Hepatitis C

• HCV is four times more common than HIV
• HCV was discovered in 1988
• In US, HCV is most common cause of blood born nonA/nonB hepatitis
• 40-60% of chronic liver disease in US is due to HCV
• HCV is the most common cause of end stage liver disease in theUS which requires transplantation; one-third of liver transplants in the US are due to HCV
• There are large reservoirs of HCV in younger people

• Inadvertent contamination of equipment (e.g. dialysis)
• IV drug abuse equipment
• Intranasal cocaine abuse equipment
• Sexual transmission rare between monogamous partners, but is a problem with many partners
• 5-6% of transmission from HCV positive mother to infant

• Blood recipients or solid organ recipients before 1992 (due to inadequate testing)
• Clotting factor recipients before 1987 (due to poor inactivation procedures)
• Intravenous immunoglobulin "gammaguard" 1993-1994
• Drug injecting addicts
• Chronic hemodialysis
• Sex partners of HCV positive people with multiple partners
• Accidentally stuck health care workers
• Hemophiliacs
• Patients with history of major surgery, trauma, cancer, premature birth

• To assess for treatment
• To counsel regarding hepatatoxins
• To counsel about minimizing the chance of transmission
• ALT is the most specific indicator of hepatocellular dysfunction (whereas there is AST activity in liver, blood and muscle cells)

• Diagnostic Hepatitis Panel
• IgM specific anti-HAV (positive indicates current HAV infection)
• HbsAg (positive indicates active HBV infection; may be acute or chronic)
• IgM specific anti-Hbc (strong positive is presumptive for acute HBV infection)
• Anti-HCV (positive indicates current or previous HCV infection)
• needs to be confirmed with RT-PCR
• 20% of HCV infected people are negative for anti-HCV initially
• Biopsy: inflammation, fibrosis, scarring, cirrhosis
• DDX: Wilson's disease, mononucleosis

• HCV is often asymptomatic initially and the course is slow (over 2-3 decades)
• 30% of HCV infected persons fully recover, usually in the first 6 to 12 months
• 70% of HCV have persistently abnormal LFTs
• Exacerbations of HCV disease are unusual unless there are hepatotoxins involved
• Patient may feel well and still have liver damage (hence need for biopsy if ALTs up persistently)
• Incidence of progression to hepatocellular carcinoma is unknown

• No alcohol intake
• Alpha Interferon subcutaneously (3 million units three times weekly for 12 months)
• observe for decreasing ALTs (check in 3 months)
• relapses off treatment are common
• contraindications to treatment include: decompensated cirrhosis, organ transplantation, active alcohol or illicit drug use, severe thrombocytopenia, severe leukopenia, other illnesses, suicide attempt
• Reponse to treatment: about 50% have no response, 20% have sustained beneficial response, 20% have relapse
• Side effects: "flu-like" syndrome (headache, fever, chills, nausea, emesis, diarrhea, depression, elevated LFTs)
• New combinations
• Groups to monitor without treatment: children, elderly, extensive cirrhosis, milder disease
• If ALTs are normal, do not treat

• No vaccine is available for HCV
• IgG is not effective post-exposure prophylaxis
• There are no tests for infectivity
• Recommendations:
• Do not share toothbrushes or razor blades with someone who is HCV positive
• Do not donate blood or organs if HCV positive
• HCV positive persons should cover wounds
• Monogamous sexual partners do not need to change practices
• HCV positive persons should get HAV and HBV vaccines

Recommended Reference

Acknowlegment