Text Copyright 2007 by Nancy Sculerati MD - all rights reserved

• Hepatitis C

• When hepatitis C infection becomes chronic, there are usually detrimental effects to overall health. In particular, the liver is at risk of becoming badly damaged, and scarred - a condition know as cirrhosis of the liver. Not only is this a serious disease all by itself, but having cirrhosis from Hepatitis C infection makes the development of liver cancer very likely. Of people who are chronically infected, only a minority (between about 5-25%) will develop cirrhosis, but besides harm to oneself, chronic infection means that the person can spread the infection to others for many years.

Although the virus is spread fastest through groups of people willing to inject illegal drugs, it can also be passed through blood transfusions and by contact with blood and body fluids. In the USA, a very sensitive test for this virus became universal in blood banks in 1992, and so, in this country, it is only blood transfusions before 1992 that put a person at risk. Once a person is infected, sexual intercourse can spread the infection to others, especially if a male is infected and shedding virus into his semen. Infection can also be maternal, that is, to an unborn child or a newly born infant, transmitted from the baby's mother. Currently, this last route is the most common cause of hepatitis C in infants and children.

Hepatitis C Facts:

• Of all cases of acute hepatitis (acute inflamation of the liver) in North America, it's estimated that about 20% are due to Hepatitis C. (Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 8th ed. Copyright © 2006 Saunders, An Imprint of Elsevier)
• The liver inflamation caused by this virus can range from very minor to very severe.
• The virus infection can cause problems outside the liver, among such manifestations are: a type of kidney disease, ulcers of the eye, several skin conditions, thyroid problems, certain kinds of lymphoma
  • The exact clinical manifestations and outcome of infection with the Hepatitis C virus is variable between individual people. In cases in which the liver is badly scarred and becomes cirrhotic, there is a high risk of a fatal liver cancer called hepatocellular carcinoma.
• In about 10% of cases, the body clears the virus on its own, and there may be no long-term damage - even without treatment.
• Currently, many, many thousands of people are infected do not know it. In most people who are infected, the virus remains active in the body for life. If treated early on, the infection can often be cleared, instead.

Back in the mid-1970's, researchers noted that there were cases of hepatitis that developed in people after blood transfusions that were not due to either Hepatitis A or B viruses - the only two hepatitis viruses that could be identified at that time. These other cases seemed to be viral infections, but no one could demonstrate the virus causing them, and all the patients were said to have "non-A, non-B viral hepatitis".

• The first of the viruses to be discovered that was responsible for some of those infections was named the Hepatitis C virus.

Currently, there is a known epidemic of Hepatitis C infection in the United States and in many other countries, but the exact extent of the global epidemic is unknown. There is no country in the world that has been shown to be free of the virus. In other words, in every country in which at least some of the population has been tested for the virus, at least a few people have been found to be positive for Hepatitis C. Since testing has not been done on enough people throughout the world, there is no accurate picture of the rates of infection in more than a few places. Still, there do not seem to be any safe areas where no one in the population has the infection.

Below, are quotes selected from peer-reviewed publications that give a general picture of the current situation.

• "Primary care physicians see many of the estimated 250, 000 Canadians chronically infected with the hepatitis C virus (HCV). Of this number, about one-third are unaware they are infected, which constitutes a large hidden epidemic. They continue to spread HCV unknowingly and cannot benefit from advances in antiviral therapy that may clear them of the virus. Many HCV-infected people remain asymptomatic, which means it is important to assess for risk factors and test patients accordingly." [Wong T -Hepatitis C: A review for primary care physicians CMAJ - 28-FEB-2006; 174(5): 649-59]
  • Although the numbers estimated in the quote above apply only to Canada - the general scenerio is true for the United States and at least some of Europe as well, that is: a very large number of people are infected with this virus and spreading it to others unknowingly. For most of these people, treatment is available, but expensive.
• "Hepatitis C virus (HCV) infection is the most common blood-borne infection in the United States and is a leading cause of chronic liver disease. The epidemiology of HCV infection in the United States has changed dramatically during the last 2 decades. The relative importance of the different risk factors for HCV infection has shifted since the development of effective screening measures and the near elimination of blood transfusion–related HCV infections. Although rates of HCV transmission remain high among injection drug users, the overall incidence of HCV infection has declined 10-fold since the 1980s...there are estimated to be about 20 million people in the USA now infected." [Bialek, Stephanie B, Terrault, Norah A. : The changing epidemiology and natural history of hepatitis C virus infection Clin Liver Dis - 01-NOV-2006; 10(4): 697-715]
• "The worldwide prevalence of HCV infection is estimated to be 2.0% overall, corresponding to approximately 120 million persons . There is substantial variation by region, with the highest prevalence in North Africa and the Middle East, particularly Egypt (>3.0%), followed by Africa (3.0%), China and other Asian countries (2.1%), Eastern Europe (2.2%), Australia (1.1%), Southeast Asia (1.2%), and northern Europe and the United Kingdom (1.1%). In more developed countries, transmission seems to be primarily a result of illicit injection drug use, whereas in less developed countries the modes of transmission are unsafe therapeutic injection practices, inadequate disinfection practices in medical and dental settings, and unscreened blood transfusions." [Bialek, Stephanie B, Terrault, Norah A. : The changing epidemiology and natural history of hepatitis C virus infection Clin Liver Dis - 01-NOV-2006; 10(4): 697-715]
  • "Unsafe therapeutic injections may be the most important source of HCV transmission worldwide . A notable example is Egypt, where the HCV prevalence among all age groups is at least fivefold higher than in developed countries. These high rates of infection have been attributed partially to mass schistosomiasis treatment campaigns in the 1960s and 1970s, in which medications were administered with reused syringes that had not been adequately disinfected." [Bialek, Stephanie B, Terrault, Norah A. : The changing epidemiology and natural history of hepatitis C virus infection Clin Liver Dis - 01-NOV-2006; 10(4): 697-715]

