Hepatitis c

Hepatitis C virus (HCV) causes both acute and chronic infection. Acute HCV infection is usually asymptomatic, and is only very rarely associated with life-threatening disease. About 15–45% of infected persons spontaneously clear the virus within 6 months of infection without any treatment.

The remaining 55–85% of persons will develop chronic HCV infection. Of those with chronic HCV infection, the risk of cirrhosis of the liver is 15–30% within 20 years.
Your liver is the largest organ inside your body. It helps your body digest food, store energy, and remove poisons. Hepatitis is an inflammation of the liver. One type, hepatitis C, is caused by the hepatitis C virus (HCV). It usually spreads through contact with infected blood. It can also spread through sex with an infected person and from mother to baby during childbirth.

Most people who are infected with hepatitis C don't have any symptoms for years. If you do get symptoms, you may feel as if you have the flu. You may also have jaundice, a yellowing of skin and eyes, dark-colored urine, and pale bowel movements. A blood test can tell if you have it. Usually, hepatitis C does not get better by itself. The infection can last a lifetime and may lead to scarring of the liver or liver cancer. Medicines sometimes help, but side effects can be a problem. Serious cases may need a liver transplant.

There is no vaccine for HCV.
Inflammation is swelling that occurs when tissues of the body become injured or infected. Inflammation can cause organs to not work properly.
The liver

removes harmful chemicals from your blood
fights infection
helps digest food
stores nutrients and vitamins
stores energy
Geographical distribution

Hepatitis C is found worldwide. The most affected regions are Africa and Central and East Asia. Depending on the country, hepatitis C infection can be concentrated in certain populations (for example, among people who inject drugs); and/or in general populations. There are multiple strains (or genotypes) of the HCV virus and their distribution varies by region.

Transmission

The hepatitis C virus is a bloodborne virus. It is most commonly transmitted through:

injecting drug use through the sharing of injection equipment;
in health care settings due to the reuse or inadequate sterilization of medical equipment, especially syringes and needles;
the transfusion of unscreened blood and blood products;
HCV can also be transmitted sexually and can be passed from an infected mother to her baby; however these modes of transmission are much less common.
Hepatitis C is not spread through breast milk, food or water or by casual contact such as hugging, kissing and sharing food or drinks with an infected person.
Screening and diagnosis

Due to the fact that acute HCV infection is usually asymptomatic, few people are diagnosed during the acute phase. In those people who go on to develop chronic HCV infection, the infection is also often undiagnosed because the infection remains asymptomatic until decades after infection when symptoms develop secondary to serious liver damage.

HCV infection is diagnosed in 2 steps:

Screening for anti-HCV antibodies with a serological test identifies people who have been infected with the virus.
If the test is positive for anti-HCV antibodies, a nucleic acid test for HCV RNA is needed to confirm chronic HCV infection because about 15–45% of people infected with HCV spontaneously clear the infection by a strong immune response without the need for treatment. Although no longer infected, they will still test positive for anti-HCV antibodies.
After a person has been diagnosed with chronic hepatitis C infection, they should have an assessment of the degree of liver damage (fibrosis and cirrhosis). This can be done by liver biopsy or through a variety of non-invasive tests.

In addition, these people should have a laboratory test to identify the genotype of the hepatitis C strain. There are 6 genotypes of the HCV and they respond differently to treatment. Furthermore, it is possible for a person to be infected with more than one genotype. The degree of liver damage and virus genotype are used to guide treatment decisions and management of the disease.

Getting tested

Early diagnosis can prevent health problems that may result from infection and prevent transmission of the virus. WHO recommends screening for people who may be at increased risk of infection.

