver. This may be acute or chronic, and may be caused by infection or injury.

Viral hepatitis has five major subtypes. Hepatitis B and C the most common in Australia, and are responsible for chronic liver disease. Hepatitis A, which causes acute illness, is less common but may be associated with rapid transmission as it spread through contaminated food and water.

Other types of hepatitis that occur in Australia include damage caused by chronic alcohol use; non-alcohol related fatty liver disease, and damage caused by medications or poisoning.

Inflammation of the liver caused by hepatitis may lead to jaundice, acute liver failure, or chronic damage such as scarring, fibrosis, and cirrhosis. Chronic inflammation of the liver is a contributor to the incidence of liver cancer in Australia, and also contributes to the rate of liver transplants in Australia. People who live with a chronic viral infection may experience malaise and altered liver function for extended periods of time, contributing to significant impact on quality of life.

Hepatitis C

Hepatitis C is a blood-borne virus that has a number of genotypes that can lead to chronic infection – roughly 75% of people will not clear the virus. Breakthroughs in the treatment of hepatitis C in recent years have transformed the prognosis of this condition from a life-long infection to a condition that has a high potential for cure. Approximately 20% of people who have hepatitis C infection are not aware that they have the virus.

Despite the availability of these treatments, it is estimated that 80% of people who may benefit from treatment have not yet accessed treatment. While it is difficult to accurately describe what is influencing this low uptake, it could be due to stigma, or it may be that individuals are not aware that new treatments are available.

Individuals may also be expecting treatments to have unpleasant side effects – interferon has been used in the past to reduce viral load, and this treatment can cause symptoms similar to influenza throughout treatment. While new Direct Acting Antiviral medications do not have these side effects, perception can have a huge impact on uptake.

Hepatitis B

Hepatitis B is virus that can be transmitted via blood and body fluids. Vaccination for hepatitis B is part of the Australian vaccination schedule, although people who have emigrated to Australia may require catch-up vaccination.

Hepatitis B has a higher rate of clearance – i.e. the virus is cleared by the individual’s immune system, meaning they may not develop chronic infection. Despite this, chronic hepatitis B affects more people than chronic hepatitis C, and approximately 37% of people are unaware that they have a chronic hepatitis B infection.

Antiviral and interferon medications may help reduce viral load for individuals with chronic hepatitis B infection, but these are not curative.

Individuals who have chronic hepatitis B and C infections should be made aware that there has been a rare incidence of acute flare up of hepatitis B when using Direct Acting Antiviral medications to treat hepatitis C. This does not constitute a contraindication to treatment, but supportive measures may be required.

Stigma

For people who have a lived experience with chronic hepatitis infection, stigma can play a significant part of their experience with healthcare providers. Stigma can take many forms, with blame and fear being the most common, and the most damaging to an individual’s confidence in health care providers.

Pharmacists need to be mindful that providing care to an individual should not include any judgement of the individual. How a person came to have a chronic condition is not relevant to their treatment, and should not alter how this treatment is provided.

With the introduction of individually-controlled electronic health records, pharmacists will have greater visibility of an individual’s health record when providing services. While this information may assist the pharmacist to provide individualised care, this information should not alter the way they interact with people who may have a chronic condition such as hepatitis.

To ensure pharmacists are equipped to appropriately respond to greater access to health information about individuals, and to better understand the nature of chronic hepatitis, Hepatitis Victoria offers online training known as HepREADY. This course provides useful information on viral hepatitis, and also discusses the impact of stigma on an individual.

Jarrod McMaugh is a community pharmacy practitioner with Capital Chemist in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.