Hepatitis is an inflammation of the liver caused by the hepatitis C virus (HCV). Symptoms can take many years to show up in a way that might cause a person to suspect he or she has hepatitis. The Centers for Disease Control Fact Sheet estimates that 80% of persons infected with HCV have no signs or symptoms.
According to the Centers for Disease Control fact sheet, an estimated 4.1 million (1.6%) Americans have been infected with HCV, of whom 3.2 million are chronically infected. The number of new infections per year has declined from an average of 240,000 in the 1980s to about 26,000 in 2004.
HCV is spread by direct contact with human blood in most of the same ways the AIDS Virus (HIV) is spread. However, much smaller amounts of blood are needed to pass HCV than to pass HIV. This makes HCV much "more infective."
Most infections are due to illegal injection drug use.
The Centers for Disease Control (CDC) says that HCV is NOT spread by sneezing, hugging, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact. Persons should not be excluded from work, school, play, child-care or other settings on the basis of their HCV infection status.
Documented routes of infection
- sharing drug injection needles (this includes drug preparation equipment that is shared) -- Simply sharing a container with a liquid drug preparation which several people use together to fill syringes is sufficient blood-to-blood contact to spread hepatitis C. Instances of transmission have been found from sharing drug "snorting" tubes. In these cases it is believed that there are small drops of blood passed from one person's raw and inflamed nostril to another.
- blood transfusions or tissue transplants before routine testing was instituted (this includes clotting factors and body organs) -- All blood donations are routinely tested for hepatitis C and have been since 1990. Today, the incidence of transmission from a blood transfusion is extremely rare (2 in 2 million).
- kidney dialysis -- Sometimes small amounts of blood have been transmitted between patients on dialysis.
- tattoos or body piercings from used and unsterilized needles
- health care settings -- via accidental needle sticks or handling blood or human tissuewithout adequate barrier protection
- sharing personal grooming items that carry blood (razors, toothbrushes, etc.)
- during birth from mother to fetus (The risk for perinatal HCV transmission is about 4%.)
- unprotected vaginal or anal sex -- According to the Centers for Disease Control, HCV can be transmitted by heterosexual or homosexual sexual activity, but the chances are "very low." The CDC advises that individuals with only one long-time sex partner do not need to change their sexual practices. Risk of infection increases with the number of partners, the existence of other sexually transmitted diseases, and during a woman's period. There is no evidence that HCV has ever been spread by oral sex.
Many individuals who have recently been found to carry hepatitis C cannot recall any risk factors, and do not know how they acquired the infection. Some of these individuals undoubtedly have used injection drugs, received injections as a child with non-disposable needles, had blood transfusions that they were unaware of during surgery, or were exposed to another person's blood in some way that they do not recall.
- If you shoot drugs, stop and get into a treatment program. If you can't stop, never reuse or share syringes, drug bottles, spoons, water, or works.
- Do not engage in activities that could expose you to someone's blood. Even very very small (unobservable) amounts of blood can transmit the virus (unlike with HIV).
- Use your own blood for transfusions whenever possible.
- You should get vaccinated against hepatitis A & B.
- You should use latex condoms correctly and every time you have intercourse -- although more for protection against AIDS and hepatitis B than hepatitis C. People with multiple sexual partners should always practice safe sex. Monogamous long-term partners should make an informed decision as to whether or not to change their sexual practices. The general consensus is that most monogamous couples do not need to change their sexual practices to avoid hepatitis C. Discuss this with your doctor.
Health care workers may be exposed to someone else's blood in the course of their work. Immediate treatment with medication can help prevent an accidental exposure from becoming an infection. The CDC has published guidelines for post-exposure prophylaxis: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm
There is no need to change daily family or personal routines simply because one member of a family has this infection. It is not necessary to use separate washrooms or eating utensils, for example. Nor is it appropriate to limit expressions of affection. Hug your children often.
Because of the way HCV mutates in the body, prior infection does not protect against re-infection with the same or different genotypes of the virus (unlike with hepatitis B). For this reason, there is no effective vaccine available.
- persons who ever injected illegal drugs, including those who injected once or a few times many years ago
- persons who were treated for clotting problems with a blood product made before 1987 (when more advanced methods for manufacturing the products were developed)
- persons who were notified that they received blood from a donor who later tested positive for hepatitis C
- persons who received a blood transfusion or solid organ transplant before July 1992 (when better testing of blood donors became available)
- long-term hemodialysis patients
- persons who have signs or symptoms of liver disease (e.g., abnormal liver enzyme tests)
- healthcare workers after exposures (e.g., needle sticks or splashes to the eye ) to HCV-positive blood on the job
- children born to HCV-positive women
- Do not donate blood, body organs, other tissue, or semen.
