Hepatitis B

1. Aetiology and Pathophysiology

The Causative Agent

• The Virus: Hepatitis B is caused by the Hepatitis B Virus (HBV).
• Virus Family: It belongs to the Hepadnaviridae family.
• Virus Type: Unlike Hepatitis A or C, Hepatitis B is a DNA virus (it contains double-stranded DNA).
• Resilience: The virus is extremely tough. It can survive outside the body on dry surfaces (like tables, medical instruments, or dried blood spots) for at least 7 days and remain highly infectious.

How the Virus Damages the Liver (Pathophysiology)

Interestingly, the Hepatitis B virus itself does not directly kill the liver cells (hepatocytes). Instead, the damage is immune-mediated:

• The virus enters the bloodstream and travels straight to the liver, where it enters the liver cells and begins to multiply.
• The body's immune system (specifically cytotoxic T-lymphocytes) recognizes that the liver cells are infected.
• In an attempt to destroy the virus, the immune system aggressively attacks and destroys its own infected liver cells.
• This massive immune attack causes severe inflammation of the liver (Hepatitis), leading to swelling, tissue death (necrosis), and the leaking of liver enzymes (ALT and AST) into the blood.

2. Modes of Transmission (How It Spreads)

Hepatitis B is highly contagious—it is 50 to 100 times more infectious than HIV. It is transmitted when blood, semen, or other body fluids from a person infected with the virus enter the body of someone who is not infected.

• Vertical Transmission (Mother-to-Child): This is the most common route of infection in highly endemic areas like Uganda. It mostly happens during childbirth when the baby is exposed to the mother's infected blood and vaginal fluids in the birth canal.
• Horizontal Transmission (Early Childhood): Spreading from an infected child to an uninfected child during the first 5 years of life (through minor cuts, bites, or sharing toothbrushes/chewed food).
• Sexual Contact: Unprotected sexual intercourse (vaginal, anal, or oral) with an infected partner. The virus is heavily present in semen and vaginal secretions.
• Contaminated Needles and Syringes: Sharing injecting equipment (common among drug users), or accidental needle-stick injuries among nurses and midwives.
• Medical and Traditional Procedures: Receiving unsafe blood transfusions, using unsterilized surgical or dental equipment, traditional scarification, tribal mark cutting, or sharing unsterilized razor blades.
• Sharing Personal Items: Sharing items that may carry microscopic drops of blood, such as shaving razors, nail clippers, or toothbrushes.

Note: Hepatitis B is NOT spread through breastfeeding, sharing eating utensils, hugging, kissing, holding hands, coughing, sneezing, or through contaminated food or water.

3. Clinical Features and Stages

The incubation period (the time from infection to the appearance of symptoms) ranges from 60 to 150 days (average is 90 days). The clinical presentation occurs in distinct phases:

1. Prodromal Phase (Pre-Icteric Phase)

This is the early stage before jaundice appears. Symptoms are vague and look like a bad flu or malaria:

• Low-grade fever.
• Severe fatigue, weakness, and general body aches (malaise).
• Loss of appetite (anorexia), nausea, and vomiting.
• Mild pain in the upper right side of the abdomen (where the liver is located).
• Joint pains (arthralgia) and skin rashes.

2. Icteric Phase (The Jaundice Stage)

This phase begins 1 to 2 weeks after the early symptoms. The liver is now actively inflamed and failing to clear waste from the blood.

• Jaundice: Yellowing of the eyes (sclera) and the skin due to high levels of bilirubin in the blood.
• Dark Urine: The urine becomes the color of dark tea or Coca-Cola because excess bilirubin is being passed out through the kidneys.
• Pale Stools: The stool becomes very light, clay-colored, or white because bile is blocked from reaching the intestines.
• Hepatomegaly: The liver becomes swollen, enlarged, and very tender to touch.
• Extreme itching of the skin (pruritus) due to bile salts accumulating under the skin.

3. Convalescent Phase (Recovery)

• The jaundice slowly fades away, and the dark urine clears up.
• Appetite returns, and the patient slowly regains energy.
• Complete recovery in healthy adults usually takes 3 to 6 months. In about 90% of healthy adults, the immune system successfully clears the virus, giving them lifelong immunity.

4. Chronic Hepatitis B

• If the body fails to clear the virus after 6 months, the infection becomes chronic (lifelong).
• Chronic infection is very common in infants (90% of infected babies become chronic carriers) but rare in adults (only 5% become chronic).
• Chronic carriers often have no symptoms for decades, but they slowly develop liver scarring (cirrhosis) and are at massive risk of liver cancer.

4. Diagnostic Investigations (Hep B Serology)

Diagnosing Hepatitis B relies heavily on blood tests to look for viral proteins (antigens) and the body's immune defense proteins (antibodies).

Other Supportive Investigations

• Liver Function Tests (LFTs): Blood tests to check the levels of liver enzymes (ALT and AST). Very high levels show that the liver cells are currently being destroyed.
• Abdominal Ultrasound Scan: Done to check the physical size of the liver, look for severe scarring (cirrhosis), or spot early signs of liver cancer tumors.

5. Hepatitis B in Pregnancy & Midwifery Management

Effect of Pregnancy on Hepatitis B

• Pregnancy generally does not make a chronic Hepatitis B infection worse.
• However, acute Hepatitis B acquired late in the third trimester can sometimes be severe and increase the risk of maternal death.

