Hepatitis C

Hepatitis C virus (HCV) infection is a major cause of chronic liver disease and associated morbidity and mortality worldwide.

 In 2015, the WHO estimated that there were approximately 71 million people (95% uncertainty interval 64–103 million, or 1% of the global population) living with chronic HCV,2 with the highest prevalence in the eastern Mediterranean region (2・3%), followed by the European region (1・5%) and the African region (1%).

The cause of this infection is the hepatitis C virus (HCV). It is transmitted through body fluids, intravenous blood use and sexual contact with an infected partner. There are many types of HCV, and the way they respond to treatment differs. Type 1 HCV is the most common type in the USA.

Stages of Hepatitis C

The virus has several stages, and it manifests in people in different ways:

• Incubation period: this is the time interval between when you are first exposed to the virus and when the symptoms start to manifest. It is usually between 14 to 80 days.

• Acute hepatitis C. This stage lasts for the first 6 months after exposure to the virus. Some people can get rid of the virus or clear the virus on their own during this stage.

• Chronic hepatitis C. hepatitis c infection progresses to the chronic stage in up to 85% of those infected, leading to serious health problems like liver cirrhosis and cancer.
• Cirrhosis. This infection leads to inflammation which stimulates the replacement of healthy cells of your liver with scar tissues. This usually takes about 20 to 30 years, but it can be hastened if you have HIV or drink alcohol.

• Liver cancer and liver failure

Symptoms of hepatitis C

Most people with this infection sometimes present with no symptoms, but during the acute phase, the following symptoms might be noticed:

• Fever
• Feeling week easily
• Dark coloured urine
• Yellowing of skin and eyes
• Joint pain
• Anorexia (loss of appetite)
• Stomach pain
• Vomiting
• Pale stool

How hepatitis C is transmitted

Hepatitis C is transmitted when the hepatitis C virus from an infected body/ body fluids find its way into your bloodstream through the following ways:

• Sharing infected needles
• An infected mother can pass it to a child during birth.
• Sharing personal items like clippers, razors and toothbrush
• Unsafe sexual activities like having several partners or unprotected sex
• Getting pierced by an unclean equipment

If you can get hepatitis C through the above ways, then how can you not get the disease?

By:

• Kissing
• Mosquito bites
• Touching/ holding hands
• Casual contact
• Hugging
• Breastfeeding (provided nipples are cracked and bleeding)
• Coughing
• Sharing of things like cooking/eating utensils and food.

 Symptoms of chronic advanced hepatitis C

You can notice the following symptoms along with the acute symptoms:

• Ascites (fluid build-up in the abdomen) or edema (fluid build-up in the legs).
• Gallstones
• Encephalopathy
• Bleeding and bruising easily
• Serious and intense itching
• Kidney failure
• Loss of muscle mass
• Memory impairment
• Difficulty concentrating
• Veins that looks like a spider on the skin
• Weight loss
• Vomiting of blood

How do you test for the virus?

Liver function tests (LFT): this test measures the levels of proteins and enzymes in your body. These enzymes and proteins are expected to rise within 7 to 8 weeks after you have been infected.  As the infection damages the liver, it leaks the enzymes into the bloodstream, resulting in the elevation of the liver enzymes. However, it is possible for the levels of the enzymes to be normal in infected patients.

Anti-HCV antibodies: antibodies are protein that the white blood cells make after coming in contact with the hepatitis C virus. The antibodies can be detected as early as 12weeks after infection.  There are rapid tests to detect these antibodies, but some tests can take between a few days to a week for the result to be available.

The result can either be positive or negative:

• If negative:
  • That means that you don’t have hepatitis C, but if you’ve been exposed within the last 6 months, you will need to go for the test again.
• If positive:
  • That means that the test picked up hepatitis C antibodies, and you’ve been infected, but you might need another test to confirm the diagnosis.

If the test picks up antibodies, you’ll need to go for an HCV RNA test.

HCV RNA measures the number of the genetic material of the hepatitis virus particles in your blood. The genetic material usually shows up 1-2 weeks after infection.

• The results can be:
  • Negative: if you don’t have hepatitis C.
  • Positive: if you currently have hepatitis C.

How is hepatitis C treated?

There is no recommended treatment for the acute stage of the disease, but there are several medications available for treating the chronic stage.

Ribavirin, Peginterferon, and Interferon used to be the main drugs used to treat hepatitis C. Still. They can have nasty side effects like anemia, skin rash, fatigue, mild anxiety, nausea, diarrhea, depression and flu-like symptoms.

On the other hand, DAA (direct-acting antiviral agent) provides a simpler, better tolerated, shorter duration and more effective treatment than the interferon-based treatment. They are usually once a day treatment for a few weeks.

The kind of treatment that you receive and its duration depends on certain factors like

• Presence of Liver cirrhosis
• Kidney failure
• Post kidney/ liver transplant

Examples of some common drugs used in the treatment of hepatitis C

• Daclatasvir (Daklinza). 
• Elbasvir -grazoprevir ( Zepatier )
• Glecaprevir-pibrentasvir ( Mavyret ). 
• Ledipasvir-sofosbuvir ( Harvoni ). 
• Ombitasvir-paritaprevir-dasabuvir-ritonavir (Viekira Pak). 
• Ombitasvir-paritaprevir- ritonavir (Technivie). 
• Ribavirin ( Copegus , Moderiba, Rebetol,  Ribasphere, Virazole ). This is a twice a day regimen for 24 to 48 weeks or longer.
• Sofosbuvir (Sovaldi) with interferon and ribavirin. .
• Sofosbuvir-velpatasvir (Epclusa). 
• Sofosbuvir-velpatasvir-voxilaprevir (Vosevi). 

For more detailed information, click here.

