Hepatitis-C

Hepatitis C virus

Hepatitis C is not the A and B virus type. It was discovered in 1989 and was found to be another type of virus contributing to acute and chronic hepatitis, as well as cirrhosis and liver cancer. The important consideration is that acute hepatitis patients usually have a very low mortality rate, only one per thousand individuals, but more than 85% of patients will progress to chronic hepatitis. The hepatitis C virus is considered a major problem worldwide. There are at least 150-170 million people worldwide with this disease. It is estimated that three to four million people will become infected with hepatitis C each year. Patients with chronic hepatitis C will progress to cirrhosis 20-30% of the time. there is a 17 times greater risk of liver cancer or 2-6% per year, and an increased mortality rate. To date, there is no vaccine for hepatitis C prevention available.

Infection

occurs in both genders, but it is found in men more than women. In Thailand, the infection rate is approximately 1-2%, but in the Northeast and Northern regions it is 6-7%.

Transmission of Hepatitis C

  1. Blood and all blood products, especially those received before 1990, since Thai Red Cross Society initiated a screening test of hepatitis C virus nationwide after 1992.
  2. Parenteral exposure by using the same syringes and needles. Illicit injection.
  3. Tattooing or ear piercing with non-standard equipment.
  4. Dialysis in chronic kidney disease patients.
  5. Sexual transmission, however, current evidence demonstrates that transmission via this route is very low and is considered as non-statistically significant, except that having multiple sex partners may increase partner infection rate.
  6. Mother-to-child or family-derived transmission. Commonly found in HIV infected mothers or persons with high viral load during pregnancy.

Diseases caused by hepatitis C virus

1. Acute hepatitis: only 20-25% can be self-recovered.
2. Chronic infection: 75-80% of patients progress to chronic infection, 20-40% of which are cirrhosis and end up with liver failure and cirrhosis complications, and 1-4% of cirrhosis patients develop liver cancer.

Factors aggravating disease severity or cirrhosis include:

  1. Exposure to virus at old age.
  2. Exposure to virus via blood transfusion.
  3. Drinking alcohol more than 30-50 grams/day; even small amount of alcohol (20 grams of alcohol) also dramatically contributes to liver damage.

Disease progression

hapc

Acute hepatitis symptoms caused by the hepatitis C virus

Flu-like symptoms, fever, muscle pain, fatigue, loss of appetite, nausea, vomiting, weight loss, and finally jaundiced skin and sclera (icterus symptoms), which can be found only 10-15% of cases. As a result, it is difficult to diagnose, since icterus symptoms do not present in the majority of patients.

Chronic hepatitis symptoms

Patients with hepatitis C virus mostly present with no symptoms. Some patients may have fatigue, lethargy, dizziness, loss of motor function, and hepatitis gradually becoming cirrhosis.In addition, other symptoms related to immunological deficiency such as kidney disease, skin disorder, skin rashes, etc.

Cirrhosis symptoms

Patients in the early phase of cirrhosis do not generally present with symptoms or abnormalities. They can still perform their regular activities the same as usual. Symptoms are represented when they gradually lose their liver function. Signs and symptoms are divided into 2 categories:

1.Symptoms caused by loss of liver cell function that contributes to abnormalities in nutrient and energy production, as well as toxin eradication. Symptoms that appear include:

  • Fatigue, loss of appetite, nausea, vomiting, weight loss.
  • Jaundiced skin and eyes.
  • Ascites, leg edema.
  • Dark, dry, and itching skin with no more lesions or rashes.
  • Nose bleeding, scurvy, bleeding on pillow.
  • Bruised skin, bruising easily.
  • More sensitive to drugs or toxins than usual.
  • Lethargy, drowsiness, confusion, or coma.

2. Symptoms caused by liver fibrosis.

  • Hematemesis, black stool, bloody stool due to a rupture or aneurysm in the esophagus.
  • Enlarged spleen.
  • Paleness, low platelets, low white blood cells.
  • Liver cancer: Patients with cirrhosis caused by hepatitis C virus have a chance of developing liver cancer of 1-4% per year. Patients will lose weight, be pale, have jaundiced skin and sclera, and feel a lump in bowel.

Hepatitis C virus testing

1. Blood tests: to detect the virus and to measure liver function
– Carriers: only the virus is detected, but liver function (ALT) is normal.
– Chronic hepatitis or cirrhosis: both the virus and abnormal liver function are detected.

2. HCV viral load: In some patients, hepatitis C virus may be detected from blood tests; however the result is false positive, because the viral load result shows a very low amount of virus.

3. Liver biopsy: The benefit of this test is to tell the severity level of liver pathology. Biopsy will be performed in case of treatment intervention.

4. Transient elastography (Fibroscan®) is a non-invasive test that helps to detect liver fibrosis and see if emergency treatment is needed.

Hepatitis C virus treatment

>> Acute hepatitis <<     

Since patients with acute hepatitis do not often present any symptoms, they thus do not require any treatment. Only symptomatic treatment will be given when acute hepatitis symptoms occur, that is, having plenty of rest, going to bed early, taking balanced meals, etc. when patients have severe fatigue. Sweet drinks are not necessary, except if there is nausea and vomiting, patients are allowed to drink them at the early stage as usual.

Nowadays, patients with the hepatitis C virus who do not achieve a level of viral suppression within 12 weeks, interferon injection is recommended for 24 weeks without taking ribavirin

>> Chronic hepatitis <<

Most patients with the hepatitis C virus develop chronic infection, and the disease progresses continuously and finally ends up with liver failure. For this reason, chronically infected hepatitis patients should receive treatment.

