II. Epidemiology
-
Prevalence
- U.S. Population: 1.8% (4 to 6.5 million)
- Chronic hepatitis Prevalence is estimated at 2.7 million
- Prevalence is underestimated due to as yet undiagnosed patients infected in the 1960s and 1970s
- Mortality from Hepatitis C in the United States is more than any other infectious disease
- World Prevalence estimated at >185 million
- Associated with 350,000 deaths per year
- Intravenous Drug Abuse: 97% (some communities)
- U.S. Population: 1.8% (4 to 6.5 million)
- Incubation 7-8 weeks
- HCV RNA found in blood within 3 weeks post-exposure
- Transmission by Blood Products and blood exposure
- Intravenous Drug Abuse (43-60% of acute cases in U.S.)
- Intravenous Immunoglobulin
- Transfusion
- Accounts for 85% transfusion associated hepatitis
- Risk from transfusion low after July 1992
- Now <1 case per 1,000,000 units transfused (2015)
- Tattoo needles
- Organ transplant (before July 1992)
- Vertical transmission from mother to child
- Delivery method does not alter transmission rate
- Average rate: 6%
- HIV coinfection: 17%
- Needle Stick injury (4-10% rate of Infectivity)
- Seroconversion in 2200 healthcare workers per year
- No apparent parenteral risk factor in 40% of cases
- Transmission by other body fluid is less common
- Transmission to simple household contacts is rare
- No association with Lactation
- Sexual transmission is much less common
- Prevalence 1.5% in longterm partners
- Higher risk behaviors that raise transmission (blood to blood transmission)
- Multiple partners
- Early sex
- Non-Condom use
- Sex with associated Trauma or open lesions
- Comorbid Sexually Transmitted Disease
- Anal sex
- Sex during Menses
- Shared sexual paraphernalia
III. Pathophysiology
- Similar to Flavivirus with RNA genome
- Similar viruses
- Yellow Fever virus
- DengueVirus
IV. Signs and Symptoms
- Acute infection
- See Viral Hepatitis
- Jaundice is uncommon in acute infection
- Constitutional symptoms in up to 35%
- Malaise
- Weakness
- Anorexia
- Minor Fatigue
- Right upper quadrant abdominal ache
- Nausea
- Arthralgias
- Chronic disease
- Most patients are asymptomatic
- Observe for signs of Cirrhosis
V. Differential Diagnosis
VI. History: Screening Indications
- Universal screening for Hepatitis C for age of 18 years old at least once, regardless of risk factors (U.S., 2019)
- Screen once all patients born between 1945 and 1965 for Hepatitic C
- Screen periodically (up to annually) for continued high risk behavior
- Intravenous Drug Abuse
- HIV positive Men who have Sex with Men (unprotected)
- Other screening indications
- Received blood Clotting Factor concentrate before 1987
- Received Blood Transfusion or transplant before 1993
- Received blood from donor later found with HCV
- Received Hemodialysis
- Symptoms or signs of liver disease, or persistently elevated serum transaminases
- Mother with HCV at the time of delivery
VII. Labs: Diagnosis
- See Hepatitis C Serology
- Screening: EIA for Anti-HCVAntibody
- Negative
- Consider False Negative if immunocompromised
- Repeat in 12 weeks if HCV exposure in prior 6 months
- Alternatively, HCV RNA may be obtained every 4-8 weeks for 6 months
- Positive
- Confirm with HCV RNA (see below)
- Negative
- Confirmation of positive xHCV: RT-PCR for HCV RNA
- Start with qualitative PCR (more sensitive)
- Positive EIA xHCV with negative PCR HCV RNA suggests resolved
- Repeat in 1-2 months if negative
- Also indicated before initiating HCV therapy
- Viral Genotype
VIII. Labs: Assessment of liver disease
-
Liver Function Tests
- Serum Albumin
- ProTime (PT) with INR
- Partial Thromboplastin Time (PTT)
- Liver Transaminase (Indicate hepatocellular necrosis)
- Comorbid Infections
- Other tests
- Serum Iron (for Hemochromatosis)
- Renal Function Tests
