Hepatitis C – Overview, Risk Factors, and Prevention.

What is hepatitis C?

Hepatitis C or Hep C is a disease that causes inflammation and infection of the liver. This condition develops after being infected with the hepatitis C virus (HCV). Hepatitis C can be either acute or chronic. Unlike hepatitis A and B, there’s no vaccine for hep C, although efforts to create one continue. Hep C is highly contagious, which explains the high number of people with the disease.

Types of Hepatitis C

Hepatitis C is often described as “acute,” meaning a new infection or “chronic,” meaning lifelong infection.

• Acute hepatitis C occurs within the first 6 months after someone is exposed to the hep C virus. Hep C can be a short-term illness, but for most people, acute infection leads to chronic infection.
• Chronic hepatitis C can be a lifelong infection with the hep C virus if left untreated. Left untreated, chronic hep C can cause serious health problems, including liver damage, cirrhosis (scarring of the liver), liver cancer, and even death.

Pathophysiology

Hepatitis C virus (HCV) is a spherical, enveloped, single-stranded RNA virus belonging to the family Flaviviridae, genus Flavivirus. Lauer and Walker reported that HCV is closely related to hep G, dengue, and yellow fever viruses. HCV can produce at least 10 trillion new viral particles each day.

The HCV genome consists of a single, open reading frame and two untranslated, highly conserved regions, 5′-UTR and 3′-UTR, at both ends of the genome. The genome has approximately 9500 base pairs and encodes a single polyprotein of 3011 amino acids that are processed into 10 structural and regulatory proteins.

The natural targets of HCV are hepatocytes and, possibly, B lymphocytes. Viral clearance is associated with the development and persistence of strong virus-specific responses by cytotoxic T lymphocytes and helper T cells.

In most infected people, viremia persists and is accompanied by variable degrees of hepatic inflammation and fibrosis. Findings from studies suggest that at least 50% of hepatocytes may be infected with HCV in patients with chronic hepatitis C.

The proteolytic cleavage of the virus results in two structural envelope glycoproteins (E1 and E2) and a core protein. Two regions of the E2 protein, designated hypervariable regions 1 and 2, have an extremely high rate of mutation, believed to result from selective pressure by virus-specific antibodies. The envelope protein E2 also contains the binding site for CD-81, a tetraspanin receptor expressed on hepatocytes and B lymphocytes that acts as a receptor or coreceptor for HCV. HCV core protein is an important risk factor in the development of liver disease; it can modulate several signaling pathways affecting cell cycle regulation, cell growth promotion, cell proliferation, apoptosis, oxidative stress, and lipid metabolism.

How is hepatitis C spread?

Hepatitis C is usually spread when blood from a person infected with the hepatitis C virus enters the body of someone who is not infected. Today, most people become infected with the hepatitis C virus by sharing needles or other equipment to prepare or inject drugs. Before 1992, hepatitis C was also commonly spread through blood transfusions and organ transplants. After that, widespread screening of the blood supply in the United States virtually eliminated this source of infection.

People can become infected with the hepatitis C virus during such activities as:

• Sharing needles, syringes, or other equipment to prepare or inject drugs
• Needlestick injuries in health care settings
• Being born to a mother who has hepatitis C

Less commonly, a person can also get hepatitis C virus through

• Sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes
• Having sexual contact with a person infected with the hepatitis C virus
• Getting a tattoo or body piercing in an unregulated setting

Hepatitis C virus is not spread by sharing eating utensils, breastfeeding, hugging, kissing, holding hands, coughing, or sneezing. It is also not spread through food or water.

Risk factors of Hepatitis C

Your risk of hep C infection is increased if you:

• Are a health care worker who has been exposed to infected blood, which may happen if an infected needle pierces your skin
• Have ever injected or inhaled illicit drugs
• Have HIV
• Received a piercing or tattoo in an unclean environment using unsterile equipment
• Received a blood transfusion or organ transplant before 1992
• Received clotting factor concentrates before 1987
• Received hemodialysis treatments for a long period of time
• Were born to a woman with a hepatitis C infection
• Were ever in prison
• Were born between 1945 and 1965, the age group with the highest incidence of hepatitis C infection

Symptoms of Hepatitis C

Long-term infection with the hepa C virus is known as chronic hepa C. Chronic hepatitis C is usually a “silent” infection for many years until the virus damages the liver enough to cause the signs and symptoms of liver disease.