Populations at increased risk of HCV infection include:

people who inject drugs
recipients of infected blood products or invasive procedures in health-care facilities with inadequate infection control practices
children born to mothers infected with HCV
people with sexual partners who are HCV-infected
people with HIV infection
prisoners or previously incarcerated persons
people who have used intranasal drugs
people who have had tattoos or piercings.
Symptoms

The incubation period for hepatitis C is 2 weeks to 6 months. Following initial infection, approximately 80% of people do not exhibit any symptoms. Those who are acutely symptomatic may exhibit fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, dark urine, grey-coloured faeces, joint pain and jaundice (yellowing of skin and the whites of the eyes).
Treatment

Hepatitis C does not always require treatment as the immune response in some people will clear the infection, and some people with chronic infection do not develop liver damage. When treatment is necessary, the goal of hepatitis C treatment is cure. The cure rate depends on several factors including the strain of the virus and the type of treatment given.

The standard of care for hepatitis C is changing rapidly. Until recently, hepatitis C treatment was based on therapy with interferon and ribavirin, which required weekly injections for 48 weeks, cured approximately half of treated patients, but caused frequent and sometimes life-threatening adverse reactions.

Recently, new antiviral drugs have been developed. These medicines, called direct antiviral agents (DAA) are much more effective, safer and better-tolerated than the older therapies. Therapy with DAAs result can cure most persons with HCV infection and treatment is shorter (usually 12 weeks) and safer. Although the production cost of DAAs is low, the initial prices are very high and likely to make access to these drugs difficult even in high-income countries.

Much needs to be done to ensure that these advances lead to greater access to treatment globally.

Prevention

Primary prevention
There is no vaccine for hepatitis C, therefore prevention of HCV infection depends upon reducing the risk of exposure to the virus in health-care settings, in higher risk populations, for example, people who inject drugs, and through sexual contact.

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

hand hygiene: including surgical hand preparation, hand washing and use of gloves;
safe handling and disposal of sharps and waste;
provision of comprehensive harm-reduction services to people who inject drugs including sterile injecting equipment;
testing of donated blood for hepatitis B and C (as well as HIV and syphilis);
training of health personnel;
promotion of correct and consistent use of condoms.
Secondary and tertiary prevention
For people infected with the hepatitis C virus, WHO recommends:

education and counselling on options for care and treatment;
immunization with the hepatitis A and B vaccines to prevent coinfection from these hepatitis viruses to protect their liver;
early and appropriate medical management including antiviral therapy if appropriate; and
regular monitoring for early diagnosis of chronic liver disease.
Screening, care and treatment of persons with hepatitis C infection

In April 2014, WHO launched "Guidelines for the screening, care and treatment of persons with hepatitis C".

These are the first guidelines dealing with hepatitis C treatment produced by WHO and complement existing guidance on the prevention of transmission of bloodborne viruses, including HCV.

They are intended for policy-makers, government officials, and others working in low- and middle-income countries who are developing programmes for the screening, care and treatment of people with HCV infection. These guidelines will help expand of treatment services to patients with HCV infection, as they provide key recommendations in these areas and discuss considerations for implementation.

Summary of key recommendations

Recommendations on screening for HCV infection
1. Screening to identify persons with HCV infection
It is recommended that HCV serology testing be offered to individuals who are part of a population with high HCV prevalence or who have a history of HCV risk exposure/ behaviour.

2. When to confirm the diagnosis of chronic HCV infection
It is suggested that nucleic acid testing (NAT) for the detection of HCV ribonucleic acid (RNA) be performed directly following a positive HCV serological test to establish the diagnosis of chronic HCV infection, in addition to NAT for HCV RNA as part of the assessment for starting treatment for HCV infection.

Recommendations on care of people infected with HCV
3. Screening for alcohol use and counselling to reduce moderate and high levels of alcohol intake
An alcohol intake assessment is recommended for all persons with HCV infection followed by the offer of a behavioural alcohol reduction intervention for persons with moderate-to-high alcohol intake.

4. Assessing degree of liver fibrosis and cirrhosis
In resource-limited settings, it is suggested that the aminotransferase/platelet ratio index (APRI) or FIB4 tests be used for the assessment of hepatic fibrosis rather than other non-invasive tests that require more resources such as elastography or Fibrotest.