Hepatitis C and pregnancy

All pregnant women should be tested for HCV infection when they register for prenatal care.

For women of reproductive age with known HCV infection, antiviral therapy is recommended before considering pregnancy to reduce HCV transmission risk to future offspring.

Initiating treatment during pregnancy is not recommended because of the lack of safety and efficacy data.

For HCV-antibody positive pregnant women, routine liver tests, RNA and HCV are recommended when they register for prenatal care in order to assess the risk of MTCT(mother to child transmission) and degree of liver disease.

All pregnant women with HCV infection should receive prenatal and intrapartum care that is appropriate for their individual obstetric risk(s)because there is currently no known intervention of reducing MTCT.

Pregnant women with HCV infection alongside pruritus or jaundice should be assigned a high index of suspicion for intrahepatic cholestasis of pregnancy. They should be assessed for the levels of alanine aminotransferase ALT, aspartate aminotransferase AST, and serum bile acids.

HCV-infected women with cirrhosis should be counseled about the increased risk of adverse maternal and perinatal outcomes(high-risk pregnancy)

Breastfeeding is not contraindicated in women with HCV infection, except when the mother has cracked/ damaged nipples, or there is co-infection with the human immunodeficiency virus.

Women with HCV infection should have their HCV RNA reevaluated after delivery to assess for spontaneous clearance.

Cesarean delivery is not recommended for the prevention of perinatal transmission.

The common Side Effects of Hepatitis C Medications

The most Frequent side effects patients on hepatitis C drugs have complained of include:

• Low blood cells counts
• Flu-like symptoms
• headache
• nervousness
• Depression
• Difficulty thinking and concentrating

The common Complications of Hepatitis C

If the infection is not treated and it’s allowed to progress to the chronic stage, it can lead to

• Cirrhosis or scarring of the liver
• Liver cancer
• Liver failure

If you have any of the complications, your doctor might start considering you as a candidate for a liver transplant.

How can you prevent yourself from contracting the virus?

There is currently no vaccine to prevent hepatitis C.

 To avoid getting the virus:

• Practise safe sexual activities like the use of latex condom.
•  Do not share personal items.  

References

1. Marcellin P, Boyer N, Gervais A, et al. Long-term histologic improvement and

loss of detectable intrahepatic HCV RNA in patients with chronic hepatitis and sustained response to interferon-alpha therapy. Ann Intern Med 1997;

127:875–81.

2. Poynard T, McHutchison J, Manns M, et al. Impact of pegylated interferon

alfa-2b and ribavirin on liver fibrosis in patients with chronic hepatitis C.

Gastroenterology, 2002; 122:1303–13.

3. Morgan RL, Baack B, Smith BD, Yartel A, Pitassi M, Falck-Ytter Y. Eradication of

hepatitis C virus infection and the development of hepatocellular carcinoma: a

meta-analysis of observational studies. Ann Intern Med 2013; 158:329–37.

4. van der Meer AJ, Veldt BJ, Feld JJ, et al. Association between sustained virological

response and all-cause mortality among patients with chronic hepatitis C and

advanced hepatic fibrosis. JAMA, 2012; 308:2584–93.

5. Veldt BJ, Heathcote EJ, Wedemeyer H, et al. Sustained virologic response and clinical

outcomes in patients with chronic hepatitis C and advanced fibrosis. Ann

Intern Med 2007; 147:677–84.

6. Fabrizi F, Dixit V, Messa P. Antiviral therapy of symptomatic HCV-associated

mixed cryoglobulinemia: a meta-analysis of clinical studies. J Med Virol 2013;

85:1019–27.

7. Sise ME, Bloom AK, Wisocky J, et al. Treatment of hepatitis C virus-associated

mixed cryoglobulinemia with direct-acting antiviral agents. Hepatology 2016;

63:408–17.

8. Gisbert JP, Garcia-Buey L, Pajares JM, Moreno-Otero R. Systematic review:

regression of lymphoproliferative disorders after treatment for hepatitis C infection.

Aliment Pharmacol Ther 2005; 21:653–62.

9. Takahashi K, Nishida N, Kawabata H, Haga H, Chiba T. Regression of Hodgkin

lymphoma in response to antiviral therapy for hepatitis C virus infection. Intern

Med 2012; 51:2745–7.

10. Svoboda J, Andreadis C, Downs LH, Miller WT Jr, Tsai DE, Schuster SJ. Regression

of advanced non-splenic marginal zone lymphoma after treatment of hepatitis C

virus infection. Leuk Lymphoma 2005; 46:1365–8.

11. Mazzaro C, Little D, Pozzato G. Regression of splenic lymphoma after treatment

of hepatitis C virus infection. N Engl J Med 2002; 347:2168–70; author reply

2168–70.

12. Backus LI, Boothroyd DB, Phillips BR, Belperio P, Halloran J, Mole LA. A sustained

virologic response reduces risk of all-cause mortality in patients with hepatitis

C. Clin Gastroenterol Hepatol 2011; 9:509–516.e1.

13. Younossi ZM, Jiang Y, Smith NJ, Stepanova M, Beckerman R. Ledipasvir/sofosbuvir

regimens for chronic hepatitis C infection: insights from a work productivity

economic model from the United States. Hepatology, 2015; 61:1471–8.

14. Younossi ZM, Stepanova M, Afdhal N, et al. Improvement of health-related

quality of life and work productivity in chronic hepatitis C patients with early

and advanced fibrosis treated with ledipasvir and sofosbuvir. J Hepatol 2015;

63:337–45.

15. Younossi ZM, Stepanova M, Feld J, et al. Sofosbuvir/velpatasvir improves

patient-reported outcomes in HCV patients: results from ASTRAL-1 placebo-

controlled trial. J Hepatol 2016; 65:33–9.