Signs and symptoms include:

• Bleeding easily
• Bruising easily
• Fatigue
• Poor appetite
• Yellow discoloration of the skin and eyes (jaundice)
• Dark-colored urine
• Itchy skin
• Fluid buildup in your abdomen (ascites)
• Swelling in your legs
• Weight loss
• Confusion, drowsiness and slurred speech (hepatic encephalopathy)
• Spiderlike blood vessels on your skin (spider angiomas)

Every chronic hepatitis C infection starts with an acute phase. Acute hepatitis C usually goes undiagnosed because it rarely causes symptoms. When signs and symptoms are present, they may include jaundice, along with fatigue, nausea, fever and muscle aches. Acute symptoms appear one to three months after exposure to the virus and the last two weeks to three months.

Acute hepatitis C infection doesn’t always become chronic. Some people clear HCV from their bodies after the acute phase, an outcome is known as spontaneous viral clearance. In studies of people diagnosed with acute HCV, rates of spontaneous viral clearance have varied from 15% to 25%. Acute hepatitis C also responds well to antiviral therapy.

What are the complications of hepatitis C?

Without treatment, hep C may lead to cirrhosis, liver failure, and liver cancer. Early diagnosis and treatment of hep C can prevent these complications.

Cirrhosis

Cirrhosis is a condition in which the liver slowly breaks down and is unable to function normally. Scar tissue replaces healthy liver tissue and partially blocks the flow of blood through the liver. In the early stages of cirrhosis, the liver continues to function. However, as cirrhosis gets worse, the liver begins to fail.

Liver failure

Also called end-stage liver disease, liver failure progresses over months, years, or even decades. With end-stage liver disease, the liver can no longer perform important functions or replace damaged cells.

Liver cancer

Having chronic hepatitis C increases your chance of developing liver cancer. If chronic hepatitis C causes severe liver damage or cirrhosis before you receive hep C treatment, you will continue to have an increased chance of liver cancer even after treatment. Your doctor may order an ultrasound NIH external link test to check for liver cancer. Finding cancer at an early stage improves the chance of curing cancer.

Diagnosis and Test

Who should get tested?

You should consider getting tested for hep C if you’re worried you could have been infected or you fall into one of the groups at an increased risk of being infected.

Hep C often has no symptoms, so you may still be infected if you feel healthy.

The following groups of people are at an increased risk of hep C:

• Ex-drug users and current drug users, particularly users of injected drugs
• People in the UK who received blood transfusions before September 1991
• UK recipients of organ or tissue transplants before 1992
• People who have lived or had medical treatment in an area where hep C is common – high-risk areas include North Africa, the Middle East, and Central and East Asia
• Babies and children whose mothers have hep C
• Anyone accidentally exposed to the virus, such as health workers
• People who have received a tattoo or piercing where equipment may not have been properly sterilized
• Sexual partners of people with hep C

If you continue to engage in high-risk activities, such as injecting drugs frequently, regular testing may be recommended. Your doctor will be able to advise you about this.

Testing for hepatitis C

Hepatitis C is usually diagnosed using 2 blood tests: the antibody test and the PCR test. The results usually come back within 2 weeks.

The antibody test

• The antibody blood test determines whether you have ever been exposed to the hep C virus by testing for the presence of antibodies to the virus. Antibodies are produced by your immune system to fight germs.
• The test will not show a positive reaction for some months after infection because your body takes time to make these antibodies.
• If the test is negative, but you have symptoms or you may have been exposed to hep C, you may be advised to have the test again.
• A positive test indicates that you have been infected at some stage. It doesn’t necessarily mean you are currently infected, as you may have since cleared the virus from your body.
• The only way to tell if you are currently infected is to have a second blood test, called a PCR test.

The PCR test

• The PCR blood test checks if the virus is still present by detecting whether it is reproducing inside your body.
• A positive test means your body has not fought off the virus and the infection has progressed to a long-term (chronic) stage.

Further tests

If you have an active hepatitis C infection, you will be referred to a specialist for further tests to check if your liver has been damaged.

