An Overview of Hepatitis C

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Hepatitis C is an infectious disease of the liver caused by the hepatitis C virus (HCV). It is typically spread through contact with infected blood and can also be transmitted through sexual contact or passed from mother to child during pregnancy.

It is a slowly progressive disease that can range in severity from a mild, flu-like illness lasting a few weeks to a serious, life-long condition that can severely damage the liver, causing inflammation and tissue scarring.

Symptoms

The course of an HCV infection is highly unpredictable. The virus can spontaneously clear in some people, become a persistent infection in others, and advance to a life-threatening illness in others. The stages of infection are also highly variable and are typically defined as being either acute, chronic, or end-stage, each with its own symptoms.

Incubation Period: Most people do not experience their first symptoms of hepatitis until about four to seven weeks after exposure to the virus, or even longer. Symptoms of acute hepatitis can take as long as five to six months to appear. 

Some people do not go on to experience any symptoms, as the body's immune system may fight off the virus. In as many as one in five cases, the virus will spontaneously clear soon after infection, showing no detectable signs in the blood. 

Acute Hepatitis: Months after HCV exposure, only a handful of individuals experience mild, flu-like symptoms of hepatitis. Acute hepatitis infection is characterized by the rapid onset of symptoms, if they occur.

Symptoms include:

  • Tiredness 
  • Joint and muscle pain 
  • Loss of appetite
  • Nausea
  • Diarrhea
  • Jaundice, which is a yellow coloring of the skin and eyes, may occur as well. A few days before jaundice becomes apparent, some people notice dark-colored urine or clay-colored stools.

During an acute infection, HCV primarily targets liver cells called hepatocytesAs the virus rapidly replicates—generating upwards of a trillion copies of itself per day—it can cause damage to the liver by directly killing hepatocytes and by stimulating the immune system to produce disease-fighting cells called lymphocytes, which kill the infected liver cells and also cause inflammation of the liver.

Chronic Hepatitis: HCV spontaneously improves within six months in about 20 to 25 percent of people with acute hepatitis. When the symptoms do not improve, HCV infection progresses to chronic hepatitis.

For people who develop chronic hepatitis C, the most common complaints are: 

  • Fatigue
  • Loss of appetite
  • Nausea
  • Weakness
  • Weight loss
  • Jaundice
  • Swelling of the abdomen
  • Abdominal pain
  • Bruising or bleeding 

End-stage hepatitis C: In 10 to 30 percent of cases, HCV infection can advance to a condition called cirrhosis in which the liver is so extensively damaged that its ability to function properly is reduced. This can progress to a stage called decompensated cirrhosis in which the liver is essentially non-functional.

Symptoms of decompensated cirrhosis include:

  • Severe weakness and fatigue
  • Weight loss
  • Abdominal pain
  • Itching 
  • Bruising and bleeding
  • Jaundice
  • Abdominal swelling
  • Memory or behavioral changes
  • Trouble walking

Hepatocellular carcinoma, a type of liver cancer, is also commonly seen in advanced cases of hepatitis C, with rates running as high as 17 times that of the general population.

End-stage disease is defined as the stage of disease where the risk of mortality is increased due to liver failure, liver cancer, or non-liver-related complications such as kidney failure. Decompensated cirrhosis and hepatocellular carcinoma are the two most common end-stage conditions associated with HCV infection. Outcomes for both are generally poor, carrying a five-year survival rate of 50 percent and 30 percent, respectively.

Causes

HCV is caused by infection hepatitis C virus, which targets the liver. You can become infected with the virus by coming into contact with contaminated blood or through sexual contact. 

Transmission of HCV: In the United States, HCV is the most common blood-borne infection, impacting around 3.2 million Americans, or roughly 1.5 percent of the adult population.

You can get the virus in the following ways:

  • Injecting drug use - about 80 percent of cases
  • Sexual contact - about 10 percent of cases
  • Mother-to-child transmission - about 4 percent of cases
  • Needlestick injury- about 2 percent of cases
  • Blood transfusion- less than .01 percent of new cases. Roughly three in four Americans living with HCV today who were born between 1945 and 1965 became infected due to contaminated blood transfusions. Advances in screening techniques have reduced such risk to less than one out of every two million transfusions.

Types of HCV:  There are at least 11 different genetic variations of the HCV virus, called genotypes. The six major HCV genotypes are distributed unevenly throughout the world, with some types predominating within specific geographic regions.

In the United States, HCV genotype 1 accounts for nearly 80 percent of all infections, followed by genotypes 2 and 3. By contrast, genotype 4 is the predominant type in Africa and the Middle East, while genotypes 5 and 6 are most frequently seen in southern Africa and Asia, respectively.

The identification of genotype is important in not only predicting the course of the disease but in determining which drugs will work best in fighting a particular viral type.

How HCV Damages the Body: During HCV infection, the activation of the immune system triggers an inflammatory response, which stimulates the production of collagen and other substances. These substances, meant to strengthen the architecture of the liver, gradually build up faster than the body can break them down. Over time, the process causes the accumulation of scar tissue, leading to the development of cirrhosis in about 10 to 15 percent of chronically infected individuals.

