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Hepatitis C virus is the most common chronic blood borne
viral infection in the United States. First identified and
named in 1988 and previously called non-A non-B hepatitis, it
is estimated to have infected as many as 242,000 Americans
annually during the 1980s. Because many people were unaware
that they were infected, the risks of transmitting the
infection to others were extremely high. Since 1989, the
incidence of HCV has declined dramatically to an estimated
30,000 new infections in 2000. Most of the decline has
occurred among injection drug users (IDUs). While the reasons
for the dramatic decline are not fully understood, it may be
due to safer injection practices resulting from intensive HIV
prevention programs as well as to the very high proportion of
injection drug users already infected.
While the
number of new infections has dropped dramatically in the last
10 years, most people with chronic HCV are still unaware of
their infection and have not sought medical care. Given the
slow progression of HCV disease in most people, the impact of
HCV infection may explode over the next 10-20 years. Because
it usually takes 20-30 years for chronic liver disease,
cirrhosis, and liver cancer to develop, it is conservatively
estimated that illness and deaths from HCV-related liver
disease among the millions of people infected during earlier
years will increase 2-to 3-fold over the next two decades.
Direct medical costs may range from $6.5 to $13.6 billion,
with even greater indirect and societal costs.
Using the
results of blood tests conducted on 21,241 persons who
participated in the third National Health and Nutrition
Examination Survey, the Centers for Disease Control and
Prevention (CDC) estimates that 1.8% of persons six years of
age or older have been infected with HCV and, of these, 74%
are chronically infected with the virus. Based on this
information, it is estimated that as many as 46,000 Arkansans
have been infected with the virus, with 34,000 possibly having
chronic HCV infection. While accurate numbers of new cases are
not available, hospital discharge records and death records
indicate a rise in both hospital admissions for HCV and HCV
related deaths in recent years.
In 2001, the
CDC launched the National Hepatitis C Prevention Strategy
in partnership with other federal, state, and private sector
agencies. This comprehensive plan is designed to lower the
incidence of acute HCV in the United States and reduce the
disease burden from chronic HCV.
The principal
components of the National Hepatitis C Prevention Strategy
are:
-
education
of healthcare and public health professionals to
improve the identification of people at risk for HCV
infection and ensure appropriate counseling, diagnosis,
medical management, and treatment;
-
education
of the public and people at risk for infection about
risk factors for HCV transmission, and the need for
testing and medical evaluation;
-
clinical
and public health activities to identify, counsel, and
test people at risk for HCV infection, and medical
evaluation or referral for those found to be infected;
-
outreach
and community-based programs to prevent practices that
put people at risk for HCV infection, and to identify
people who need to get tested;
-
surveillance
to monitor acute and chronic disease trends and evaluate
the effectiveness of prevention and medical care
activities; and
-
research
to better guide prevention efforts.
Select a question below to view information
| Frequently
Asked Questions |
What is
hepatitis C?
Hepatitis C is a liver disease caused by the hepatitis C virus
(HCV), which is found in the blood of persons who have this
disease. HCV is spread by contact with the blood of an
infected person.
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)
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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.
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.
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 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.
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 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 12
months of age as anti-HCV from the mother may last until
this age. If testing is desired prior to 12 months of age,
PCR could be performed at or after an infant's first
well-child visit at age 1-2 months.
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:
-
the tools that are
used have someone else's blood on them.
-
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.
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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:
-
75 to 85 persons may
develop long-term infection
-
70 persons may develop
chronic liver disease
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15 persons may develop
cirrhosis over a period of 20 to 30 years
-
Less than 3% of
persons may 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 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.
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?
Antiviral drugs are
not licensed for persons under 18 years of age. Children
with hepatitis C should be referred to a children's
specialist in liver diseases. You may want to ask your
doctor about clinical trials that may be on-going for
children.
Genotype
What does
the term genotype mean?
Genotype refers to
the genetic make-up of an organism or a virus. There are
at least 6 distinct HCV genotypes identified. Genotype 1
is the most common genotype seen in the United States.
Is it
necessary to do genotyping when managing a person with
chronic hepatitis C?
Yes, as there are 6 known genotypes and more than 50
subtypes of HCV, and genotype information is helpful in
defining the epidemiology of hepatitis C. Knowing the
genotype or serotype (genotype-specific antibodies) of HCV
is helpful in making recommendations and counseling
regarding therapy. Patients with genotypes 2 and 3 are
almost three times more likely than patients with genotype
1 to respond to therapy with alpha interferon or the
combination of alpha interferon and ribavirin.
Furthermore, when using combination therapy, the
recommended duration of treatment depends on the genotype.
For patients with genotypes 2 and 3, a 24-week course of
combination treatment is adequate, whereas for patients
with genotype 1, a 48-week course is recommended. For
these reasons, testing for HCV genotype is often
clinically helpful. Once the genotype is identified, it
need not be tested again; genotypes do not change during
the course of infection.
Why
do most persons remain infected?
Persons
infected with HCV mount an antibody response to parts of
the virus, but changes in the virus during infection
result in changes that are not recognized by preexisting
antibodies. This appears to be how the virus establishes
and maintains long-lasting infection.
Can
persons become infected with different genotypes?
Yes. Because
of the ineffective immune response described above, prior
infection does not protect against reinfection with the
same or different genotypes of the virus. For the same
reason, there is no effective pre- or postexposure
prophylaxis (i.e, immune globulin) available.
Hepatitis C and
Healthcare Workers
What is the
risk for HCV infection from a needle-stick exposure to HCV
contaminated blood?
After needle stick or sharps exposure to HCV positive
blood, about 2 (1.8%) healthcare workers out of 100 will
get infected with HCV (range 0%-10%).
What are
the recommendations for follow-up of healthcare workers
after exposure to HCV positive blood?
Anti-viral agents (e.g., interferon) or immune globulin
should not be used for postexposure prophylaxis.
| 1. |
For the source,
baseline testing for anti-HCV. |
| 2. |
For the person exposed
to an HCV-positive source, baseline and follow-up
testing including
baseline testing for anti-HCV and ALT activity; and
follow-up testing for anti-HCV (e.g., at 4-6 months)
and ALT activity. (If earlier diagnosis of HCV
infection is desired, testing for HCV RNA may be
performed at 4-6 weeks.) |
| 3. |
Confirmation by
supplemental anti-HCV testing of all anti-HCV results
reported as positive by enzyme immunoassay. |
Should
HCV-infected healthcare workers be restricted in their
work?
No, there
are no recommendations to restrict a healthcare worker who
is infected with HCV. The risk of transmission from an
infected healthcare worker to a patient appears to be very
low. As recommended for all healthcare workers, those who
are HCV positive should follow strict aseptic technique
and standard precautions, including appropriate use of
hand washing, protective barriers, and care in the use and
disposal of needles and other sharp instruments.
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