IX. Labs: Post-exposure to Hepatitis C Virus
- Indications
- Blood-borne Exposure to Hepatitis C positive source (xHCV positive with detectable HCV RNA)
- Protocol
- Baseline (at time of exposure)
- Hepatitis C Antibody
- Hepatitis C RNA
- Alanine Transaminase (ALT)
- Week 4-6 post-exposure
- Hepatitis C RNA
- Month 4-6 post-exposure
- Hepatitis C Antibody
- Hepatitis C RNA
- Alanine Transaminase (ALT)
- Baseline (at time of exposure)
X. Grading
- See Metavir Scoring System (liver fibrosis, Cirrhosis)
XI. Management: General
- See Prevention of Liver Disease Progression
- Avoid Alcohol
- Alcohol and Hepatitis C work synergistically
- Alcohol decreases response to Interferon therapy
- Avoid Hepatotoxins
- Avoid iron supplements
- Maintain a Low Fat Diet
- Vaccination (decreases Hepatitis C progression risk)
- Prevent transmission
- Do not share razors or ToothBrushes
- Cover skin lesions
- Do not donate Blood Products
- Use protection for intercourse
XII. Management: HCV-Related Cirrhosis
- Refer for consideration of liver Transplantation (see below)
-
Hepatocellular Carcinoma monitoring
- Obtain RUQ Ultrasound and a-fetoprotein every 6-12 months
-
Esophageal Varices monitoring
- Obtain upper endoscopy every 1-2 years
XIII. Management: Antiviral Agents
- See Hepatitis C Antiviral Regimen
- Consider early treatment for Acute Hepatitis C (started within 4 weeks of onset)
- Improves prognosis and decreases risk of chronic infection
- Wiegand (2006) Hepatology 43(2): 250-6 [PubMed]
XIV. Management: Liver Transplantation
- Hepatitis C is most common cause of liver transplant
- Post-transplant survival similar to other liver failure
- One year survival post-transplant: 84%
- Five year survival post-transplant: 68%
- Ten year survival post-transplant: 60%
- Predictors of poorer outcome
- Female liver donor
- Recipient over age 52 years
- Preoperative Serum Creatinine >1 mg/dl
- More urgent UNOS status
- Increased Serum AST and Serum ALT levels
- References
XV. Complications
-
Cirrhosis (20% in 20 years)
- Individualized risk can be calculated (see below)
- Decompensated Cirrhosis
- One Year: 3.9%
- Five Years: 18%
- Ten Years: 29%
-
Hepatocellular Carcinoma
- Annual risk: 2-4% if Cirrhosis present
- Five Years: 7%
- Ten Years: 14%
- Other associated conditions
- Diabetes Mellitus
- Sjogren's Syndrome
- Lymphoma
- Glomerulonephritis
- Dermatologic conditions
- Porphyria cutanea tarda
- Lichen Planus
- Cutaneous necrotizing Vasculitis
XVI. Course
- Progression after acute HCV infection
- Spontaneous resolution: 15-50% of cases (undetectable HCV at 6 months after acute HCV)
- Chronic Hepatitis: 50 to 85% of cases
- Survival
- One Year: 96%
- Five Years: 91%
- Ten Years: 79%
- Risk Factors for Progression to fibrosis and Cirrhosis
XVII. Resources
- IDSA HCV Management Guidelines
- Probablility of Cirrhosis in Patients with Hepatitis C
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Related Studies
Definition (NCI) | A viral infection caused by the hepatitis C virus. |
Definition (MSH) | INFLAMMATION of the LIVER in humans caused by HEPATITIS C VIRUS, a single-stranded RNA virus. Its incubation period is 30-90 days. Hepatitis C is transmitted primarily by contaminated blood parenterally, and is often associated with transfusion and intravenous drug abuse. However, in a significant number of cases, the source of hepatitis C infection is unknown. |
Definition (CSP) | viral disease caused by hepatitis C virus; most common form of post transfusion hepatitis, also is a common acute sporadic hepatitis; may also follow parental drug abuse. |
Concepts | Disease or Syndrome (T047) |
MSH | D006526 |
ICD9 | 070.7 |
ICD10 | B19.2 , B19.20 |
SnomedCT | 123324009, 154349000, 186643004, 50711007, 186634008 |
LNC | LA19423-5 |
