Prepared by: Hanan F. Khalaf, RPH
What is hepatitis C?
Hepatitis C is an inflammation of the liver that is caused by a virus called hepatitis C virus HCV, a type of ribonucleic acid (RNA) viruses that was discovered in 1989 by investigators at Chiron, Inc. Before 1989, this type of hepatitis was called non-A, non-B hepatitis, meaning that it was not caused by the viruses that produce hepatitis A or hepatitis B (two other viruses that can cause hepatitis). Currently, there are 6 major types of HCV (genotypes) and there is a distinct distribution of genotypes in certain geographic regions around the world.
Why hepatitis C is of great health concern?
Globally, an estimated 170 million persons are chronically infected with HCV and 3 to 4 million persons are newly infected every year. Up to date, there is no way to protect ourselves against this virus except by practicing cautionary measures. There is no known vaccine against hepatitis C, unlike hepatitis A and B.
How is hepatitis C transmitted from one person to another?
Hepatitis C mainly spreads through exposure to contaminated blood. Documented methods of transfer include:
- Infected blood or blood products transfusion or solid organ transplantation from an infected source (currently, risk of hepatitis C transmission from blood transfusion dropped to 1 in 100,000).
- Sharing needles as with IV drug users (has been accused as major source of transmission).
- Long-term dialysis increases the chance.
- Healthcare workers exposed to needlesticks.
- Baby borne to hepatitis C positive mother (occurs in about 4 out of 100 infants born to HCV-infected mothers).
- Sexual relationship with an infected partner.
- Spread within a household can occur upon sharing of items contaminated with blood as razors and toothbrushes and others.
In around 10% of cases the cause of transmission is not identified.
Some other methods have been considered as possible ways e.g. body piercing, medical and dental work, and tattooing as they pose at least a theoretical risk of transmitting the virus. On the other hand, hepatitis C virus cannot be transmitted to others through casual contact such as sneezing, coughing, shaking hands, hugging, kissing, sharing eating utensils or drinking glasses, swimming in a pool, using public toilets or touching doorknobs.
Can the use of latex condoms protect against HCV transmission?
HCV has been isolated from semen, vaginal fluid, and saliva. Nevertheless, the chance for HCV transmission through sexual relationship in a life-time without any barrier is estimated to be 1-4%. It is thought that the proper and steady use of condoms can lower the chance of HCV transmission to a greater degree particularly for those with multiple partners, although its efficacy in preventing the transmission is unknown. The Centers for Disease Control and Prevention CDC has not recommended using a barrier technique (for example, condoms) for hepatitis C virus infected individuals in a long-term monogamous relationship.
Can HCV transmit through breastfeeding as it can during delivery?
There is no evidence that breast-feeding spreads HCV. However, HCV-positive mothers should consider abstaining from breast-feeding if their nipples are cracked or bleeding.
How long can HCV live outside the body and be able to transmit the infection?
It is estimated that HCV can survive on environmental surfaces at room temperature at least 16 hours, but no longer than 4 days, according to studies
What is the recommended method of cleaning contaminated environmental surfaces?
You should clean up any blood spills - including dried blood, which can still be infectious - using 1:10 dilution of one part household bleach to 10 parts of water for disinfecting the area. Use gloves when cleaning up any blood spills.
What are the consequences of such infection?
The way that hepatitis affects people is different for different people. Some are not affected (a small percentage) and will get rid of it within 2-6months. On the other hand, about 80% of newly infected patients progress to develop chronic infection (chronic inflammation of liver cells). Cirrhosis develops in about 10% to 20% of persons with chronic infection within 10-15 years, and liver cancer develops in 1% to 5% of persons with chronic infection over a period of 20 to 30 years.
What are the symptoms of hepatitis C infection?
Many patients (between 60-70%) who acquire hepatitis C infection have no symptoms, including those who develop chronic infection. In acute infection, however, the most common symptoms are fatigue, muscular aches, poor appetite, and low-grade fever. Rarely, yellowing of the skin and/or eyes (jaundice) also occurs. Those symptoms occur in around 25% of patients with acute infection. It usually takes 15-150 days for the symptoms to develop after exposure.
How can hepatitis C be diagnosed?