Diagnosis 

HCV infection shows signs and symptoms that are very similar to those of other infections early on. Diagnosis of HCV can be confirmed with antibody tests and detection of the virus in the blood. If you have been exposed to HCV, or if you have signs that suggest you may have HCV infection, you should get tested for the infection. 

Hepatitis C testing is currently recommended for all adults at high risk of infection, as well as any person born between the years of 1945 and 1965.

Rapid Diagnostic Test: A rapid diagnostic test, which is endorsed by the World Health Organization (WHO), can detect HCV antibodies in the blood. Antibodies are produced by the immune cells that your body uses to fight infection. This test has several advantages. It only requires a small amount of blood, it can be done without a lab, and it does not need to be performed by healthcare workers who have extensive training. The WHO describes it as similar to a pregnancy test. Results are ready in about 20 minutes. If you test positive for HCV with a rapid diagnostic test, it is recommended that you have a different test to confirm your diagnosis, because the rapid diagnostic test can show antibodies even if you have effectively fought off the infection but do not have a current infection. 

Enzyme Immunoassay (EIA): HCV infections are confirmed by a blood test that detects antibodies, specific to the virus. The test is very sensitive, but not very selective in looking for antibodies, so a positive EIA might not be correct. On average, it takes six to eight weeks for the body to produce enough antibodies for a test to be considered accurate. EIA is considered the gold standard in HCV antibody testing, but, like the rapid test, results may be positive even if you are not infected if you have been infected and effectively fought off HCV in the past. 

HCV RNA Quantitative Testing: A blood test can detect the presence and amount of HCV in your blood. If you do not have detectable virus in your blood, this means that you do not have the infection. This test is also used to follow people who are getting treated for HCV because it can quantifiably measure whether the virus is decreasing in your blood in response to therapy. 

Liver Function Tests (LFTs): HCV affects the liver and several of the proteins and enzymes that your liver makes. LFTs can be the first diagnostic clue that you have a liver disease if you do not have obvious symptoms. If your LFTs are abnormal, it could be the result of HCV infection, but other illnesses can also result in abnormal LFTs. 

Treatment

Recent advances in hepatitis C therapy have made a huge impact on the lives of people who have the infection, particularly when you consider that HCV was only officially identified in 1989. Direct acting antivirals (DAAs) produce cure rates of as high as 99 percent in some groups. DAAs generally work by interrupting the life cycle of the virus. Other medications can also be used along with DAAs, and a liver transplant may be an option for some people with late-stage HCV infection. 

Treatment of hepatitis C is generally recommended when a person shows signs of liver inflammation. The course and duration of therapy are determined by the genotype of a person’s virus, as well as the diagnosed stage of infection.

The most common DAAs include:

  • Epclusa (sofosbuvir/velpatasvir)
  • Sovaldi (sofosbuvir)
  • Zepatier (elbasvir/grazoprevir)
  • Daklinza (daclatasvir)
  • Mavyret (glecapravir, pibrentasvir)

Other medications used for HCV infection, along with DAAs, include:

  • Peginterferon, which modifies the body's immune response to HCV
  • Ribavirin, which is an oral medication that interferes with the replication of a number of different viruses, including HCV. 

liver transplant is considered the only effective option for people with end-stage liver disease, although HCV is known to recur in around 80 percent of cases. A liver transplant provides a person with end-stage liver disease with a functional liver but does not eliminate the virus from the body. 

Prevention

While injecting drug use remains a primary route of infection in developed countries, unsterilized medical procedures—particularly unsafe injections—are considered among the leading cause of hepatitis C in the developing world. Prevention is based on avoiding known risks of HCV transmission. 

Avoiding the following activities can prevent you from getting HCV:

  • Sharing needles for drug use or any other reason
  • Having a medical procedure or an injection with unsterilized equipment
  • Getting a needle-based tattoo
  • Getting body piercings
  • Sharing personal items that may have blood on them, such as razors, earrings, toothbrushes
  • Having unprotected sex with someone who could have HCV

Healthcare workers are also at risk of exposure to HCV from patient blood, needles, glass, or equipment. Wearing gloves and disposing of sharp objects properly decrease the risk of becoming infected with HCV. 

Unlike hepatitis A or hepatitis B, there is still no vaccine to prevent hepatitis C infection.

Coping

Coping with HCV requires taking care of yourself and protecting others from infection. If you have HCV, you can exercise, take part in recreational activities, work, and travel as long as you have the energy to do so. 

Taking Care of Yourself: With new treatments, you have a good chance of recovering from your HCV infection without developing advanced disease. However, if you develop advanced HCV infection, there are effective medical and surgical treatments that can provide you will a very strong chance of a cure. 

Protecting Others: If you have HCV, you cannot donate blood, and you should take precautions to avoid infecting others. You should inform sexual partners of your infection and use condoms to prevent spreading the infection to others. You should also be sure to avoid sharing needles, razors or anything that has been in contact with your blood. 

Stigma: Studies show that people with HCV infection experience discrimination that can interfere with quality of life and may prevent some people who have HCV from taking part in activities with others. Some people with HCV may feel excluded and discouraged from working. If you have had these experiences, support groups and therapists can provide you with advice and listen to your concerns. 

Symptoms of Hepatitis C Virus
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