- Do not share personal items that might have your blood on them, such as toothbrushes, dental appliances, nail-grooming equipment or razors.
- Cover your cuts and skin sores to keep from spreading HCV.
- If you shoot drugs, stop and get into a treatment program. If you can't stop, never reuse or share syringes, drug bottles, spoons, water, or drug works.
- If you are a healthcare worker, always follow routine barrier precautions and safely handle needles and other sharps.
- 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. People should use gloves when cleaning up any blood spills
You might have flu-like symptoms right after being exposed. Most people who have these symptoms attribute them to the flu.:
- Feel tired. Persistent fatigue is often the first recognizable sign of hepatitis C
- Feel sick to your stomach.
- Have a fever.
- Not want to eat.
- Have stomach pain.
- Have diarrhea.
Some people have:
- Dark yellow urine.
- Light-colored stools.
- Yellowish eyes and skin.
What blood tests are there?
There are several blood tests that can be done to determine if you have been infected with HCV. Your doctor may order just one or a combination of these tests. The following are the types of tests your doctor may order and the purpose for each:
Anti-HCV (antibody to HCV) confirms the presence of the antibody but does not tell whether the infection is new (acute), chronic (long-term) or is no longer present. 9 out of 10 people test positive for the antibody within 3 months after symptoms begin.
EIA (enzyme immunoassay)...This test is usually done first. If positive, it should be confirmed
RIBA (recombinant immunoblot assay)...A supplemental test used to confirm a positive EIA test
Liver EnzymesPeople who are HCV+ will have their liver enzymes (e.g. ALT) checked by their doctors. Liver enzyme counts go up as an indication that the liver is in distress. Sometimes, the liver enzymes will be normal or may go up and down.
Viral Presence Tests - tell you if the virus is in your blood. These are qualitative tests to detect presence or absence of virus (HCV RNA). It is possible to find HCV within 1 to 2 weeks after being infected with the virus.
Generic polymerase chain reaction (PCR)
Viral Load Tests - tell you how much hepatitis C virus you have in your blood. These are quantitative tests to detect amount (titer) of virus (HCV RNA)
Amplicor HCV Monitor
Quantiplex HCV RNA (bDNA)
A false positive can happen (you test positive but you're not really positive). It is important to confirm a positive anti-HCV test with a supplemental test as most false positive anti-HCV tests are reported as negative on supplemental testing. This is done routinely.
A false negative can also happen (you test negative, but you really have the virus). Persons with early infection may not as yet have developed antibody levels high enough that the test can measure. In addition, some persons may lack the immune response necessary for the test to work well.
Children born to HCV+ mothers should not be tested for anti-HCV before 12 months of age as anti-HCV from the mother may last until this age. If testing is desired prior to 12 months of age, PCR could be performed at or after an infant's first well-child visit at age 1-2 months.
Genotype refers to the genetic make-up the virus. There are 6 known genotypes and more than 50 subtypes of HCV. Genotype 1 is the most common genotype seen in the United States.
Genotype information is helpful in the study of how the virus is spread. Knowing the genotype can help your doctor predict what drugs will work best and how long you should take them.
People with genotypes 2 and 3 are almost three times more likely than people with genotype 1 to respond to therapy with alpha interferon or the combination of alpha interferon and ribavirin. For patients with genotypes 2 and 3, a 24-week course of combination treatment is adequate, whereas for patients with genotype 1, a 48-week course is recommended.
For these reasons, testing for HCV genotype is often clinically helpful. Once the genotype is identified, it need not be tested again; genotypes do not change during the course of infection.
Your doctor may recommend that you have a liver biopsy to determine how badly your liver is damaged. Knowing the amount of liver damage will help you and your doctor to decide if and when to start treatment with medicine.
A liver biopsy is a procedure where the doctor uses a needle to remove a small "plug" of liver tissue so that it can be examined in the laboratory for the presence of permanent liver damage or cancer.
People who have had liver biopsies report varying degrees of discomfort with the procedure. You will be given a sedative to help you relax and a local painkiller. Occasionally there will be a small-to-moderate amount of pain afterwards. If you find that you are uncomfortable, your doctor will generally prescribe a light painkiller immediately after the biopsy. The pain may occur at a different place that the biopsy site, possibly in the pit of your stomach or in the right shoulder. The liver itself has no pain-sensing nerve fibers, but a small amount of blood in the abdominal cavity or up under the diaphragm can be irritating and painful. Very occasionally, small adhesions (scar tissue) may form at or near the biopsy site, and can cause a chronic pain that persists near the liver area after the biopsy.
Anti-HCV (the antibody to hepatitis C) can be found in 7-out-of-10 persons when symptoms begin, and in about 9-out-of-10 persons within 3 months after symptoms begin. However, it is important to note that many persons who have hepatitis C have no symptoms.
