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Hepatitis Back to Course Index

 

 

                                                                     

 

INTRODUCTION and OVERVIEW

 

This continuing education offering is intended to educate the reader on the general subject of hepatitis.   It is not intended to offer medical advice or to be a substitute for the services of a medical professional.   

 

If you stopped the average person on the street and asked them to briefly explain HIV they would most likely come fairly close to what it is and how you contract it.  If you asked the average person about Hepatitis most likely not be able to come nearly as close to a description.  Yet, some types of hepatitis, such as HBV are 100 times more infectious than HIV.  HIV, especially when first identified had such a horrible survival rate that it seemed to take precedence over almost all other diseases. However, because of the threat of grave consequences, we have to take hepatitis seriously.  

Hepatitis is an enormous health issue; so extensive in fact that even if you are not working in a health care setting there is a good chance you associate with one or people with hepatitis. Like HIV, hepatitis comes with a stigma. Often people with hepatitis find it easier to keep their diagnosis private.  This is mainly due to the difficulties they can experience due to the ignorance of others. As such, it is crucial that we make education and research a vital part of the treatment process. 

Hepatitis is a disease that impairs liver function either temporarily or permanently, sometimes even leading to death. It can be initiated by a host of factors, but primarily by viruses. Drugs also can cause hepatitis but when the specific drug is discontinued, the liver usually returns to normal.  

 

 

HISTORY OF HEPATITIS

Unlike HIV, hepatitis was believed to exist in viral form from ancient times as a disease existed that affected the liver and caused yellowing of the skin (jaundice).  . As early as the 1800s and early 1900s 2 types were identified as either serum type or viral type. In 1963 there was a major breakthrough that identified the cause of serum hepatitis and named the hepatitis B virus (HBV). Ten years later the cause of infectious hepatitis was found and named the Hepatitis A virus (HAV), and although scientists knew other viruses existed it was not until 1989 that the hepatitis C virus (HCV) was isolated. (Dr. Jerry Kennard, Men’s Health, 2005)

Although the hepatitis delta virus (HDV) was known since the mid-1970s, it was only in the late 1980s -1990s that it was understood to exist only in the presence of hepatitis B. In 1990, hepatitis E virus (HEV) and in 1995, Hepatitis G virus (HGV), were identified. Other viruses, hepatitis F virus (HFV) and transfusion transmission virus (TTV) are thought to exist but are not as yet proven.  (Dr. Jerry Kennard, Men’s Health, 2005)

 

HEPATITIS

 

Merriam Webster’s medical desk dictionary, 1993 defines hepatitis as an inflammation of the liver.  It goes on to state that hepatitis is a “disease or condition marked by inflammation of the liver”.  

 

There are five identified types of viral hepatitis and a different virus causes each one. Each type of viral hepatitis is different. They have different characteristics and are known by alphabetical names – hepatitis A through to E. Four other types exist F, G,

TTV (Transfusion Transmitted Virus) and S.E.N-V (these are the initials of the person in which this form of the virus was first identified – V standing for the virus). Behavioral precautions and treatment depend on the type of hepatitis.

 

 

Hepatitis A, Hepatitis B, and Hepatitis C are the most common types in the United States.  The hepatitis A virus causes hepatitis A; the hepatitis B virus causes hepatitis B and the hepatitis C virus causes hepatitis C. 

 

While viral types of hepatitis get the most attention, hepatitis can also be caused by bacterial infections or prolonged exposures to alcohol and/or other drugs as well as toxic chemicals, such as those found in aerosol sprays and paint thinners.  Hepatitis can also result from an autoimmune disorder, in which the body mistakenly sends disease-fighting microorganisms to attack its own healthy tissue, in this case in the liver.  No matter what its cause, hepatitis reduces the liver’s ability to perform life-preserving functions, including filtering harmful toxins from the blood, storing blood sugar and converting it to unable energy forms, and producing many nutrients, which are necessary for life.

 

 

ROLE OF THE LIVER

 

The primary function of the liver is to filter toxins (harmful substances) and waste products from the bloodstream.  The liver also stores nutrients such as vitamins and minerals and plays a role in managing levels of cholesterol, hormones and sugars, and other chemicals.  Another function is to help the body to digest food and to break down harmful substances by producing a substance called bile.  The liver helps in processing hemoglobin and in producing blood-clotting factors. 

 

The liver can be damaged by excessive use of alcohol and/or other drugs, cancer, or infections such as hepatitis.  Damaged cells lose their ability to filter the blood.  A buildup of scar tissue on the liver is called fibrosis and this condition slows the liver’s ability to process blood and to remove harmful products.  Over time the resultant scar tissue replaces normal tissue—this condition is called cirrhosis and can be fatal.   

 

 

TYPES OF VIRAL HEPATITIS

 

The five primary viral hepatitis strains are: A, B, C, D, and E.  The most common ones that are  encountered in the United States are A, B and C.  An overview of each strain/virus follows:

 

Hepatitis A Virus

 

Hepatitis A is common in the United States and has been estimated to affect 1 out of 3 Americans some time during their life.   The good news is that most people who are infected will recover completely without treatment and once the infection has subsided the infected individual will have lifetime immunity to the disease.

