Hepatitis C

What is hepatitis C?

Hepatitis C is a virus that infects the liver. It can result in serious health issues, including liver failure and death. The virus spreads mainly during blood-to-blood contact.

An estimated 130-200 million people is affected worldwide, about 3% of the global population. ^{[1] [2]} Since the virus was identified in 1989, infection rates have reduced, probably as a result of hepatitis C testing of blood transfusions and promotion of using sterile needles in drug use.

Causes

Hepatitis C is caused by the hepatitis C virus, or HCV for short. It can be transmitted from person to person mainly during blood-to-blood contact.

Blood-to-blood contact

A majority of hepatitis C infections occur through sharing of infected needles or using unsterilized medical supplies or tattooing equipment. Intravenous drug users have a very high chance of contracting hepatitis C, particularly with repeated needle-sharing habits. The virus can also be transmitted through infected cuts and open sores. Blood-to-blood contact can occur during sharing of personal items such as razors, toothbrushes or nail scissors.

Blood transfusions

Blood transfusions, organ transplants and blood products were a major infection route before the virus was identified. Since the early 1990s, many countries test all blood donations for hepatitis C, so infection through this route has become much less common.

Other infection routes

The hepatitis C virus can, on rare occasions, be transferred between people through other routes, such as mother-to-child transmission during pregnancy or birth. The risk of transmission through unprotected sex with an infected person is low, but increases when the sexual practice has a higher chance of blood-to-blood contact, such as anal sex.

Hepatitis C is not transmitted by saliva during sharing of food, cutlery, or from contact with by sneeze and cough droplets from infected people.

Types

A hepatitis C infection can be divided into two stages: acute and chronic.

Acute hepatitis C

The initial stage of a hepatitis C infection is known as the acute stage. It can take several weeks before the symptoms appear, and it can last up to six months. ^[3] Most of the infected people (about 80%) either do not display any or develop only minor symptoms.

The outcome of infection with the hepatitis C virus changes from person to person. In 15-40% of people exposed to the HCV virus, the infection clears naturally without the need for medical treatment. ^[4] The virus does not remain in the body.

Chronic hepatitis C

For the remaining 60-85% of infected people, in whom natural clearance does not occur, the virus will remain in the body indefinitely unless treated (and often even after treatment - see below). This is known as chronic hepatitis C infection.

People with a chronic hepatitis C infection are able to transmit the virus to other people, but most of them show few, if any, signs of trouble throughout their lives. However, between 15-30% of people with chronic hepatitis C go on to develop liver failure and other serious complications, which may result in death (see below). ^[2]

Signs and symptoms

Acute hepatitis C

In the small proportion of individuals who develop symptoms of acute hepatitis C, symptoms can include:

• Fatigue;
• Loss of appetite;
• Nausea and vomiting;
• Dark urine;
• Muscle and joint pain;
• Jaundice - a yellowing of the skin and/or eyes (this appears in one of five people with the infection);
• Fever (usually during the first few weeks after infection), and;
• Pain in the liver, in the upper-right area of the abdomen.

These symptoms usually improve over a few months, as the virus is cleared from the body or the body adapts to living with the virus (chronic hepatitis C).

Chronic hepatitis C

The liver can sustain a fair amount of damage before it starts malfunctioning. As a result, in many conditions that cause liver failure, the signs and symptoms can be slow to appear.

In the months and years following the acute stage, symptoms of chronic hepatitis C can include:

• Fatigue;
• Itchy skin;
• Easy bruising and bleeding;
• Fluid accumulation throughout the body, causing abdominal distension (ascites) and leg swelling;
• Weight loss;
• Depression;
• Prominent small vessels on the skin's surface, and;
• Confusion and drowsiness.

Without treatment, the symptoms can worsen leading to eventual death.

Methods for diagnosis

Hepatitis C is diagnosed through blood tests, which measure liver function and detect the presence of antibodies to the HCV virus in the blood. In the common cases of people who do not show any signs of a hepatitis C infection, an infection is suspected from blood tests that indicate an abnormal liver function.

Additional blood tests can be performed to identify presence of other blood-borne infections, which can occur together with hepatitis C, such as HIV and hepatitis B virus (HBV). Scans, such as ultrasound, can also help to monitor the severity of liver failure.

