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You are Here: Home Page > Strategic Plan > Viral Hepatitis Strategic Plan  

Viral Hepatitis Strategic Plan

Overview of Viral Hepatitis

Hepatitis C

Overview

Hepatitis C infection is caused by the hepatitis C virus (HCV). This virus accounts for much of what was known as non-A non-B hepatitis until 1989. Hepatitis C is the most common bloodborne infection in the U.S. Approximately 4 million (1.8%) persons in the U.S. have been infected with HCV, 2.7 million of them chronically infected. In 2001, the CDC estimated the number of new acute cases was 25,000, a decrease from 40,000 in 1998. Hepatitis C is the leading reason for liver transplant in the U.S. The estimated annual number of deaths from chronic liver disease associated with HCV is 8,000-10,000.

The NHANES III study found that 1.5% of whites, 3.2% of blacks and 2.1% of Mexicans were infected with hepatitis C.² According to the CDC, males aged 40-59 years have the highest prevalence of HCV infection.¹² Approximately 30% of those infected with HIV are co-infected with HCV.

Clinical Features

The incubation period for hepatitis C infection ranges from 14-180 days, with an average of 45 days. The majority of individuals infected with hepatitis C do not have symptoms. When symptoms are present, they include jaundice, fatigue, dark urine, abdominal pain, loss of appetite and nausea. Seventy-85% of those infected will become chronically infected. About 15-30% of patients exposed will clear the virus without treatment. Complications from HCV infection include cirrhosis and hepatocellular carcinoma. Five to 20% of individuals infected with HCV will develop cirrhosis as a complication of HCV infection.

Diagnosis

Detection of HCV antibody (anti-HCV)

Two main types of testing are available for the detection of the anti-HCV antibody: enzyme immunoassay (EIA) and recombinant immunoblot assay (RIBA). Although these tests are useful in detecting antibodies for hepatitis C virus, they do not distinguish between acute, chronic, or resolved infection. The EIA is used as a screening test to detect HCV antibody. It becomes positive 3-6 months after exposure, although some immunocompromised persons may be infected but not have antibody. There are false positive EIAs; therefore, a positive test must be confirmed by the RIBA, or, in high-risk groups, by proceeding directly to the PCR, which is required to differentiate acute or chronic infection from a past infection. To make a diagnosis of hepatitis C, the following laboratory criteria must be met: anti-HCV positive verified by a more specific assay (i.e., RIBA, polymerase chain reaction(PCR) ; or anti-HCV EIA positive with a signal to cut-off ratio predictive of a true positive as determined for the particular assay (e.g., >3.8 for the enzyme immunoassay). Furthermore, in order to distinguish an acute case of HCV infection from a chronic case, the individual must also have clinical symptoms and elevated liver function tests.

Detection of HCV RNA

Hepatitis C virus RNA becomes detectable one to two weeks after exposure. Confirmation of current HCV infection is determined by the presence of circulating HCV virus in the blood. In order to determine the presence or absence of HCV RNA circulating in the blood, HCV PCR testing must be conducted. PCR testing plays an important role in the monitoring of HCV treatment and is more useful in diagnosing acute infection after initial exposure (e.g., occupational exposure) since HCV virus is present 1-2 weeks after initial exposure and HCV antibodies are not present until 8-9 weeks after exposure.

There are two types of PCR testing, qualitative and quantitative. Qualitative PCR determines the presence or absence of circulating virus. Quantitative PCR determines the actual number of viral particles circulating and is used to determine the likelihood of response to treatment. PCR testing has its limitations. It is unable to detect viral loads below certain values, and therefore may elicit a false negative test result. Thus, it is recommended that repeat testing be conducted a few months after an initial negative result.

Transmission

Hepatitis C is a bloodborne pathogen and is transmitted primarily by percutaneous exposure to blood. Injection drug use currently accounts for most HCV transmission in the U S. and has accounted for a substantial proportion of HCV infections in past decades. Other factors associated with transmission include receiving a transfusion or organ transplant before 1992, receiving long-term hemodialysis, or receiving clotting factor produced before 1987. HCV is less efficiently transmitted between sexual partners or from mother to infant. The estimated seroprevalence of HCV infection among long-term spouses of patients with chronic HCV is 1.5% . The average rate of HCV infection is 5% among infants born to HCV-positive women and 14% among infants born to women co-infected with HCV and human immunodeficiency virus (HIV).

At-Risk Groups

Persons at-risk for hepatitis C include:

• Intravenous drug users,
• Individuals who received a blood transfusion/organ donation prior to 1992,
• Individuals who received clotting factors before 1987, and
• Long-term hemodialysis patients.

Treatment

Individuals infected with hepatitis C should be evaluated by a specialist before beginning treatment. Not everyone is a candidate for treatment. According to the June 2002 National Institutes of Health (NIH) Consensus Statement, treatment of HCV is recommended for those with persistently elevated liver enzymes, detectable HCV RNA, and an abnormal liver biopsy.¹³ The primary goal of treatment is to achieve a sustained viral response defined as having no virus detected 6 months after treatment has stopped.

FDA-approved treatments for chronic hepatitis C are interferon, alone or in combination with ribavirin, and pegylated interferon, alone or in combination with ribavirin. The standard treatment for chronic HCV infection is pegylated inter feron plus ribavirin. HCV treatments have been approved for use only on individuals chronically infected with HCV who have never received inter feron treatment in the past. Initial studies have shown pegylated interferon combination therapy can ef fectively eliminate the virus in up to 40% of those infected with the most common genotype, type 1, and up to 80% in those infected with genotypes 2 or 3.

Side effects of HCV treatment are significant. Side effects are sometimes the reason why individuals choose not to be treated or discontinue treatment after it has been started. Treatment is contraindicated in pregnancy. The side effects include flu-like symptoms, anemia, hair loss, depression, which may lead to suicide in severe cases, autoimmune disorders, and irritability.

Prevention

Currently there is no vaccine for hepatitis C. So prevention messages are key. Primary prevention messages for hepatitis C include:

• If an individual is an injection drug user:
  • Stop injecting.
  • Enter and complete a substance abuse treatment program.
  • If an individual chooses to continue to inject:
    • Never reuse or share syringes, needles, water or drug preparation equipment (cotton, cooker, water).
    • If they must reuse, be sure to clean with bleach and water first.
    • Use only sterile syringes obtained from a reliable source.
    • Use a new sterile syringe to prepare and inject drugs.
    • Use sterile water or clean tap water to prepare drugs.
    • Use a new or disinfected cooker and a new piece of cotton.
    • Clean injection site before injection with alcohol swab.
    • Always dispose syringes safely after one use.
• If an individual is sexually active:
  • Persons having sex with multiple sexual partners should use a latex condom correctly each time they have sex.
  • Persons in a monogamous relationship, in which one partner is infected, may choose not to use a condom since the transmission rate is low.
• Secondary prevention messages for individuals already infected include:
  • Do not donate blood, body organs, other tissue or semen.
  • Do not share items that might have blood on them such as:
    • Personal care items (e.g., razors, toothbrushes)
    • Home therapy items (e.g., needles)
  • Cover cuts and sores on the skin.
• Tertiary prevention messages for individuals infected with hepatitis C to maintain a healthy lifestyle include:
  • Do not use alcohol.
  • See a doctor regularly.
  • Do not start any new medicines including over-the-counter, herbal, and other medicines, without a physician's knowledge.
  • Get vaccinated against hepatitis A and B if determined to be susceptible and at-risk.