The tests you may have include:

• Blood tests – these measure certain enzymes and proteins in your bloodstream that indicate whether your liver is damaged or inflamed
• Ultrasound scans – where sound waves are used to test how stiff your liver is; stiffness suggests the liver is scarred

The specialist can also talk to you about any treatment you may need.

Treatment and medications

Who treats Hepatitis C?

If you think you are at risk of having Hepatitis C, talk to your current healthcare provider about getting tested.  Once you’ve been diagnosed with Hepatitis C infection, you may want to see a specialist.  Specialists who work with people with Hepatitis C include the following healthcare providers:

• The physician who specializes in liver diseases (hepatologist)
• A doctor who specializes in the stomach and intestinal diseases (gastroenterologist)
• Doctors who specialize in infectious disease
• Nurse practitioners whose practice concentrates on people with liver diseases

Nurse practitioners are registered nurses who are prepared – through advanced education and clinical training – to assume some of the duties formerly assumed only by physicians.  They work in a medical care team and can provide a wide range of health care services, including the diagnosis and management of common, as well as complex medical conditions.

Antiviral medications

Hepatitis C infection is treated with antiviral medications intended to clear the virus from your body. The goal of treatment is to have no hepatitis C virus detected in your body at least 12 weeks after you complete treatment.

Researchers have recently made significant advances in treatment for hepatitis C using new, “direct-acting” antiviral medications, sometimes in combination with existing ones. As a result, people experience better outcomes, fewer side effects and shorter treatment times — some as short as eight weeks. The choice of medications and length of treatment depends on the hepatitis C genotype, presence of existing liver damage, other medical conditions and prior treatments.

Due to the pace of research, recommendations for medications and treatment regimens are changing rapidly. It is, therefore, best to discuss your treatment options with a specialist.

Throughout treatment, your care team will monitor your response to medications.

Liver transplantation

If you have developed serious complications from chronic hepatitis C infection, liver transplantation may be an option. During liver transplantation, the surgeon removes your damaged liver and replaces it with a healthy liver. Most transplanted livers come from deceased donors, though a small number come from living donors who donate a portion of their livers.

In most cases, a liver transplant alone doesn’t cure hepatitis C. The infection is likely to return, requiring treatment with antiviral medication to prevent damage to the transplanted liver. Several studies have demonstrated that new, direct-acting antiviral medication regimens are effective at curing post-transplant hepatitis C. At the same time, treatment with direct-acting antivirals can be achieved in appropriately selected patients before liver transplantation.

Vaccinations

Although there is no vaccine for hep C, your doctor will likely recommend that you receive vaccines against hepatitis A and B viruses. These are separate viruses that also can cause liver damage and complicate the course of chronic hepatitis C.

Things you can do during treatment for hep C

There are some things you can do to help limit any damage to your liver and prevent the infection from spreading to others.

These can include:

• Eating a healthy, balanced diet
• Exercising regularly
• Cutting out alcohol or limiting how much you drink
• Stopping smoking
• Keeping personal items, such as toothbrushes or razors, for your own use
• Not sharing any needles or syringes with others

Prevention

Primary prevention

There is no effective vaccine against hep C, therefore prevention of HCV infection depends upon reducing the risk of exposure to the virus in health-care settings and in higher-risk populations, for example, people who inject drugs and men who have sex with men, particularly those infected with HIV or those who are taking pre-exposure prophylaxis against HIV.

The following list provides a limited example of primary prevention interventions recommended by WHO:

• Safe and appropriate use of health care injections;
• Safe handling and disposal of sharps and waste;
• Provision of comprehensive harm-reduction services to people who inject drugs including sterile injecting equipment and effective treatment of dependence;
• Testing of donated blood for HBV and HCV (as well as HIV and syphilis);
• Training of health personnel;
• Prevention of exposure to blood during sex;
• Hand hygiene, including surgical hand preparation, hand washing and use of gloves; and
• Promotion of correct and consistent use of condoms.

Secondary prevention

For people infected with the hep C virus, WHO recommends:

• Education and counseling on options for care and treatment;
• Immunization with the hep A and B vaccines to prevent coinfection from these hepatitis viruses and to protect their liver;
• Early and appropriate medical management including antiviral therapy; and
• Regular monitoring for early diagnosis of chronic liver disease.