 

The primary way hepatitis A is transmitted is by a fecal-to-oral route through contact or consumption of contaminated food or water, or because of poor personnel hygiene.  An individual can also contact hepatitis A by eating shellfish from contaminated water sources.

 

The hepatitis A virus lives in the intestinal tract and is spread when individuals who are exposed to excretions do not wash their hands properly after using the toilet and then handling food, or when a person changes an infected infant’s diaper and then handles food before washing his or her hands.  People who consume contaminated food run a high risk of becoming infected. 

 

The virus can also be spread by drinking contaminated water or by using contaminated water to wash fruits or vegetables.  Eating raw or partially cooked shellfish harvested from contaminated water can also lead to HAV infection.  Outbreaks occur more easily in overcrowded areas where poor sanitary conditions exist.  Outbreaks of hepatitis A have also been reported among Injecting Drug Users (IDU’s).   This outbreak (between IDU’s) is thought to be related to hygiene in lieu of sharing of drug related items.

 

It has been estimated that over 100,000 cases of hepatitis A infections occur in the United States each year.  Individuals with hepatitis A can spread the disease to others as early as two weeks before symptoms appear.  In addition to the general hepatitis symptoms, such as nausea, fatigue, and jaundice, hepatitis A may also cause diarrhea.  There is no treatment for hepatitis A.  Most people will recover on their own without any serious after effects, although a few rare cases may result in severe liver damage.  Hepatitis A can be prevented through immunization.

 

          

Hepatitis B

 

Hepatitis B is a blood-borne virus that is transmitted sexually or through sharing of contaminated needles or other drug related items (such as water, drug mixing containers, and cotton filters).  Hepatitis B virus (HBV) infection occurs when blood or body fluids from an infected person enter the body of an uninfected person.  High-risk sexual behaviors (unprotected sex with multiple partners) and injection drug use are the major risk factors.  Patients with hepatitis B develop chronic hepatitis, which can cause severe damage to the liver.   Pregnant women infected with hepatitis B risk passing the infection on to their unborn child, with potentially fatal consequences.  About 5% of individual in the U.S. have evidence of past infection with HBV and approximately 1.25 million people have chronic HBV infection.  Like hepatitis C, hepatitis B disproportionately affects people of color.  An estimated 73,000 new HBV infections occurred in 2000.  Most infections occurred in young adults, aged 15-39 years.  There is an effective vaccine for this virus, which is routinely given to health-care workers. 

 

HBV can live on a dry surface for at least seven days and can take up to 160 days between the time of infection and the onset of symptoms; the onset of symptoms averages 10 weeks.

 

For those who are not vaccinated, hepatitis B immune globulin can give temporary immunity if taken immediately after exposure.  There is no cure for hepatitis B.

 

Hepatitis C

Hepatitis C is caused by the hepatitis C virus (HCV). The infection is spread by contact with the blood of an infected person. Recent studies on hepatitis C point to it as being the most common cause for chronic hepatitis; some people harbor the hepatitis C virus for several years. Some infected people have few symptoms while others experience all the symptoms typical of chronic hepatitis.  It is serious for some, but not others, most people who get hepatitis C carry the virus for the rest of their life. Most have some liver damage but many do not feel sick from the disease. As a result of the liver damage, cirrhosis (scarring) of the liver and liver failure may develop.

For a slight majority of patients, the illness begins suddenly as though one had come down with the flu. Except that this “flu” doesn’t seem to completely go away. For many other patients, the onset appears gradually over a long period of time. Infants and young children often have no symptoms at all. Many other symptoms may also be present, however they will typically be different among different patients. These include: fatigue, low-grade fever, headaches; slight sore throat, loss of appetite, nausea, vomiting, stiff or aching joints, and liver damage. Many people develop a pain in the right side, over the liver area. The urine may become dark brown, and the feces may be pale. In severe acute infections, some people may develop jaundice in which the skin and whites of the eyes become yellowish.

The degree of severity from Hepatitis C can differ widely among patients, and will also vary over time for the same patient. Severity can vary between getting unusually fatigued following stressful events, to being totally bedridden and completely disabled. The hepatitis C symptoms have a tendency to wax and wane over time.

As stated previously, hepatitis C virus (HCV) infection occurs when blood (or to a lesser extent other body fluids such as semen or vaginal fluid) from an infected person enters the body of an uninfected person.  Injection drug use is the major risk factor for HCV infection.  About 4 million Americans have been infected with HCV and 2.7 million have chronic HCV infection.  Hepatics C disproportionately affect people of color: 3.2 % of African Americans and 2.1 % of Mexican Americans are infected with HCV, compared to 1.5% of non-Hispanic whites.  These numbers under-estimate the actual impact because they do not include infections in prisoners or the homeless.  In 2000, about 30,000 new infections occurred.  Most of these infections occurred among young adults 20-39 years old.  

The immune system fights hepatitis C through a body wide network of cells and organs that has evolved to defend the body against attacks by foreign entities such as bacteria, fungi, parasites, and viruses.  Obviously, the immune system by itself is not totally effective against hepatitis C; however, through a healthy lifestyle (including proper diet, exercise and sobriety) an individual can enhance their ability to defend against the virus.  There is no vaccine and no “silver bullet” cure for hepatitis C.