Several tests are available, each has specific indications, as initial diagnosis or follow up of treatment:
- Anti-HCV test: Test the presence of antibodies against hepatitis C, but does not distinguish among acute, chronic, and resolved hepatitis C virus infections because the anti-hepatitis C virus antibodies are in the blood in all three of these situations. It is important to know that these antibodies do not confer protection to the patient against acquiring hepatitis C virus. Rather, they only indicate exposure of the patient to the virus. Tests available are:
- EIA (enzyme immunoassay) or CIA (enhanced chemiluminescence immunoassay)
Test is usually done first, it detects the presence of antibodies to the virus, usually reported as "Positive" or "Negative". If the test is "Weak Positive", result should be confirmed by another type of test before reporting. This test is widely used for initial screaning.
- Recombinant immunoblot assay (RIBA): is an additional test to confirm the presence of antibodies to the virus.
2. Qualitative tests to detect the presence or absence of virus (HCV RNA), it is a more sensitive test than both anti-HCV antibodies and
quantitative tests, to confirm diagnosis, e.g. polymerase chain reaction (PCR), and branched DNA assay.
3. Quantitative tests to detect amount (titer) of virus (HCV RNA), mainly indicated to monitor response to treatment.
4. Viral Genotype: PCR assays of nucleic acid are used to determine genotype of the virus. This is important before starting treatment and to
follow the response. It is known that genotype 1 is less responsive to treatment than type 2&3.
Who is recommended for screening tests?
According to CDC, screening tests should be performed for the following:
1. persons who ever injected illegal drugs, including those who injected once or a few times many years ago.
2. persons who were treated for clotting problems with a blood product made before 1987 when more advanced methods for manufacturing the products were developed.
3. persons who were notified that they received blood from a donor who later tested positive for hepatitis C.
4. persons who received a blood transfusion or solid organ transplant before July 1992 when better testing of blood donors became available.
5. Long-term hemodialysis patients.
6. persons who have signs and symptoms of liver disease (e.g. abnormal liver enzyme tests).
7. healthcare workers after exposure (e.g. needle sticks or splashes to the eye) to HCV-positive blood on the job.
8. children borne to HCV positive women.
Moreover, the National Institutes of Health Consensus Development Conference recommends that persons with multiple sex partners or a history of sexually transmitted disease and those with long term steady sex partners of an hepatitis C virus positive person should be tested as well.
What treatment options are available for HCV patients?
The standard treatment consists of weekly injections of a drug called pegylated interferon alfa combined with twice-daily oral doses of ribavirin (Rebetol®) — a broad-spectrum antiviral agent. Two pegylated interferon medications are available, peginterferon alfa-2b (Peg-Intron®) and peginterferon alfa-2a (Pegasys®), both are equally effective. Combined antiviral treatment clears the virus in 40-80% of patients, depending on the viral genotype. Patients vary in their response to treatment so tend to have a sustained response, relapse, or non-response. The optimal one is sustained response which means absence of detectable hepatitis C virus RNA using the PCR assay 6 months after treatment is stopped. Treatment is generally very costly.
What is the duration of treatment?
Duration of treatment depends on viral genotype, so for genotype 1, a duration of 48weeks is recommended, while for genotype 2 & 3 a 24weeks duration is recommended. Treatment coursed might be repeated or modified depending whether there is a relapse or no-response.
What side effects are expected from antiviral treatment?
Side effects that occur commonly with interferon include: severe flu-like symptoms, irritability, depression, concentration and memory problems, skin irritation, fatigue and insomnia.
Ribavirin can cause a low red blood cell count (anemia), itchiness, nasal congestion, skin irritation, fatigue and birth defects.
Combined treatment may cause psychosis or suicidal ideation.
The use of combined therapy, is it suitable for all HCV positive patients?
There are a number of clinical situation where combined treatment is considered not applicable or even contraindicated, as severe depression, pregnancy, untreated thyroid disease, low red blood cell counts and autoimmune diseases.
Are all patients infected with HCV eligible for treatment?
The goal of treatment is to clear the virus from the blood, prevent complications of chronic HCV infection, normalize liver functions tests and improve the quality of life.
The NIH Consensus Development Conference recommends antiviral treatment for those patients who are at the greatest risk of developing cirrhosis. Such individuals have all of the following characteristics:
1. Detectable hepatitis C virus RNA.
2. A biopsy that indicates significant liver damage.
3. Persistently elevated levels of a liver enzyme called alanine aminotransferase (ALT) in blood.
Can HCV transmission be prevented?
The most effective means of preventing hepatitis C is to avoid contact with human blood.
Avoid sharing toothbrushes, razors or other items that might have blood on them.
Persons with high-risk drugs and sexual practices should seek counseling to reduce the risk of transmission.
Persons who acquire HCV infection should be vaccinated against Hepatitis B and A.