Types of treatment

Hepatitis C can be treated with a combination of several antiviral drugs, commonly pegylated interferon and ribavirin. The success of the treatment is around 50%. ^{[1] [3]} Some people infected with hepatitis C may decide, after consulting their doctor, to not have any treatment, as the side effects of current treatments can be significant (see below).

In late 2013, two new medications for hepatitis C - sofosbuvir and simeprevir - have been shown in clinical trials to have significantly better rates of removing the virus from the body, with fewer side effects. These new drugs are now approved and increasingly available for use. The development and testing of further new-generation drugs for hepatitis C are currently in high gear. These new treatments are expected to improve treatment success rates significantly in the near future. ^{[4] [5]} However, the high cost of these advanced drugs is a key concern, particularly in developing countries.

An early diagnosis of infection can improve the likelihood of successful treatment. There is currently no vaccine for hepatitis C.

Potential complications

Liver failure

Most people with chronic hepatitis C, do not develop any or have only minor symptoms throughout their lives. However, 15-30% of cases will suffer significant liver damage, leading to cirrhosis or liver failure, which seriously affects their health. If this occurs, a liver transplant may be required in order to avoid death.

In a minority of cases, this condition can contribute to the development of liver cancer (hepatocellular carcinoma).

Cancer

Hepatocellular carcinoma, a cancer of the liver cells, is a dangerous complication of liver failure. It occurs in 1-3% of cases and is the leading cause of death in people with chronic hepatitis C. ^{[2] [3]}

Treatment side effects

The side effects of hepatitis C treatment vary from person to person and commonly include:

Mental side effects:

• Depression;
• Anxiety;
• Irritability;
• Difficulty concentrating, and;
• Sleep problems, such as insomnia.

Physical side effects:

• Fatigue;
• Headache;
• Anemia;
• Increased risk of bleeding;
• Fever and chills;
• Muscle ache;
• Blurred vision;
• Nausea or loss of appetite;
• Hair loss, and;
• Itchiness.

Prognosis

With treatment, more than 50% of people with chronic hepatitis C successfully treat their condition. However, it is important to strictly follow treatment routines, to improve the chance of a cure. In those who fail to remove the virus from their body, it normally takes 20-30 years before developing liver failure.

People living with hepatitis C should not be restricted in their social and work lives. If they avoid blood-to-blood contact, they are unlikely to pass the infection onto others.

Prevention

The best way of preventing infection with hepatitis C is to avoid coming into contact with other people's blood.

Avoiding transmission

If you are infected with hepatitis C, you can prevent transmission of the disease to others by:

• Avoiding untested blood or organ donations;
• Avoiding sharing of needles, razors, toothbrushes, nail scissors;
• Telling health professionals about your condition, particularly doctors, dentists and others who might come into contact with your blood;
• Dressing wounds and cuts, and disposing of any blood-stained items safely,
• Avoiding getting tattoos or body piercings, and;
• Practicing safe sex.

Reducing the chance of complications

The chance of experiencing the severe complications of hepatitis C can be reduced somewhat by making lifestyle changes, such as:

• Cutting alcohol consumption, which can further damage the liver;
• Cautious use of medications, such as acetaminophen, that can also damage the liver;
• Eating a balanced diet low in fat to prevent obesity and type 2 diabetes, and;
• Quitting smoking of cigarettes and cannabis.

References

1. Arora S. Thornton K. Murata G. et al. (2011) Outcomes of treatment for hepatitis C virus infection by primary care providers. New England Journal of Medicine 364:2199–2207.,
2. Hajarizadeh B. Grebely J. and Dore G.J. (2013) Epidemiology and natural history of HCV infection. Nature Reviews Gastroenterology & Hepatology 10:553-562.
3. Rosen H.R. (2011). Chronic hepatitis C Infection. New England Journal of Medicine 364:2429–2438.
4. Thomas D.L. (2013). Global control of hepatitis C: where challenge meets opportunity. Nature Medicine 19:850-858.
5. Scheel T.K.H. and Rice C.M. (2013) Understanding the hepatitis C virus life cycle paves the way for highly effective therapies. Nature medicine 19:837–849.
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