Hepatitis D

Hepatitis D is a liver disease caused by the hepatitis D virus and is found in the blood of persons infected with the virus. HDV is a defective single-stranded RNA virus that requires the helper function of HBV to replicate. HDV requires HBV for synthesis of envelope protein composed of HBsAg, which is used to encapsulate the HDV genome.  The hepatitis D characteristics are similar to HBV and it is not common in the U.S.   

Hepatitis E

Hepatitis E is a liver disease caused by the hepatitis E virus  (HEV) transmitted in much the same way as the hepatitis A virus.  Hepatitis E does not occur often in the United States.

 

THE MEDICAL COST OF VIRAL HEPATITIS

Each year approximately 10,000 people die from the complications of liver disease caused by hepatitis C and about 5,000 die from complications caused by hepatitis B.  Chronic liver disease is currently the 10th leading cause of death, and liver failure due to hepatitis C is the leading reason for liver transplants.  Annual health care costs and lost wages associated with hepatitis-related liver disease are estimated to be over $500 million for hepatitis C and several million more for hepatitis B.  The costs to individuals and society for illnesses related to hepatitis A are also substantial.

 

VIRAL HEPATITIS CAN BE INSIDIOUS

Frequently, symptoms of newly acquired  (acute) infection are mild or nonexistent, so people may NOT even be diagnosed as having viral hepatitis.  Those who do have symptoms might experience flu-like symptoms such as fatigue, nausea, and pain in the upper abdomen and sometimes jaundice.

Most people who get HAV infection are able to clear the virus from their bodies and recover fully without significant involvement from the medical community.  They also develop a lifelong immunity to the virus.  The situation is different with hepatitis B and hepatitis C.

The majority of people who acquire HBV after age 5 are able to clear the virus from their bodies.  However, about 3 % are unable to clear the virus and go on to become chronically infected.  A much higher percentage of those who acquire HBV infection as infants (90%) or young children (30%) become chronically infected.

Approximately 75% of people with HCV infection are unable to clear the virus and become chronically infected.  Many people with chronic infection- 60% of those with HBV and 70% of those with HCV infection- develop chronic liver disease, a situation in which the virus damages the liver.  The damage may progress to severe disease, including cirrhosis, liver cancer, and liver failure.  This progressive liver disease usually develops slowly over 20 to 30 years.  Because symptoms are so frequently mild or nonexistent, the majority of people with chronic HBV and HCV infections do not know they are infected and can unknowingly transmit the virus to others.  For many, signs and symptoms appear only when liver disease is advanced and treatments are less effective.

 

HEPATITIS C IS PARTICULAR CONCERN

HCV infections in the 1960s, 1970s and 1980s was estimated to be approximately 240,000 per year and many persons were unaware they were infected; consequently, the risk of spreading the disease to others was very high.  Since then, the incidence of HCV infection has declined dramatically (approximately 30,000 new infections in the year 2000).  The data indicates that most of the decline occurred in the IDU subpopulation.  This decrease is probably a result of the focus on education and the work with Injecting Drug Users to minimize the risk of spreading the disease due to shat\ring of syringes and other drug related items.  Also, some health care workers think the drug using population is fairly well saturated; consequently, the spread is somewhat limited as fewer individual are choosing to enter the drug culture.

Another aspect or concern for HCV is that most people with HCV infection develop chronic infection, which frequently leads to chronic liver disease.  As noted previously, it takes from 20 to 30 years for chronic liver disease such as cirrhosis and liver cancer to occur or to become sufficiently severe to require medical intervention.  Some health care workers estimate the impact of HCV infection may explode over the next 10-20 years.  It is conservativley estimated that illness and deaths from HCV-related liver disease among the millions of people infected during earlier years could increase by 2-3 times the current level over the next two decades.  Direct medial costs may range from $7 to $14 billion, with even larger indirect and societal costs.  Again, no vaccine or cure for HCV is available.

 

VIRAL HEPATITIS RELATED TO INJECTING DRUG USERS (IDU’s)

IDUs are at a very high risk of acquiring and transmitting HBV and HCV as both are transmitted through exposure to infected blood and body fluids.  For example, (and noted previously) it is estimated that 60% (17,000) of the 30,000 new cases of HCV that occurred in 2000 occurred involving IDUs.  It is estimated that 17% (13,000) of the 73,000 new cases of HBV that occurred in 2000 occurred involving IDUs. 

HBV and HCV infections are also acquired relatively rapidly between IDUs.  Within 5 years of beginning injection drug use, over 50% of IDUs become infected with HBV. Slightly higher percentage becomes infected with HCV during the same 5 years period.  It is also usually the first blood-borne virus they acquire.  Special factors favor the rapid spread of infections between IDUs:

· Viral factors – HCV is transmitted efficiently through blood exposure.

· Host factors- a large number of individuals are infected and this provides multiple opportunities for transmission to others especially if one is involved with multiple partners or users.

· IDU factors – IDUs often jointly purchase drugs and prepare the drug solution together; this solution is divided among users.  Sharing the drug solution, syringes, or other preparation equipment (such as water, drug mixing containers, and cotton filters) all increase the risk of transmission if any of these components are infected with HCV.

Other circumstance also contribute to the heavy impact of viral hepatitis on IDUs:

·  IDUs are at very high risk of co-infection with HIV and HCV.

