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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.


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.


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.


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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