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Definition
Hepatitis C is a blood-borne virus which primarily affects the liver. Without treatment, chronic hepatitis C can cause advanced liver disease (cirrhosis), liver cancer (hepatocellular carcinoma) and sometimes death (National Institute for Health and Clinical Excellence (NICE), 2006). There is a health burden for people living with hepatitis C and an escalating cost to health services.
Epidemiology
There are approximately 123 million people chronically infected with hepatitis C worldwide (Shepard et al, 2005). England is considered a low prevalence country (0.5%) (Department of Health (DH), 2002a). The number of people diagnosed with hepatitis C in England up to 2010 was 85 565, although it is estimated that 161 320 people are actually infected (Health Protection Agency (HPA), 2011a). Around 90% of infections in England are attributable to injecting drug use (HPA, 2011b).
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Risk factors
Drug use
The greatest risk of acquiring hepatitis C in England is through the sharing of blood-contaminated equipment (for example spoons, filters and water) by current or former injecting drug users (even if they only injected themselves on one or two occasions) with approximately half reporting infection (HPA, 2011b). Although needle and syringe sharing has declined over recent years from 31% in 2000 to 21% in 2010 (HPA, 2011b), there has been no such decline in hepatitis C prevalence among recent initiates (i.e. those who first injected in the preceding three years), with a prevalence of 18% in this category (Hope et al, 2012).
Blood transfusion or blood products
Others may have been at risk through having a blood transfusion (before 1991), or being given blood products (before 1986) (DH, 2004). In 1991, routine screening of blood donors was introduced in addition to viral inactivation of
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Symptoms
Hepatitis C is often referred to as the ‘silent epidemic’ (DH, 2004) because infected individuals are often asymptomatic, with only 10% reporting symptoms associated with jaundice (Booth et al, 2001). About 80% of those exposed to the virus go on to develop chronic hepatitis (NICE, 2006). Patients with chronic hepatitis C often have no symptoms but may complain of non-specific complaints, such as fatigue (the most common symptom), muscle aches, anorexia, upper right quadrant pain and nausea.
Hepatitis C infections have been associated with a number of other conditions, including autoimmune hepatitis, cryoglobulinemia, lichen planus, Sjögren’s syndrome, thyroiditis, membranous glomerulonephritis and polyarteritis nodosa (Booth et al, 2001). Recognition of hepatitis C involvement in conditions such as cryoglobulinaemia and idiopathic thrombocytopenic pupura will enable consideration of interferon therapy for these non-hepatic diseases.
Natural history of hepatitis C
Natural clearance
Approximately 20% of those infected with hepatitis C will spontaneously
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Diagnosis
Diagnosis of acute and chronic hepatitis C
The discovery of hepatitis C led to the development of an antibody diagnostic test. A positive antibody test indicates exposure to the virus, but it does not distinguish between resolved or current infection. In patients whose exposure has been recent and whose first test is negative, the antibody test should be repeated 3 months after the last possible exposure to avoid misdiagnosis. The presence or absence of ongoing infection is established in those with positive serology by testing for hepatitis C RNA. Diagnosis of chronic infection is made when hepatitis C RNA persists for more than 6 months. In the case of a new diagnosis, it is good practice to obtain a second sample for confirmation. Individuals with chronic infection are usually referred to a specialist team for assessment and consideration of treatment.
The incubation period of acute hepatitis C infection is commonly
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Treatment
In recent years, effective curative treatments for chronic hepatitis C have become available. Treatment with pegylated interferon-alpha and ribavrin—the current ‘standard of care’—is successful in over 50% of treated patients (NICE, 2006).
Before deciding on an appropriate course of treatment, it is important to consider factors which in combination have been shown to be associated with less successful treatment (Table 2). For example, some people who are overweight might be recommended to lose weight to optimize their chances of treatment success. Practice nurses may help and support patients in making changes to their diet and to increase their levels of physical activity.
| Major factors | Minor factors |
|---|---|
| High baseline viral load (>800,000 iu/ml) | Age (>40 years) |
| Presence of advanced liver disease or cirrhosis | High body mass index (BMI) (>30 kg/m2) |
| Previous treatment failure before; null response | Ethnic origin (black) |
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Resources
References
Afdhal NH. The natural history of hepatitis C. Semin Liver Dis. 2004;24(Suppl2):3–8. https://doi.org/10.1055/s-2004-832922
Aspinall RJ, Pockros PJ. The management of side-effects during therapy for hepatitis C. Aliment Pharmacol Ther. 2004;20(9):917–929. https://doi.org/10.1111/j.1365-2036.2004.02192.x
Booth JCL, O’Grady J, Neuberger J. Clinical guidelines on the management of hepatitis C. Gut. 2001;49(Suppl 1):i1-i21. http://dx.doi.org/10.1136/gut.49.suppl_1.I1
Brook G, Main J, Nelson, M et al. British HIV Association guidelines for the management of coinfection with HIV-1 and hepatitis B or C virus 2010. 2010. https://www.bhiva.org/hepbc2010 (accessed 13 December 2022)
Department of Health. Hepatitis C strategy for England. 2002. https://webarchive.nationalarchives.gov.uk/ukgwa/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4059510.pdf (accessed 13 January 2022)
Department of Health. Hepatitis C infected health care workers. 2002b. https://webarchive.nationalarchives.gov.uk/ukgwa/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4059544.pdf (accessed 13 January 2022)
Department of Health. Hepatitis C Action Plan for England. 2004. https://www.globalhep.org/sites/default/files/content/resource/files/2020-03/England%20Hepatitis%20Action%20C%20Plan%202004.pdf (accessed 13 January 2022)
Dietrerich DT, Spivak JL. Hematologic disorders associated with hepatitis c virus infection and their management. Clin Infect Dis. 2003;37:533–41. https://doi.org/10.1086/376971
European Association for the Study
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