Recommendations on treatment of HCV infection
5. Assessing for HCV treatment
All adults and children with chronic HCV infection, including people who inject drugs, should be assessed for antiviral treatment.

6. Treatment with pegylated interferon and ribavirin
Pegylated interferon in combination with ribavirin is recommended for the treatment of chronic HCV infection rather than standard non-pegylated interferon with ribavirin.

7. Treatment with telaprevir or boceprevir
Treatment with the direct-acting antivirals telaprevir or boceprevir, given in combination with pegylated interferon and ribavirin, is suggested for genotype 1 chronic HCV infection rather than pegylated interferon and ribavirin alone.

8. Treatment with sofosbuvir
Sofosbuvir, given in combination with ribavirin with or without pegylated interferon (depending on the HCV genotype), is recommended in genotypes 1, 2, 3 and 4 HCV infection rather than pegylated interferon and ribavirin alone, or no treatment for persons who cannot tolerate interferon.

9. Treatment with simeprevir
Simeprevir, given in combination with pegylated interferon and ribavirin, is recommended for persons with genotype 1b HCV infection and for persons with genotype 1a HCV infection without the Q80K polymorphism rather than pegylated interferon and ribavirin alone.

Note: Recommendations 8 and 9 were made without taking resource use into consideration, as pricing information was not available for any country other than the United States at the time this recommendation was formulated.

WHO response

WHO is working in the following areas to prevent and control viral hepatitis:

raising awareness, promoting partnerships and mobilizing resources;
formulating evidence-based policy and data for action;
preventing transmission; and
executing screening, care and treatment.
WHO also organizes World Hepatitis Day on 28 July every year to increase awareness and understanding of viral hepatitis
Who gets hepatitis C?
Anyone can get hepatitis C, but those more likely to are people who

were born to a mother with hepatitis C
are in contact with blood or infected needles at work
have had more than one sex partner in the last 6 months or have a history of sexually transmitted disease
are on kidney dialysis—the process of filtering wastes and extra water from the body by means other than the kidneys
are infected with HIV
have injected illegal drugs
have had tattoos or body piercings
work or live in a prison
had a blood transfusion or organ transplant before July 1992
have hemophilia and received clotting factor before 1987
Also, men who have sex with men are more likely to get hepatitis C
How could I get hepatitis C?
You could get hepatitis C through contact with an infected person’s blood. This contact could occur by

being born to a mother with hepatitis C
getting an accidental stick with a needle that was used on an infected person
having unprotected sex with an infected person
having contact with blood or open sores of an infected person
sharing drug needles or other drug materials with an infected person
being tattooed or pierced with unsterilized tools that were used on an infected person
using an infected person’s razor, toothbrush, or nail clippers
Most people do not have any symptoms until the hepatitis C virus causes liver damage, which can take 10 or more years to happen. Others may have one or more of the following symptoms:

feeling tired
muscle soreness
upset stomach
stomach pain
fever
loss of appetite
diarrhea
dark-yellow urine
light-colored stools
yellowish eyes and skin, called jaundice
What is acute hepatitis C?
Acute hepatitis C is a short-term infection with the hepatitis C virus. Symptoms can last up to 6 months. The infection sometimes clears up because your body is able to fight off the infection and get rid of the virus.



What is chronic hepatitis C?
Chronic hepatitis C is a long-lasting infection with the hepatitis C virus. Chronic hepatitis C occurs when the body can’t get rid of the hepatitis C virus. Most hepatitis C infections become chronic.

Without treatment, chronic hepatitis C can cause liver cancer or severe liver damage that leads to liver failure. Liver failure occurs when the liver stops working properly.

How is hepatitis C diagnosed?
A blood test will show if you have hepatitis C. Blood tests are done at a doctor’s office or outpatient facility. A blood sample is taken using a needle inserted into a vein in your arm or hand. The blood sample is sent to a lab to test for hepatitis C.

If you are at higher risk of getting hepatitis C, get tested. Many people with hepatitis C do not know they are infected.