English | Hepatitis, Viral, Non-A, Non-B, Parenterally-Transmitted, Parenterally-Transmitted Non-A, Non-B Hepatitis, PT-NANBH, HEPATITIS C, HEPATITIS NON-A NON-B, PT NANBH, nonA nonB hepatitis, viral hepatitis C infection, hepatitis C infection (diagnosis), hepatitis C infection, Hepatitis C Infection, Hep non-A non-B, Non-A non-B hepatitis, Unspecified viral hepatitis C, Viral hepatitis C NOS, Hepatitis C [Disease/Finding], hepatitis c viral, hepatitis C, hepatitis non-a non-b, viral hepatitis c, hepatitis viral c, non b hepatitis, Parenterally Transmitted Non A, Non B Hepatitis, Viral hepatitis, non-A, non-B, Hepatitis C (disorder), Viral hepatitis, non-A, non-B (disorder), Hepatitis (non-A non-B), Viral hepatitis C (disorder), Viral hepatitis type C (disorder), Viral hepatitis type C, Type C viral hepatitis, Viral hepatitis C, Hepatitis non-A non-B, Hepatitis non-A non-B (disorder), hepatitis nonA nonB, hepatitis non A non B, hepatitis; virus, non-A, non-B, hepatitis; virus, type C, non-A non-B-hepatitis, virus; hepatitis, non-A, non-B, Non-A, non-B hepatitis, Viral hepatitis, non-A, non-B -RETIRED-, Hepatitis C, NANBH, Non-A, Non-B Hepatitis, Unspecified viral hepatitis C NOS |
Portuguese | HEPATITE C, Hepatite a vírus C, Hepatite não A não-B, HEPATITE NAO-A NAO-B, Hepatite não A não B de Transmissão Parental, Hepatite Viral não A não B de Transmissão Parental, Hepatite Viral C, Hepatite não-A não-B, Hepatite C |
Spanish | HEPATITIS C, Hepatitis (no A no B), Hepatitis vírica C, hepatitis viral, no A, no B, hepatitis vírica tipo C, hepatitis NANB, hepatitis C (trastorno), hepatitis viral, no A, no B - RETIRADO -, hepatitis viral, NANB, hepatitis viral, no A, no B - RETIRADO - (concepto no activo), hepatitis C, hepatitis ni A ni B (trastorno), hepatitis ni A ni B, hepatitis no A no B, hepatitis viral tipo C (trastorno), hepatitis viral tipo C, Hepatitis no A no B, Hepatitis C, Hepatitis no-A no-B de Transmisión Parental, Hepatitis Viral no-A no-B de Transmisión Parental |
Italian | Epatite non-A non-B, Epatite (non-A non-B), Epatite virale C, Epatite virale non A non B trasmessa per via parenterale, Epatite C |
Dutch | hepatitis (non-A non-B), non-A-non-B-hepatitis, virale hepatitis C, hepatitis; virus, non-A, non-B, hepatitis; virus, type C, virus; hepatitis, non-A, non-B, hepatitis C, hepatitis non-A non-B, Hepatitis C, Hepatitis, non-A-non-B-, Non-A-non-B-hepatitis |
French | Hépatite (non A non B), Hépatite non A non B, Hép non-A non-B, HEPATITE NON-A NON-B, HEPATITE VIRALE C, Hépatite virale non A-non B, Hépatite C, Hépatite virale C, Hépatite virale non-A non-B transmise par voie parentérale |
German | Hep non-A non-B, Hepatitis (non-A non-B), virale Hepatitis C, HEPATITIS NON-A NON-B, Hepatitis non-A non-B, Hepatitis C, Hepatitis, virale, Non-A, Non-B, parenteral übertragene, Parenteral übertragene Non-A, Non-B-Hepatitis |
Japanese | 非A非B型肝炎, 肝炎(非A非B), C型肝炎, カンエンヒAヒB, Cガタカンエン, ヒAヒBガタカンエン, Cガタウイルスセイカンエン, C型ウイルス性肝炎, 肝炎-C型, C型肝炎, PT非A非B肝炎, 非経口性非A非Bウイルス肝炎, 肝炎-ウイルス性-非A非B非経口性, 肝炎-ウイルス性-非経口性非A非B |
Swedish | Hepatit C |
Czech | hepatitida virová non-A, non-B, hepatitida C, Hepatitida non A non B, Hepatitida C, Hepatitida (non A non B), Hepatitida non-A non-B, Virová hepatitida C |
Finnish | Maksatulehdus C |
Russian | GEPATIT C, GEPATIT VIRUSNYI NI-A, NI-B, PARENTERAL'NO-PEREDAVAEMYI, PARENTERAL'NO-PEREDAVAEMYI GEPATIT NI-A, NI-B, ГЕПАТИТ C, ГЕПАТИТ ВИРУСНЫЙ НИ-A, НИ-B, ПАРЕНТЕРАЛЬНО-ПЕРЕДАВАЕМЫЙ, ПАРЕНТЕРАЛЬНО-ПЕРЕДАВАЕМЫЙ ГЕПАТИТ НИ-A, НИ-B |
Croatian | HEPATITIS C |
Polish | Zapalenie wątroby wirusowe nie A nie B, Zapalenie wątroby wirusowe C, Zapalenie wątroby C |
Hungarian | Viralis hepatitis C, hepatitis non-A non-B, non-A non-B hepatitis, hepatitis C, Hepatitis (non-A non-B), Hepatitis non-A non-B |
Norwegian | Hepatitt C |