·  Many IDUs drink alcohol, which damages the liver and accelerates the progression of liver diseases.

·  HAV infection can be severe and very dangerous in those who already have liver disease from chronic hepatitis B or chronic hepatitis C.

·  Treatment of chronic hepatitis B or chronic hepatitis C can be complicated and adherence difficult for infected IDUs because many have other conditions (HIV, mental illness, alcoholism, other illnesses), are poor and have unstable living situations.  Also, they frequently lack health insurance and are limited by the level of medical care they can obtain, as well as the stigma surrounding individuals who choose that lifestyle.

 

HEPATITIS AT A GLANCE (U.S. most common only)

Virus A:

 Risk of Transmission

  • Low risk due to injecting (outbreaks occur among IDUs but transmission is thought to be due to poor hygiene).
  • Low due to transfusion/transplants
  • High risk due to ‘high risk’ sex 
  • High due to personal hygiene (fecal-to-oral route)

Course of Infection

  • Acute to resolved

Does Protective Immunity develop?

Yes

Vaccine Available

Yes

 

Virus B

Risk of Transmission

  • High risk due to injecting drug use
  • Low risk due to transfusions/transplants (after 1987) 
  • High risk due to ‘high risk’ sex

Course of Infection

  • Acute to chronic in 90 % of infants; 30% in children aged 1-5; 2-5% other

Immunity Develop

Yes

Vaccine

Yes

 

Virus C

      Risk of Transmission

  • HHigh risk due to injecting drug use
  • Low risk due to transfusion/transplants (after 1987)
  • Possible with ‘high risk’ sex

 

Course of infection

  • Acute to chronic in 75 to 85 % of adults

Vaccine

No

 

 TREATMENT RECOMMENDATIONS:

      The following treatment recommendations have been made for individual who have chronic viral hepatitis:

·  Stop consumption of all alcoholic beverages.  If necessary, get into a substance abuse treatment program.

·  Stop injecting drugs and get into a substance abuse treatment program.  If abstinence cannot be maintained, follow safe injection practices (always use a sterile syringe; do not share drug solution, syringes or drug preparation equipment).

· All individuals with chronic liver disease should undergo immunization for hepatitis A.  Individuals with chronic HCV infection that are at risk for HBV infection also should be immunized against hepatitis B.

· Individuals with chronic HBV and/or HCV infection should be under medical supervision.

Antiviral therapy is available for chronic hepatitis B and chronic hepatitis C; however, it is not recommended for all chronically infected individuals.  All treatment should be under the care and supervision of a physician and should be determined based on regular monitoring for the development and extent of liver disease.  Because of advances in the field of antiviral therapy chronic hepatitis, standards of practice might change, and those with choric infection should consult with health care providers who are experienced in treating viral hepatitis.

Other illnesses (such as HIV, alcohol abuse, diabetes, or tuberculosis) are common with individuals with HBV or HCV, especially IDU’s.  However, with careful monitoring by a physician or health care professional who is experienced in hepatitis and/or additional and other related conditions, IDUs can be successfully treated.  Antiviral therapy for chronic hepatitis B individuals with chronic HBV infection – those who have tested positive for hepatitis B surface antigen (HbsAg) for at least 6 months  – should have an initial evaluation that consists of:

· Blood test for liver disease, such as those that measure alanine aminotransferase (ALT), which are enzymes released by damaged liver cells: and

· Blood tests for the virus (HbeAg), anti-Hbe, HBV DNA).

The food and drug administration  (FDA) has approved two drugs for use in treating chronic hepatitis B:  alpha interferon (given for 16 weeks to adults and 24 weeks for children) and lamivudine (given for 52 weeks).  Alpha interferon stimulates the body’s immune system to fight the infection, but it is expensive, must be administered by injection, and has many side effects.  Lamivudine is taken in pill form and has few, if any, side effects.  However, the response to lamivudine may not last as long as with alpha interferon.  In addition, stopping lamivudine is often followed by relapse, and continuing lamivudine indefinitely often leads to antiviral resistance.

 

HEPATITIS FACT SHEETS

The following FACT SHETS were obtained from the Center of  Disease Control website: http://www.cdc.gov /ncidod/disease/hepatitis/d/.  Anyone using this continuing education offering should consult with the CDC website to obtain the latest information.

HEPATITIS A FACT SHEET

SIGNS & SYMPTOMS

Adults will have signs and symptoms more often than children.

  • Jaundice
  • Fatigue
  • Abdominal pain
  • Loss of appetite
  • Nausea
  • Diarrhea
  • Fever

 

CAUSE

  • Hepatitis A virus (HAV)

LONG-TERM EFFECTS

  • There is no chronic (long-term) infection.
  • Once you have had hepatitis A you cannot get it again.
  • About 15% of people infected with HAV will have prolonged or relapsing symptoms over a 6-9 month period.

TRANSMISSION

  • HAV is found in the stool (feces) of persons with hepatitis A. 
  • HAV is usually spread from person to person by putting something in the mouth (even though it may look clean) that has been contaminated with the stool of a person with hepatitis A. 