Image of a female health care provider drawing blood from the arm of a female patient, who is sitting in a chair.
A blood test will show if you have hepatitis C.

Your doctor may suggest getting a liver biopsy if chronic hepatitis C is suspected. A liver biopsy is a test to take a small piece of your liver to look for liver damage. The doctor may ask you to stop taking certain medicines before the test. You may be asked to fast for 8 hours before the test.

During the test, you lie on a table with your right hand resting above your head. Medicine is applied to numb the area where the biopsy needle will be inserted. If needed, sedatives and pain medicine are also given. The doctor uses a needle to take a small piece of liver tissue. After the test, you must lie on your right side for up to 2 hours. You will stay 2 to 4 hours after the test before being sent home.

A liver biopsy is performed at a hospital or outpatient center by a doctor. The liver sample is sent to a special lab where a doctor looks at the tissue with a microscope and sends a report to your doctor.

How is hepatitis C treated?
Hepatitis C is usually not treated unless it becomes chronic. Chronic hepatitis C is treated with medicines that slow or stop the virus from damaging the liver. Your doctor will closely watch your symptoms and schedule regular blood tests to make sure the treatment is working.

Medicines for Chronic Hepatitis C
Chronic hepatitis C is most often treated with a medicine combination that attacks the hepatitis C virus. Treatment may last from 24 to 48 weeks.

Today, newer treatments with medicine for chronic hepatitis C are appearing quickly. Talk with your doctor if you have questions about treatment.

Talk with your doctor before taking other prescription medicines and over-the-counter medicines.

Drawing of a male doctor talking with a female patient. Both are seated at a desk.

Liver Transplant
A liver transplant may be necessary if chronic hepatitis C causes severe liver damage that leads to liver failure. Symptoms of severe liver damage include the symptoms of hepatitis C and

generalized itching
a longer than usual amount of time for bleeding to stop
easy bruising
swollen stomach or ankles
spiderlike blood vessels, called spider angiomas, that develop on the skin
Liver transplant is surgery to remove a diseased or injured liver and replace it with a healthy one from another person, called a donor. If your doctors tell you that you need a transplant, you should talk with them about the long-term demands of living with a liver transplant.

A team of surgeons—doctors who specialize in surgery—performs a liver transplant in a hospital. You will learn how to take care of yourself after you go home and about the medicines you’ll need to take to protect your new liver. You will continue to take medicines because hepatitis C may come back after surgery.

Testing for Liver Cancer
Having hepatitis C increases your risk for liver cancer, so your doctor may suggest an ultrasound test of the liver every 6 to 12 months. Finding cancer early makes it more treatable. Ultrasound is a machine that uses sound waves to create a picture of your liver. Ultrasound is performed at a hospital or radiology center by a specially trained technician. The image, called a sonogram, can show the liver’s size and the presence of cancerous tumors.

How can I avoid getting hepatitis C?
You can protect yourself and others from getting hepatitis C if you

do not share drug needles and other drug materials
do not donate blood or blood products
wear gloves if you have to touch another person’s blood or open sores
do not share or borrow a toothbrush, razor, or nail clippers
make sure any tattoos or body piercings you get are done with sterile tools
tell your doctor and your dentist if you have hepatitis C
use a condom during sex
A vaccine for hepatitis C does not yet exist.

Drawing of a man taking a clean drug needle from a plastic sleeve.
Do not share drug needles and other drug materials.

What should I do if I think I have been in contact with the hepatitis C virus?
See your doctor right away if you think you have been in contact with the hepatitis C virus. Early diagnosis and treatment of chronic hepatitis C can help prevent liver damage.

Eating, Diet, and Nutrition
If you have chronic hepatitis C, you should do things to take care of yourself, including eating a healthy diet. Avoid drinking alcohol, which can harm the liver. Talk with your doctor before taking vitamins and other supplements.

