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Hepatitis C
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Hepatitis C
See Also
Viral Hepatitis
Bloodborne Pathogen Exposure
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)
Incubation 7-8 weeks
HCV RNA found in blood within 3 weeks post-exposure
Transmission by
Blood Product
s 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
Pathophysiology
Similar to
Flavivirus
with RNA genome
Similar viruses
Yellow Fever
virus
Dengue
Virus
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
Arthralgia
s
Chronic disease
Most patients are asymptomatic
Observe for signs of
Cirrhosis
Differential Diagnosis
Acute Hepatitis Causes
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
Labs
Diagnosis
See
Hepatitis C Serology
Screening:
EIA for Anti-HCV
Antibody
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)
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
Indicated before initiating HCV therapy
Of 6 HCV
Genotype
s, types Ia, Ib, 2 and 3 account for 97% of U.S. HCV infections
HCV
Genotype
s 2 and 3 have better prognosis than HCV
Genotype
1
Labs
Assessment of liver disease
Liver Function Test
s
Serum Albumin
ProTime
(PT) with INR
Partial Thromboplastin Time
(PTT)
Liver
Transaminase (Indicate hepatocellular necrosis)
Serum AST
Serum ALT
Increases by 2-21 weeks from onset (mean 7 weeks)
Normal in up to one third of patients
Comorbid Infections
Human Immunodeficiency Virus
Test (
HIV Test
)
Anti-HAV (
Hepatitis A Virus
Antibody
)
Hepatitis B Surface Antigen
(
HBsAg
)
Other tests
Serum Iron
(for
Hemochromatosis
)
Renal Function
Tests
Serum Creatinine
Blood Urea Nitrogen
(BUN)
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)
Grading
See
Metavir Scoring System
(liver fibrosis,
Cirrhosis
)
Management
Gene
ral
See
Prevention of Liver Disease Progression
Avoid
Alcohol
Alcohol
and Hepatitis C work synergistically
Alcohol
decreases response to
Interferon
therapy
Avoid
Hepatotoxin
s
Avoid iron supplements
Maintain a
Low Fat Diet
Vaccination
(decreases Hepatitis C progression risk)
Hepatitis A Vaccine
Hepatitis B Vaccine
Prevent transmission
Do not share razors or
ToothBrush
es
Cover skin lesions
Do not donate
Blood Product
s
Use protection for intercourse
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
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]
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
Ghobrial (2001) Ann Surg 234:384-94 [PubMed]
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
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
Cirrhosis
develops in 20% of chronic HCV after 20-30 years, with a 75% mortality
Chronic HCV mortality is secondary to
Cirrhosis
, end-stage liver disease and hepatocellular cancer
Survival
One Year: 96%
Five Years: 91%
Ten Years: 79%
Risk Factors for Progression to fibrosis and
Cirrhosis
Age over 40 years at time of infection
Duration of infection
Median duration of infection to
Cirrhosis
: 30 years
In up to one third,
Cirrhosis
delayed for >50 years
Male gender
Excessive
Alcohol
intake
Marked risk at >50 grams/day
Moderate risk
Men: >40 grams/day
Women: >20 grams/day (2 beers, 1 pint wine)
Resources
IDSA HCV Management Guidelines
http://www.hcvguidelines.org
Probablility of
Cirrhosis
in Patients with Hepatitis C
http://www.aafp.org/afp/20031101/poc.html
References
Gross (1998) Mayo Clin Proc 73(4):355-60 [PubMed]
Morton (1998) Ann Emerg Med 31:381-90 [PubMed]
Heathcote (2000) N Engl J Med 343:1673-80 [PubMed]
Ward (2004) Am Fam Physician 69(6):1429-40 [PubMed]
Wilkins (2015) Am Fam Physician 91(12): 835-42 [PubMed]
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