Lab Test Results in Hepatitis C Infection

• "Factors independently associated with HCC development included [alpha]-fetoprotein (AFP) greater than 20 ng/ml, [gamma]-glutamyl transferase (GGT) greater than 58 U/l, and male gender."(Kulik LM. Advancements in hepatocellular carcinoma. Current Opinion in Gastroenterology. 23(3):268-74, 2007 May)
• "Most infected infants do not test HCV RNA positive during the first month of birth, suggesting that infection occurs at the time of delivery rather than in utero. By age 6 months, virtually all infected infants test positive for HCV RNA. Because maternal antibody may remain detectable in the uninfected infant for more than 1 year [37], [39], anti-HCV testing is not recommended before age 18 months ." [Bialek, Stephanie B, Terrault, Norah A. : The changing epidemiology and natural history of hepatitis C virus infection Clin Liver Dis - 01-NOV-2006; 10(4): 697-715]

It is intravenous drug abusers, prostitutes and sexually promiscuous people who are at highest risk for this disease in North America and many parts of the world, but the idea that risk is confined to people in those categories is just plain wrong and misleading.

• Every surgeon and operating room nurse is at risk for hepatitis C
• Every woman who has sexual intercourse with a man who has had a blood transfusion before 1992, ever been in prison, a man who has ever had sex (including forced sex) with another man, or a man that has ever injected illegal drugs, or is a surgeon or operating room nurse who has not been tested, is at risk for having Hepatitis C - even if this man is her husband and she has never had sex with anyone else. She is at risk if he has done these things (or had them done to him) whether or not he told her about them (unless he has been tested negative for the virus). Knowingly or not, she is at risk.
• Every person who had a blood transfusion before 1992 is at risk for this disease.
• Every baby born to a mother with Hepatitis C is at risk for Hepatitis C- whether that mother knows she has it, or not. There are women who have found out that they have it only after the baby is born with it and becomes sick.

It's smart to be tested for this infection. The results of that test can help you and the people that you love. Men who are at very high risk for the reasons mentioned can protect their women and children by having the test. People who come back positive have a chance of clearing the virus - if treated. Are you pregnant? Make sure you are tested. The tests for this virus involve having a blood sample drawn and sent to a serology lab where antibodies to the virus and antigens made by the virus are sought. "Serologic evidence for HCV infection has been found in all regions of the world in which it has been sought. In developed countries, 0.1–2% of the general population have antibody to the virus, as measured by currently available tests. In developing countries, the prevalence is somewhat higher but generally less than 5–10% of the population. An exception is Egypt, where prevalences as great as 20% have been recorded." (Purcell, Robert H: Hepatitis C Virus (Flaviviridae), in Encyclopedia of Virology, Copyright © 2004, 2007 ElsevierAcademic Press, ISBN-13: 978-0-12-227030-7)

• Know your results. No one is at zero risk. If a doctor tells you, oh- you don't need to know...ask why not? Why don't you matter enough?

That's my opinion, anyway.

Nancy Sculerati, MD

• Purcell, Robert H: Hepatitis C Virus (Flaviviridae), in Encyclopedia of Virology, Copyright © 2004, 2007 ElsevierAcademic Press, ISBN-13: 978-0-12-227030-7 Pages 657-663
• Wong T -Hepatitis C: A review for primary care physicians CMAJ - 28-FEB-2006; 174(5): 649-59
• Bialek, Stephanie B, Terrault, Norah A. : The changing epidemiology and natural history of hepatitis C virus infection Clin Liver Dis - 01-NOV-2006; 10(4): 697-715

Articles aimed at patients without specialized knowlege or science education

http://www.ncbi.nlm.nih.gov/ICTVdb/index.htm