Effect of Hepatitis B on Pregnancy

• High risk of premature labor (preterm birth).
• Low birth weight babies.
• Gestational diabetes risk is slightly elevated.
• High risk of severe bleeding during delivery because a damaged liver cannot produce enough blood-clotting factors (like Fibrinogen).

Midwifery Care & Delivery Management

• Antenatal Care: Every single pregnant woman MUST be screened for HBsAg during her first ANC visit.
• Antiviral Therapy in Pregnancy: If the mother's viral load (HBV DNA) is very high, the doctor will start her on Tenofovir (TDF) in the 3rd trimester (usually at 28 weeks). Tenofovir is highly effective and completely safe for the baby. It lowers the viral load to prevent transmission during birth.
• Conducting the Delivery:
  • Strict Infection Prevention and Control (IPC) must be maintained. The midwife must wear double gloves, goggles, and an apron to prevent accidental blood splashes.
  • Avoid unnecessary traumatic procedures that mix mother and baby's blood (e.g., avoid routine episiotomies, avoid artificial rupture of membranes, and avoid vacuum extractions unless absolutely necessary).
• Immediate Newborn Care (The First 12 Hours):
  • Immediate Washing: Carefully wipe and wash off all maternal blood and vaginal fluids from the newborn's skin immediately before giving any injections.
  • Birth Dose Vaccine: Administer the single-antigen Hepatitis B birth dose vaccine within 12 to 24 hours of birth.
  • HBIG Administration: Give Hepatitis B Immune Globulin (HBIG) along with the vaccine (in the opposite thigh) within 12 hours. HBIG provides instant, ready-made antibodies to fight off any virus that entered during birth.
• Breastfeeding: Breastfeeding is 100% encouraged and perfectly safe as long as the baby receives the birth dose vaccine and HBIG. The mother must ensure she has no cracked, bleeding nipples.

6. Medical Management and Treatment

Acute Hepatitis B

There is no specific cure or strong medicine for acute Hepatitis B. Care is strictly supportive:

• Strict bed rest to reduce the liver's workload.
• Encourage plenty of oral fluids and fresh fruit juices to provide energy and prevent dehydration from vomiting.
• Provide a high-carbohydrate, low-fat, and moderate-protein diet. (The liver struggles to digest heavy fats).
• Avoid all alcohol completely, as it acts as a direct poison to the already damaged liver.
• Strictly avoid drugs that are processed by the liver (hepatotoxic drugs), such as heavy doses of Paracetamol.

Chronic Hepatitis B

If the infection lasts more than 6 months, the patient needs long-term suppression of the virus.

• Antiviral Medications: The goal is to completely suppress the virus from multiplying, though it rarely cures it completely. The two most effective, once-daily oral pills used globally and in Uganda are Tenofovir (TDF) and Entecavir.
• Interferon : Interferon alfa-2b is a synthetic version of a protein that the body naturally produces. Injections of interferon alfa-2b are given to suppress the growth of the HBV virus in the body. It can also help to reduce the intensity of liver damage.
• Liver transplant: If liver damage has advanced significantly, you or your loved one may need to undergo a liver transplant. This surgical procedure removes the damaged liver and replaces it with a healthy one from either a living or deceased donor. As the liver can regenerate slowly, it is possible to use a part of a healthy liver for the transplant. An unfortunate side effect of a transplant is that the receiver will need to take anti-rejection drugs for as long as they live.
• Regular Monitoring: Chronic patients must undergo an ultrasound scan every 6 months to catch early signs of liver cancer.

7. Severe Complications of Hepatitis B

If chronic Hepatitis B is left unmonitored and untreated, the constant immune attacks on the liver lead to devastating consequences:

• Liver Cirrhosis: The healthy, soft liver tissue is completely replaced by hard, useless scar tissue. The liver shrinks and stops working.
• Hepatocellular Carcinoma (HCC): Primary liver cancer. Hepatitis B is one of the leading causes of cancer deaths worldwide.
• Fulminant Hepatitis: A rare but deadly acute complication where the liver completely shuts down (acute liver failure) within days of infection, leading to a deep coma and death.
• Portal Hypertension: Because the scarred liver blocks blood flow, pressure builds up in the abdominal veins, causing massive fluid buildup in the belly (ascites) and swollen, bleeding veins in the throat (esophageal varices).

8. General Prevention and Immunization

1. Universal Vaccination

The Hepatitis B vaccine is highly effective (98-100% protection) and is the ultimate way to prevent the disease.

• Uganda EPI Schedule: The vaccine is combined into the Pentavalent vaccine (DPT-HepB-Hib). It is given to all infants at 6 weeks, 10 weeks, and 14 weeks of age.
• Healthcare Workers: Every midwife, nurse, and medical student MUST receive the full 3-dose series of the adult Hepatitis B vaccine (at 0, 1, and 6 months) to protect themselves from needle-stick injuries.

2. Post-Exposure Prophylaxis (PEP)

• If an unvaccinated midwife accidentally pricks her finger with a needle used on an HBsAg positive patient, she must immediately receive the Hepatitis B Immune Globulin (HBIG) injection within 24 hours, followed by the first dose of the Hepatitis B vaccine.

3. Standard Infection Control

• Always use strict Universal Precautions (gloves, aprons).
• Never recap used needles (this is the number one cause of needle-stick injuries). Dispose of them immediately in a puncture-proof sharps box.
• Properly sterilize all medical, surgical, and dental equipment.
• Ensure 100% safe screening of all donated blood before transfusions.
• Promote safe sex practices and the consistent use of condoms.