PERSONS AT RISK OF INFECTION

  • Household contacts of infected persons
  • Sex contacts of infected persons
  • Persons, especially children, living in areas with increased rates of hepatitis A during the baseline period from 1987-1997.
  • Persons traveling to countries where hepatitis A is common
  • Men who have sex with men
  • Injecting and non-injecting drug users

PREVENTION

  • Hepatitis A vaccine is the best protection.
  • Short-term protection against hepatitis A is available from immune globulin. It can be given before and within 2 weeks after coming in contact with HAV. 
  • Always wash your hands with soap and water after using the bathroom, changing a diaper, and before preparing and eating food.

VACCINE RECOMMENDATIONS

Vaccine is recommended for the following persons 2 years of age and older:

  • Travelers to areas with increased rates of hepatitis A
  • Men who have sex with men
  • Injecting and non-injecting drug users
  • Persons with clotting-factor disorders (e.g. hemophilia)
  • Persons with chronic liver disease
  • Children living in areas with increased rates of hepatitis A during the baseline period from 1987-1997.

TRENDS & STATISTICS 

 

  • Occurs in epidemics both nationwide and in communities
  • During epidemic years, the number of reported cases reached 35,000.
  • In the late 1990s, hepatitis A vaccine was more widely used and the number of cases reached historic lows.
  • One-third of Americans have evidence of past infection (immunity).

 

HEPATITIS B FACT SHEET

 

SIGNS & SYMPTOMS

About 30% of persons have no signs or symptoms. 
Signs and symptoms are less common in children than adults.

  • Jaundice
  • Fatigue
  • Abdominal pain
  • Loss of appetite
  • Nausea, vomiting 
  • Joint pain

CAUSE

  • Hepatitis B virus (HBV)

LONG-TERM EFFECTS WITHOUT VACCINATION

Chronic infection occurs in:

  • 90% of infants infected at birth
  • 30% of children infected at age 1 – 5 years 
  • 6% of persons infected after age 5 years 

Death from chronic liver disease occurs in:

  • 15-25% of chronically infected persons

TRANSMISSION

·         Occurs when blood or body fluids from an infected person enters the body of a person who is not immune. 

  • HBV is spread through having sex with an infected person without using a condom (the efficacy of latex condoms in preventing infection with HBV is unknown, but their proper use may reduce transmission), by sharing drugs, needles, or “works” when “shooting” drugs, through needle sticks or sharps exposures on the job, or from an infected mother to her baby during birth.

Persons at risk for HBV infection might also be at risk for infection with hepatitis C virus (HCV) or HIV.

RISK GROUPS

 

  • Persons with multiple sex partners or diagnosis of a sexually transmitted disease
  • Men who have sex with men
  • Sex contacts of infected persons
  • Injection drug users
  • Household contacts of chronically infected persons

PREVENTION

  • Hepatitis B vaccine is the best protection.
  • If you are having sex, but not with one steady partner, use latex condoms correctly and every time you have sex. The efficacy of latex condoms in preventing infection with HBV is unknown, but their proper use may reduce transmission.
  • If you are pregnant, you should get a blood test for hepatitis B; Infants born to HBV-infected mothers should be given HBIG (hepatitis B immune globulin) and vaccine within 12 hours after birth.
  • Do not shoot drugs; if you shoot drugs, stop and get into a treatment program; if you can’t stop, never share drugs, needles, syringes, water, or “works”, and get vaccinated against hepatitis A and B.
  • Do not share personal care items that might have blood on them (razors, toothbrushes).
  • Consider the risks if you are thinking about getting a tattoo or body piercing. You might get infected if the tools have someone else’s blood on them or if the artist or piercer does not follow good health practices.
  • If you have or had hepatitis B, do not donate blood, organs, or tissue.
  • If you are a health care or public safety worker, get vaccinated against hepatitis B, and always follow routine barrier precautions and safely handle needles and other sharps. (View current post-exposure prophylaxis recommendations.)

VACCINE RECOMMENDATIONS

  • Hepatitis B vaccine available since 1982
  • Routine vaccination of 0-18 year olds
  • Vaccination of risk groups of all ages (see section on risk groups

TREATMENT & MEDICAL MANAGEMENT

  • HBV infected persons should be evaluated by their doctor for liver disease.
  • Adefovir dipivoxil, alpha interferon, lamivudine, and entecavir are four drugs licensed for the treatment of persons with chronic hepatitis B.
  • These drugs should not be used by pregnant women.
  • Drinking alcohol can make your liver disease worse.

TRENDS & STATISTICS

 

 

  • Number of new infections per year has declined from an average of 260,000 in the 1980s to about 73,000 in 2003.
  • Highest rate of disease occurs in 20-49-year-olds.
  • Greatest decline has happened among children and adolescents due to routine hepatitis B vaccination. 
  • Estimated 1.25 million chronically infected Americans, of whom 20-30% acquired their infection in childhood.

HEPATITIS C FACT SHEETS

SIGNS & SYMPTOMS

80% of persons have no signs or symptoms.