In Thailand, the treatment plan for all hepatitis strains and HIV-infected with chronic hepatitis C virus is approved in 3 national health insurance policies including public servant coverage, national health insurance, and social security insurance since 2015.

  • Eligibility criteria for patients to receive treatment include:
  1. Age 18-65 years
  2. Stopped drinking alcohol more than 6 months
  3. Positive test of hepatitis C virus: viral load and viral RNA are positive with more than 5,000 iu/ml
  4. Results from the biopsy test demonstrated liver fibrosis equal to F2 level or results by transient elastography procedure given value more than 7.5 kPa
  5. Initial phase of liver cirrhosis
  6. Well controlled co-morbidities such as diabetes, hypertension, etc.
  7. For HIV patients who have been treated with antiviral medications, the HIV virus should not be detected and CD4 level is 350 cells/mm3 or higher. HIV patients who do not received antiviral medication should have CD4 level 500 cells/mm3 or higher
  8. Written consent for treatment to be given, acknowledgement of possible complications, consent to treatment withdrawal

Although the majority of hepatitis C virus patients should receive treatment, because the World Health Organization announced that this disease should be completely cured in 2020, but due to limited budget, they have still not been able to provide treatment in some patients who do not meet eligibility criteria.

  • Patients who are not eligible to receive treatment include the following:
  1. Patients who are unable to stop drinking alcohol, as alcohol not only induces more hepatitis, but it also lowers treatment response.
  2. Patients who use illicit drug injections, since they are at higher risk of re-infection.
  3. Late stage cirrhosis or liver failure, including jaundiced skin and eyes, leg edema, ascites, low white blood cells, low platelets, a rupture or aneurysm in the esophagus or liver failure.
  4. Chronic kidney disease.
  5. Severe mental conditions, especially in patients with depression and schizophrenia
  6. Patients with autoimmune diseases, e.g. SLE, autoimmune hepatitis.
  7. Patients who have kidney, heart or lung transplantation.
  8. Uncontrolled hyperthyroidism.
  9. Patients who are pregnant or not able to use contraception while receiving treatment.
  10. Patients who are suffering from other serious diseases, e.g. hypertension, heart failure, cardiovascular disease, uncontrolled diabetes, emphysema.
  11. HIV infected patients with CD4 level lower than 200/mm3.

Hepatitis C virus treatment objectives Instructions for patients with the hepatitis C virus

The main objective for treatment of the hepatitis C virus is to completely eradicate the virus from the body. The outcome is to decrease hepatitis or to recover hepatitis to a normal status, and thus slow progression of cirrhosis. In addition, treatment of the hepatitis C virus can prevent liver cancer, even though ALT is not decreased to normal level.

Instructions for patients with the hepatitis C virus

  1. Stop donating blood.
  2. Do not use cutlery, i.e. razor, nail cutter, with others.
  3. Do not use needles with others.
  4. Use standard equipment for tattooing or any piercing and do not use with others.
  5. Stop drinking alcohol, because alcohol consumption of only 20-30 grams/day (1 can of beer or 1 glass of wine) can aggravate severe liver disease, and drinking alcohol more than 50 grams/day will shorten time of cirrhosis formation.
  6. Avoid other toxins, e.g. foods supplements, herbs with unknown ingredients or side effects, since they may increase hepatitis or cirrhosis.
  7. Avoid multiple sex partners or violent sexual behavior, since partners are more likely to get infected.
  8. Come to see a doctor every 3-6 months, even with no symptoms, or visit a clinic as per doctor’s schedules to check if there is any hepatitis, or if cirrhosis occurs, or to screen cancer at the initial stage.

Prevention of the hepatitis C virus

To date, there is no vaccine for prevention of the hepatitis C virus, thus avoidance of such risk factors to prevent infection is recommended. The most important risk factor is blood or blood product exposure, thus blood transfusion should be avoided. For a non-emergency surgery, it is recommended to use your blood by preparing it before a surgery, however, if more blood is needed, blood should derive from a low risk donator. Do not buy blood products from blood sellers, but if there is no choice, standard blood chemistry tests should be used to screen for the hepatitis C virus. Parents and teachers should advise their children not to use needles together. Adolescents may acquire the hepatitis C virus because of trial and error behavior, thus it is better to prevent such infection before it is too late for treatment.

  • For adolescent boys and girls, appearance is important. They like to get tattoos and piercings. They should be careful not to use equipment with others. Tattoo and piercing service providers should have standard equipment, as well as personnel who are responsible for consequences. Responsible personnel must not utilize used equipment with others.
  • Couples with one or the other of them infected with the hepatitis C virus should not be too concerned, since chances of transmission from one person to another is quite low. Condom use for prevention is not necessary, however, they should avoid violent sexual habits, as that might cause open wounds. Avoid sexual intercourse during menstrual periods.
  • It is recommended that women of child bearing age with a hepatitis C infection should receive treatment prior to pregnancy to prevent virus transmission to infants.

Cancer screening

All hepatitis C patients with cirrhosis, even though they are completely cured, should have a cancer screening every 6 months by ultrasound technique or measurement of cancer biomarker (alfa-fetoprotein).

Conclusion

Hepatitis C virus is a virus that causes liver damage starting from chronic infection, chronic hepatitis, cirrhosis and ending up with liver cancer. Despite current blood screening tests providing more accuracy and a campaign against illicit drug injection with the same needle reducing infection caused by these sources, infection is likely to increase due to some habits, e.g. tattooing or piercing, which is popular in adolescents. Furthermore, a vaccine for prevention has not been discovered, thus the best prevention method is avoidance of blood or blood product transfusion and using standard needles for tattooing or piercing. Patients infected with the hepatitis virus should take care of their health and strictly follow doctor’s instruction.