Points to Remember
Hepatitis C is a virus, or infection, that causes inflammation of the liver.
Anyone can get hepatitis C, but some people are more likely to than others.
You could get hepatitis C through contact with an infected person’s blood.
Most people do not have any symptoms until the hepatitis C virus causes liver damage, which can take 10 or more years to happen.
See a doctor right away if you or a child in your care has symptoms of hepatitis C.
Acute hepatitis C is a short-term infection with the hepatitis C virus.
Chronic hepatitis C is a long-lasting infection with the hepatitis C virus. Chronic hepatitis C occurs when the body can’t get rid of the hepatitis C virus.
A blood test will show if you have hepatitis C.
If you are at higher risk of getting hepatitis C, get tested. Many people with hepatitis C do not know they are infected.
Hepatitis C usually is not treated unless it becomes chronic. Chronic hepatitis C is treated with medicines that slow or stop the virus from damaging the liver.
Tell your doctor and your dentist if you have hepatitis C.
See your doctor right away if you think you have been in contact with the hepatitis C virus. Early diagnosis and treatment of chronic hepatitis C can help prevent liver damage.
Exams and Tests
Blood tests are done to check for hepatitis C:

Enzyme immunoassay (EIA) to detect hepatitis C antibody
Hepatitis C RNA assays to measure virus levels (viral load)
Everyone born from 1945 to 1965 (the baby boomer generation) should get a one-time test for hepatitis C.

Genetic testing is done to check for the type of hepatitis C (genotype). There are six types of the virus (genotypes 1 through 6). Test results can help your health care provider choose treatment that is best for you.

The following tests are done to identify and monitor liver damage from hepatitis C:

Albumin level
Liver function tests
Prothrombin time
Liver biopsy
Treatment
You should talk to your provider about your treatment options and when treatment should begin.

The goal of treatment is to rid the body of the virus. This can prevent liver damage that may lead to liver failure or liver cancer.
Your provider will monitor you by checking liver blood tests, viral load (the amount of HCV in your blood), imaging tests, and biopsy results.
Treatment is especially important for people who are showing signs liver fibrosis or scarring.
Medicines used to treat hepatitis C are called antiviral drugs because they fight the HCV. Newer antiviral drugs:

Provide a much improved cure rate
Have fewer side effects and are easier to take
Are taken by mouth for 12 to 24 weeks
The choice of which drug depends on the genotype of the virus you have.

A liver transplant may be recommended for people who develop cirrhosis and liver cancer. Your provider can tell you more about liver transplant.

If you have hepatitis C:

Do not take over-the-counter medicines that you have not taken before without asking your provider. Also ask about vitamins and other supplements.
Do not use alcohol or street drugs. Alcohol can speed up the damage to your liver. It can also reduce how well medicines work.
Ask your provider whether you need the hepatitis A and hepatitis B vaccines.
Support Groups
Joining a support group can help ease the stress of having hepatitis C. Ask your provider about liver disease resources and support groups in your area.

Outlook (Prognosis)
Most people (75 to 85%) who are infected with the virus develop chronic hepatitis C. This condition poses a risk for cirrhosis, liver cancer, or both. The outlook for hepatitis C depends in part on the genotype.

A good response to treatment occurs when the virus can no longer be detected in the blood 12 weeks or more after treatment. This is called "sustained virologic response" (SVR). Up to 90% of those treated for some genotypes have this type of response.

Some people do not respond to initial treatment. They may need to be re-treated with a different drug regimen.

Also, some people can become re-infected or infected with a different genotype strain
If I have no symptoms, how will I know if I have hepatitis C?
To determine whether or not you have hepatitis C, you will need to have blood tests. (see section entitled ‘Who should get tested?)
Can I get hepatitis C more than once?
Although your body’s immune system makes antibodies to HCV, these antibodies do not protect you. The virus changes so quickly that it escapes your body’s defences. This means that you cannot have lifelong protection from hepatitis C. Also, no hepatitis C vaccine exists at this time. If you are treated for HCV and get rid of the virus, you can still be infected again. However, what you do, or do not do, can affect your level of risk for getting hepatitis C again


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