Hepatitis C

The Hepatitis C Virus (HCV) is a Ribonucleic Acid Virus (RNA), which affects the Liver cells leading to both acute and chronic infection. It is the most common chronic viral infection in the United States. About 2.7 to 3.9 million people are suffering from chronic HCV infection.

Transmission of HCV is predominantly through direct contact with blood and blood products. Currently, over 50% of reported cases of HCV infection is due to IV drug use and needle sharing. Transmission through sexual intercourse or from an infected mother to her child is very rare.

Symptoms of HCV Infection

Infection with HCV can present as an Acute HCV infection but it is more commonly asymptomatic initially and persists as a chronic illness. Up to 85% of those infected, progress to develop chronic hepatitis.

Acute hepatitis

• Fever
• Muscle and joint pains
• Skin rash
• Jaundice

Chronic Hepatitis

Chronic infection with HCV is moderate in severity with a rising and falling level of liver enzymes. Over time, there is risk of progression to chronic liver disease.  Several non-liver conditions are associated with HCV infection such as

• Cryglobulinemia: This is an elevation in the blood levels of cryoglobulins. These are proteins (predominantly immunoglobulins) which become insoluble at low temperatures. They can cause blood clots and kidney damage.
• Membranoproliferative glomerulonephritis: This is a type of inflammation of the kidney tissue which leads to leakage of protein. The patient may experience blood in the urine and declining kidney function.
• Porphyria cutanea tarda: this is a disease associated with an enzyme defect in the pathway for synthesising haemoglobin. There is accumulation of porphyrins which can lead to a painful blistering skin rash on exposure to sunlight.

Complications of HCV infection

• Cirrhosis of the Liver: This is a chronic scarring and fibrosis of the liver due to persistent viral infection of the liver. This develops in about 20% over 20 t o30 years. This can result in vascular resistance in the veins supplying the liver with back pressure to the abdomen organs. They develop ascites or fluid in the abdominal cavity and an increase in the size of the spleen along with other symptoms of chronic liver failure.
• Liver Cancer: Among those infected with chronic HCV, 5% have the risk of developing liver cancer  annually.

Diagnosis of HCV infection

In case of an acute illness, HCV infection can be diagnosed using blood tests for serum antibodies against HCV (IgM antibodies). However, most patients with chronic HCV may be completely asymptomatic. Hence, major health organisations like the WHO and CDC recommend screening for the following high risk groups.

• IV drug users, including those who may be former users
• Everyone born between 1945 to 1965 (Baby boomer generation)
• Patients undergoing long term hemodialysis
• Individuals with HIV infection
• Children born to mothers with HCV infection
• People who have received blood transfusion of organ transplants before July 1992
• People who have received clotting factors before 1987
• Health care workers with exposure to HCV positive blood through needle stick injuries
• Individuals known to have received blood or organs from HCV positive individuals

Investigations

1. Antibody Screening: The screening test looks for anti-HCV antibodies. Not: patients who have cleared the virus from the body also have the antibodies.
2. Testing for HCV RNA: This test detects virus in the blood stream suing PCR (polymerase chain reaction) and helps to confirm the diagnosis of chronic HCV infection.
3. Liver function tests: These test for elevated liver enzymes (ALT and AST)
4. Abdominal Ultrasound: This is used to look for cirrhosis of the liver and can also be used to screen for development of Liver cancer.

Treatment of Hepatitis C

Until the last decade, Chronic Hepatitis C was considered un treatable. But now, we have many options of different drug regimens which can provide a cure and clear the body from the body. These are as follows:

1. Older medicines: Ribavirin, inferferons
2. Newer medicines (directly acting anti- virals): sofosbuvir, ledipasvir, simeprevir etc.

The exact treatment regimen is arrived at by a specialist based on the following factors

1. The genotype of the HCV virus infecting the patient
2. History of previous intake of anti-HCV treatment
3. Extent of liver damage

Prognosis of HCV infection

Without treatment, the patient continues on a gradual course with progressive liver damage. As mentioned above, 20% develop cirrhosis over 20 to 30 years and a majority may develop liver cancer in later years. The newly introduced directly acting antiviral medications can potentially cure individuals with HCV. These are unfortunately very expensive and patients may require assistance from government and private organisations to support the cost.

Prevention of HCV

There is currently no vaccine to protect from HCV infection

References:

• Hepatitis C Questions and Answers for the Public | CDC [Internet]. 2018 [cited 2018 Jul 29]
• Hepatitis C [Internet]. World Health Organization. [cited 2018 Jul 29]
• Hepatitis C | NIDDK [Internet]. National Institute of Diabetes and Digestive and Kidney Diseases. [cited 2018 Jul 29]