  • Jaundice
  • fatigue
  • dark urine
  • abdominal pain 
  • loss of appetite
  • nausea

CAUSE

  • Hepatitis C virus (HCV)

LONG-TERM EFFECTS

  • Chronic infection: 55%-85% of infected persons
  • Chronic liver disease: 70% of chronically infected persons
  • Deaths from chronic liver disease: 1%-5% of infected persons may die
  • Leading indication for liver transplant

TRANSMISSION

 

 

Recommendations for testing based on risk for HCV infection

  • Occurs when blood or body fluids from an infected person enters the body of a person who is not infected. 
  • HCV is spread through sharing needles or “works” when “shooting” drugs, through needlesticks or sharps exposures on the job, or from an infected mother to her baby during birth.

Persons at risk for HCV infection might also be at risk for infection with hepatitis B virus (HBV) or HIV.

Recommendations for Testing Based on Risk for HCV Infection

PERSONS

RISK OF INFECTION

 TESTING RECOMMENDED?

Injecting drug users

High

Yes

Recipients of clotting factors made before 1987

High

Yes

Hemodialysis patients

Intermediate

Yes

Recipients of blood and/or solid organs before 1992

Intermediate

Yes

People with undiagnosed liver problems

Intermediate

Yes

Infants born to infected mothers

Intermediate

After 12-18 mos. old

Healthcare/public safety workers

Low

Only after known exposure

People having sex with multiple partners

Low

No*

People having sex with an infected steady partner

Low

No*

*Anyone who wants to get tested should ask their doctor.

PREVENTION

  • There is no vaccine to prevent hepatitis C.
  • Do not shoot drugs; if you shoot drugs, stop and get into a treatment program; if you can’t stop, never share needles, syringes, water, or “works”, and get vaccinated against hepatitis A & B.
  • Do not share personal care items that might have blood on them (razors, toothbrushes).
  • If you are a health care or public safety worker, always follow routine barrier precautions and safely handle needles and other sharps; get vaccinated against hepatitis B.
  • Consider the risks if you are thinking about getting a tattoo or body piercing. You might get infected if the tools have someone else’s blood on them or if the artist or piercer does not follow good health practices.
  • HCV can be spread by sex, but this is rare. If you are having sex with more than one steady sex partner, use latex condoms* correctly and every time to prevent the spread of sexually transmitted diseases. You should also get vaccinated against hepatitis B.
  • If you are HCV positive, do not donate blood, organs, or tissue.

TREATMENT & MEDICAL MANAGEMENT

 

 

  • HCV positive persons should be evaluated by their doctor for liver disease.
  • Interferon and ribavirin are two drugs licensed for the treatment of persons with chronic hepatitis C. 
  • Interferon can be taken alone or in combination with ribavirin. Combination therapy, using pegylated interferon and ribavirin, is currently the treatment of choice.
  • Combination therapy can get rid of the virus in up to 5 out of 10 persons for genotype 1 and in up to 8 out of 10 persons for genotype 2 and 3. 
  • Drinking alcohol can make your liver disease worse.

STATISTICS & TRENDS

  • Number of new infections per year has declined from an average of 240,000 in the 1980s to about 30,000 in 2003.
  • Most infections are due to illegal injection drug use.
  • Transfusion-associated cases occurred prior to blood donor screening; now occurs in less than one per million transfused unit of blood.
  • Estimated 3.9 million (1.8%) Americans have been infected with HCV, of whom 2.7 million are chronically infected.

 

FREQUENLY ASKED QUESTIONS (FAQ’s)

The FAQ’s were obtained from the Hepatitis C section of the CDC website (http://www.cdc.gov).  This website is updated often and should be referenced for the latest information regarding hepatitis.  There are also FAQ’s for hepatitis A and hepatitis B on the website.

Diagnosis and testing

What blood tests are available to check for hepatitis C?
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:

a) Anti-HCV (antibody to HCV)

  • EIA (enzyme immunoassay) or CIA (enhanced chemiluminescence immunoassay)
    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

Anti-HCV does not tell whether the infection is new (acute), chronic (long-term) or is no longer present.

 

b) Qualitative tests to detect presence or absence of virus (HCV RNA)

c) Quantitative tests to detect amount (titer) of virus (HCV RNA)

A single positive PCR test indicates infection with HCV. A single negative test does not prove that a person is not infected. Virus may be present in the blood and just not found by PCR. Also, a person infected in the past who has recovered may have a negative test. When hepatitis C is suspected and PCR is negative, PCR should be repeated.

Can you have a “false positive” anti-HCV test result?
Yes. A false positive test means the test looks as if it is positive, but it is really negative. This happens more often in persons who have a low risk for the disease for which they are being tested. For example, false positive anti-HCV tests happen more often in persons such as blood donors who are at low risk for hepatitis C. Therefore, 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. Click here for more information on Guidelines for Laboratory Testing and Result Reporting of Antibody to Hepatitis C Virus.

Can you have a “false negative” anti-HCV test result?
Yes. 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. In these persons, research-based tests such as PCR may be considered.

How long after exposure to HCV does it take to test positive for anti-HCV?
Anti-HCV 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.

How long after exposure to HCV does it take to test positive with PCR?
It is possible to find HCV within 1 to 2 weeks after being infected with the virus.

Who should get tested for hepatitis C?

·         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

What is the next step if you have a confirmed positive anti-HCV test?
Measure the level of ALT ( alanine aminotransferase, a liver enzyme) in the blood. An elevated ALT indicates inflammation of the liver and you should be checked further for chronic (long-term) liver disease and possible treatment. The evaluation should be done by a healthcare professional familiar with chronic hepatitis C.