It is possible to find HCV within 1-to-2-weeks after being infected with the virus.
- Stop using alcohol.
- See your doctor regularly.
- Don't take any medicines without a physician's knowledge. This includes use of over-the-counter, herbal, and other medicines or vitamins.
- Get vaccinated against hepatitis A if liver damage is present.
- Take moderate exercise.
- Eat a healthy diet.
- Get plenty of rest.
- Get involved in a support group to help relieve emotional stress.
Of every 100 persons infected with HCV about:
- 85 persons may develop long-term infection (chronic hepatitis C). This means that they carry the virus in their bodies and can pass it on to others, usually for the rest of their lives,
- 70 persons may develop chronic liver disease,
- 15 persons may develop cirrhosis over a period of 20 to 30 years, and
- 5 persons may die from the consequences of long term infection (liver cancer, cirrhosis, or liver failure).
The disease appears to progress slowly, symptoms often do not appear for ten or twenty years.
A small percentage of persons with chronic hepatitis C develop medical conditions outside the liver (this is called extrahepatic). These conditions are thought to occur due to the body's natural immune system fighting against itself.
- Glomerulonephritis (kidney disease)
- essential mixed cryoglobulinemia
- porphyria cutanea tarda
Mutations (genetic changes in the virus during infection) result in changes that are not recognized by existing antibodies.
In other words, the virus changes faster than the body can learn to recognize it. This appears to be how the virus establishes and maintains long-lasting infection.
The riskiest time for the new baby to get HCV is while it is being born. About 4 out of every 100 infants born to HCV infected women become infected. This occurs at the time of birth, and there is no treatment that can prevent this from happening. The risk for babies born to mothers who also have HIV goes way up (to about 1-in-5 babies born to "co-infected" moms).
Most infants infected with HCV at the time of birth have no symptoms and do well during childhood. More studies are needed to find out if these children will have problems from the infection as they grow older. There are no licensed treatments or guidelines for the treatment of infants or children infected with HCV. Children with elevated ALT (liver enzyme) levels should be referred for evaluation to a specialist familiar with the management of children with HCV-related disease.
Should I breast feed if I have HCV?
There is no evidence that HVC is spread in breast milk. HCV-positive mothers should consider not breast-feeding if their nipples are cracked or bleeding.
A referral for consultation with a specialist for further evaluation and possible treatment may be considered if a person tests positive for the antibody and has elevated liver enzyme levels. Any physician who manages a person with hepatitis C should be knowledgeable and current on all aspects of the care of a person with hepatitis C.
Antiviral drugs such as interferon used alone or in combination with ribavirin, are approved for the treatment of persons with chronic hepatitis C. Interferon works in 10 to 20 persons out of 100 treated. Interferon combined with ribavirin works (on the viral strain that is mostly found in the U.S.) in about 30-40 persons out of 100. Ribavirin, when used alone, does not seem to work.
Liver transplant. Some people whose hepatitis C progresses to liver failure may be candidates for liver transplant.
As with any medical treatment the potential benefits must be weighed against the existence of side-effects. This is an important ongoing conversation that you must have with your doctor.
Side Effects of Interferon.
Most persons on Interferon have flu-like symptoms (fever, chills, headache, muscle and joint aches, fast heart rate) early in treatment, but these lessen with continued treatment, and can be reduced by taking acetaminophen before treatment.
Later side effects of Interferon may include
- hair loss
- low blood count
- trouble with thinking
Severe side effects of Interferon are rare (seen in less than 2 out of 100 persons). These include
- thyroid disease
- depression with suicidal thoughts
- acute heart or kidney failure
- eye and lung problems
- hearing loss
- blood infection
An important side effect of interferon is worsening of liver disease with treatment, which can be severe and even fatal.
Deaths have occurred (although rarely) due to liver failure or blood infection, mostly in persons with cirrhosis. Interferon dosage must be reduced in up to 40 out of 100 persons because of severity of side effects, and treatment must be stopped in up to 15 out of 100 persons. Pregnant women should not be treated with interferon. Some side effects may be reduced by giving interferon at night or lowering the dosage of the drug.
Side Effects of Ribavirin
People on ribavirin can have serious anemia (low red blood cell count) which can be a serious problem for persons with conditions that cause anemia, such as kidney failure. In these persons, combination therapy should be avoided or attempts should be made to correct the anemia. Anemia caused by ribavirin can be life-threatening for persons with certain types of heart or blood vessel disease. Ribavirin causes birth defects and pregnancy should be avoided during treatment. Patients and their healthcare providers should carefully review the product manufacturer information prior to treatment.