Can you have a normal liver enzyme (e.g., ALT) level and still have chronic hepatitis C?
Yes. It is common for persons with chronic hepatitis C to have a liver enzyme level that goes up and down, with periodic returns to normal or near normal. Some persons have a liver enzyme level that is normal for over a year but they still have chronic liver disease. If the liver enzyme level is normal, persons should have their enzyme level re-checked several times over a 6 to 12 month period. If the liver enzyme level remains normal, your doctor may check it less frequently, such as once a year.

Can I donate blood if I have had any type of viral hepatitis?
If you had any type of viral hepatitis since aged 11 years, you are not eligible to donate blood. In addition, if you ever tested positive for hepatitis B or hepatitis C, at any age, you are not eligible to donate, even if you were never sick or jaundiced from the infection.

How is HCV spread from one person to another?

How could a person have gotten hepatitis C?
HCV is spread primarily by direct contact with human blood. For example, you may have gotten infected with HCV if:

·         you ever injected street drugs, as the needles and/or other drug “works” used to prepare or inject the drug(s) may have had someone else’s blood that contained HCV on them.

·         you received blood, blood products, or solid organs from a donor whose blood contained HCV.

·         you were ever on long-term kidney dialysis as you may have unknowingly shared supplies/equipment that had someone else’s blood on them.

·         you were ever a healthcare worker and had frequent contact with blood on the job, especially accidental needlesticks.

·         your mother had hepatitis C at the time she gave birth to you. During the birth her blood may have gotten into your body.

·         you ever had sex with a person infected with HCV.

·         you lived with someone who was infected with HCV and shared items such as razors or toothbrushes that might have had his/her blood on them.

How long can HCV live outside the body and transmit infection?
Recent studies suggest that HCV may survive on environmental surfaces at room temperature at least 16 hours, but no longer than 4 days.

What do you use to remove HCV from environmental surfaces?
You should clean up any blood spills – including dried blood, which can still be infectious – using 1:100 dilution of one part household bleach to 100 parts of water for disinfecting the area. Use gloves when cleaning up any blood spills.

Is there any evidence that HCV has been spread during medical or dental procedures done in the United States?
Medical and dental procedures done in the United States generally do not pose a risk for the spread of HCV. However, there have been a few situations in which HCV has been spread between patients when supplies or equipment were shared between them.

Can HCV be spread by sexual activity?
Yes, but this does not occur very often. See section below on counseling for more information on hepatitis C and sexual activity.

Can HCV be spread by oral sex?
There is no evidence that HCV has been spread by oral sex. See section on counseling for more information on hepatitis C and sexual activity.

Can HCV be spread within a household?
Yes, but this does not occur very often. If HCV is spread within a household, it is most likely due to direct exposure to the blood of an infected household member.

Can you get Hepatitis C from getting a tattoo?
Although biologically possible when poor infection control practices are used, there is no evidence that hepatitis C virus (HCV) has been spread through tattooing.

Since more advanced tests have been developed for use in blood banks, what is the chance now that a person can get HCV infection from transfused blood or blood products?
Less than 1 chance per 2 million units transfused.

Pregnancy and Breast feeding

Should pregnant women be routinely tested for anti-HCV? No. Pregnant women have no greater risk of being infected with HCV then non-pregnant women. If pregnant women have risk factors for hepatitis C, they should be tested for anti-HCV.

What is the risk that HCV infected women will spread HCV to their newborn infants?
About 5 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. 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 a woman with hepatitis C be advised against breast-feeding?
No. There is no evidence that breast-feeding spreads HCV. HCV-positive mothers should consider abstaining from breast-feeding if their nipples are cracked or bleeding.

When should babies born to mothers with hepatitis C be tested to see if they were infected at birth?
Children should not be tested for anti-HCV before 18 months of age as anti-HCV from the mother might last until this age. If diagnosis is desired prior to 18 months of age, testing for HCV RNA could be performed at or after an infant’s first well-child visit at age 1-2 months. HCV RNA testing should then be repeated at a subsequent visit independent of the initial HCV RNA test result.

Counseling

How can persons infected with HCV prevent spreading HCV to others?

·         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.

How can a person protect themselves from getting hepatitis C and other diseases spread by contact with human blood?

·         Don’t ever shoot drugs. If you shoot drugs, stop and get into a treatment program. If you can’t stop, never reuse or share syringes, water, or drug works, and get vaccinated against hepatitis A and hepatitis B.

·         Do not share toothbrushes, razors, or other personal care articles. They might have blood on them.

·         If you are a healthcare worker, always follow routine barrier precautions and safely handle needles and other sharps. Get vaccinated against hepatitis B

·         Consider the health risks if you are thinking about getting a tattoo or body piercing: You can get infected if:

o        the tools that are used have someone else’s blood on them.

o        the artist or piercer doesn’t follow good health practices, such as washing hands and using disposable gloves.

HCV can be spread by sex, but this does not occur very often. If you are having sex, but not with one steady partner:

·         You and your partners can get other diseases spread by having sex (e.g., AIDS, hepatitis B, gonorrhea or chlamydia).

·         You should use latex condoms correctly and every time. The efficacy of latex condoms in preventing infection with HCV is unknown, but their proper use may reduce transmission.

·         You should get vaccinated against hepatitis B.

Should patients with hepatitis C change their sexual practices if they have only one long-term steady sex partner? No. There is a very low chance of spreading HCV to that partner through sexual activity. If you want to lower the small chance of spreading HCV to your sex partner, you may decide to use barrier precautions such as latex condoms. The efficacy of latex condoms in preventing infection with HCV is unknown, but their proper use may reduce transmission. Ask your doctor about having your sex partner tested.

What can persons with HCV infection do to protect their liver?

·         Stop using alcohol.

·         See your doctor regularly.

·         Don’t start any new medicines or use over-the-counter, herbal, and other medicines without a physician’s knowledge.

·         Get vaccinated against hepatitis A if liver damage is present.

What other information should patients with hepatitis C be aware of?

·         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.

·         Involvement with a support group may help patients cope with hepatitis C.

Should persons with chronic hepatitis C be vaccinated against hepatitis B?
If persons are in risk groups for whom hepatitis B vaccine is recommended, they should be vaccinated. (A Comprehensive Strategy for Eliminating Transmission in the United States Through Universal Childhood Vaccination)

Long-term Consequences of HCV Infection

What are the chances of persons with HCV infection developing long term infection, chronic liver disease, cirrhosis, liver cancer, or dying as a result of hepatitis C?
Of every 100 persons infected with HCV about:

·         55-85 of persons might develop long-term infection

·         70 persons might develop chronic liver disease

·         5-20 persons might develop cirrhosis over a period of 20 to 30 years

·         1-5 of persons might die from the consequences of long term infection (liver cancer or cirrhosis)

Hepatitis C is a leading indication for liver transplants.

Do medical conditions outside the liver occur in persons with chronic hepatitis C?
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. Such conditions include: glomerulonephritis, essential mixed cryoglobulinemia, and porphyria cutanea tarda.

 

Management and Treatment of Chronic Hepatitis C

When might a specialist (gastroenterologist, infectious disease physician, or hepatologist) be consulted in the management of HCV-infected persons?
A referral to or consultation with a specialist for further evaluation and possible treatment may be considered if a person is anti-HCV positive 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.

What is the treatment for chronic hepatitis C?
Combination therapy with pegylated interferon and ribavirin is the treatment of choice resulting in sustained response rates of 40%-80%. (up to 50% for patients infected with the most common genotype found in the U.S. [genotype 1] and up to 80% for patients infected with genotypes 2 or 3). Interferon monotherapy is generally reserved for patients in whom ribavirin is contraindicated. Ribavirin, when used alone, does not work. Combination therapy using interferon and ribavirin is now FDA approved for the use in children aged 3-17 years.

What are the side effects of interferon therapy?
Most persons have flu-like symptoms (fever, chills, headache, muscle and joint aches, fast heart rate) early in treatment, but these lessen with continued treatment. Later side effects may include tiredness, hair loss, low blood count, trouble with thinking, moodiness, and depression. Severe side effects are rare (seen in less than 2 out of 100 persons). These include thyroid disease, depression with suicidal thoughts, seizures, acute heart or kidney failure, eye and lung problems, hearing loss, and blood infection. Although rare, deaths have occurred due to liver failure or blood infection, mostly in persons with cirrhosis. An important side effect of interferon is worsening of liver disease with treatment, which can be severe and even fatal. 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.

What are the side effects of combination (ribavirin + interferon) treatment?
In addition to the side effects due to interferon described above, ribavirin can cause serious anemia (low red blood cell count) and 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.

Can anything be done to reduce symptoms or side effects due to antiviral treatment?
You should report what you are feeling to your doctor. Some side effects may be reduced by giving interferon at night or lowering the dosage of the drug. In addition, flu-like symptoms can be reduced by taking acetaminophen before treatment.

Can children receive interferon therapy for chronic hepatitis C?
The Food and Drug Administration has approved the use of the combination anti-viral therapy for the treatment of hepatitis C in children 3 to 17 years old. For details please refer to page 11 of AASLD Practice Guideline: Diagnosis, Treatment, and Management of Hepatitis C.

 

 

REFERENCES

This course is based on information obtained form the Center of Disease Control (CDC) website- http://www.cdc.gov.  Some of the information from the website was edited for applicability to this course and other sections were used verbatim.

 

Everson, Gregory T. and Weinbers, Hedy, Living with Hepatitis C:  A Survival Guide, 3rd Revised Edition, April 2002

 

Horn, Lyle W. and Alcam, I. Edward, Hepatitis, March 2005

 

Kennard M.D., Jerry, What is Hepatitis?, Mens Health, June 2005

 

Palmer, Melissa, Dr. Melissa Palmers’s Guide to Hepatitis and Liver Disease, May 2004

 

Parker, James N., and Parker Phillip M., Hepatitis C Virus-A Medical Dictionary, Bibliography, and Annotated Research Guide  to Internet References, October 2004

 

Worman, Howard J., The Hepatitis C Sourcebook, May 2004

 

Merriam Webster Dictionary, 1993

 

Internet:

      Center of Disease Control website:  http:/www.cdc.gov

      Other/various articles and websites related to hepatitis