Hepatitis C: Risk Factors, Signs & Symptoms, Treatment

Introduction

Hepatitis C is a contagious liver disease that results from infection with the hepatitis C virus (HCV). HCV is a hepatotropic RNA virus that belongs to the family Flaviviridae. HCV causes progressive liver damage, which might result in liver cirrhosis and hepatocellular carcinoma.

• It is the most common virus infecting the liver and is considered a major cause of parenterally transmitted hepatitis.
• Infection with HCV remains chronic in 70-80% of the infected individuals.
• There are eight known hepatitis C genotypes distributed across different regions. At the global level, most infections are caused by genotype 1, followed by genotypes 3, and genotypes 2 and 4.
• There is no prophylactic vaccine or specific immunoglobulin against it.
• Effective antiviral treatment exists which results in an effective prognosis for the disease.

Types of Hepatitis C

Acute Hepatitis C

• It is a short-term infection where symptoms can last up to 6 months.
• Most people do not show any symptoms during this phase, some do have symptoms and the illness is so mild that they do not even recognize having the liver disease.
• The immune system fights off the infection from the body and virus goes away and liver heals completely.

Chronic Hepatitis C

• When a body is unable to fight off the virus and the infection persists for more than six months, the persistent state is known as chronic hepatitis C.
• The liver becomes more inflamed and scared over years.
• Early diagnosis and treatment of chronic hepatitis can prevent liver damage.

Incidence

• According to WHO the highest burden of disease is seen in the Eastern Mediterranean Region and European Region, infecting 12 million people chronically in each region.
• Globally 58 million people are infected with chronic hepatitis C, with about 1.5 million new infections occurring per year.
• Around 3.2 million adolescents and children are diagnosed with chronic infection.
• As per WHO, approximately 290,000 people died from hepatitis, because of end-stage liver disease (cirrhosis and hepatocellular carcinoma) in 2019.
• In the United States, HCV is the most common cause of chronic hepatitis.

Causes of Hepatitis C

• Hepatitis C is caused by the hepatitis C virus (HCV) and the infection spreads through contaminated blood and body fluids.

Risk Factors of Hepatitis C

• Injecting street drugs or sharing a needle with infected people
• Having dialysis for a long period
• Having regular contact with blood at work (health care worker)
• Having unprotected sex with an infected person
• Baby born from HCV-infected mother
• Receiving tattoos or piercing with unsterilized needles
• HIV infected patient
• Organ transplant patients

Mode of transmission

HCV is commonly transmitted through

Parenteral

• Transfusion of infected blood or its products.
• Using non-sterile syringes, needles, and medical instruments.
• Transplantation of infected donor organs or tissues.
• Occupational exposure with infected blood.

Sexual

• The risk is higher among persongs having multiple sex partners.

Mother to child

• The chance of vertical transmission of HCV is about -7%. The risk increases if HCV viral load in the mother’s blood is high.

Incubation Period

• The incubation period for hepatitis C is 2 weeks to 6 months.

Signs and Symptoms of Hepatitis C

Following initial infection, approximately 80% of people do not exhibit any symptoms.

Acute Hepatitis C

• Fever
• Fatigue
• Decreased appetite
• Nausea
• Vomiting
• Abdominal pain
• Dark urine
• Grey colored feces
• Joint pain
• Jaundice

Chronic Hepatitis C

• Ascites
• Easy bleeding
• Easy bruising
• Hepatic encephalopathy-confusion, drowsiness, and slurred speech
• Jaundice of the skin
• Hives or rashes
• Itchy skin
• Spider angiomas-spidery blood vessels under your skin.
• Swollen legs
• Weight loss

Pathophysiology of Hepatitis C

• HCV enters a susceptible host either directly, through inoculation or transfusion of contaminated blood, or breakage of a percutaneous barrier.
• The hepatitis C RNA virus enters the hepatocytes or other susceptible cells, through unique surface molecules or molecules, as the viral receptor.
• After uptake, the virus uncoats and releases the genome to begin replication. The viral genome serves as the template for translation of the polyprotein.
• The processed nonstructural proteins then form a complex with the genome and initiate synthesis of the negative strand synthesis.
• The replication complex resides in a membranous compartment in the cytoplasm, derived from the endoplasmic reticulum.
• The RNA replicative intermediate matures and interacts with the core and envelope proteins to assemble into a virion.
• Some non-structural proteins play critical roles in viral replication and produce infections.

Diagnosis of Hepatitis C

Different test helping in the diagnosis includes

Blood test

• A series of blood tests include complete blood count, Glomerular Filtration Rate (GFR), thyroid function, INR, prothrombin time, etc..
• Enzyme immunoassay (EIA) helps in detecting HCV antibodies.
• A PCR test helps in identifying the activeness of the virus and measuring the amount of virus in the blood.

Genotype test

• It reveals which hepatitis C genotype is present for the selection of an effective treatment approach.

Liver function test

• Normal AST, ALT, PT, and albumin become abnormal if cirrhosis occurs.

Liver biopsy

• A small piece of tissue from liver is taken and sent as a sample for cell abnormalities.
• It helps in identifying liver damage.

Magnetic resonance elastography (MRE)

• It combines magnetic resonance imaging (MRI) technology with patterns formed by sound waves bouncing off the liver showing gradients of stiffness of the liver.
• Stiff liver tissue indicates scarring of liver tissues.

Transient elastography

• It is an ultrasound that transmits vibration into the liver and measures the speed of dispersal through liver tissue to estimate its stiffness.

Treatment of Hepatitis C

It does not always require treatment because some people’s immune response will clear the infection and some people with chronic infection do not develop liver damage.

Alpha interferon

• It is a host protein that is made in response to viral infection and has an antiviral capacity.

Combination therapy

• A combination of anti-viral therapy with interferon and ribavirin has been the mainstay of treating Hepatitis C which requires weekly injections for 48 weeks.

Direct antiviral agents (DAAs)

• Recently developed antiviral drugs called DAAs are more effective, safer, and better tolerated.
• This therapy cures most persons with HCV infection and treatment is shorter usually 12 weeks.

Complications

Delaying in diagnosis and long-term untreated infection can result in the following complications.

Cirrhosis

• It is a condition in which liver slowly breaks down and is unable to function normally.
• Scar tissues replace the healthy liver tissue and partially block the blood flow through the liver.

Liver failure

• It is an end-stage liver disease where the liver can no longer perform functions or replace damaged cells.

Liver cancer

• Hepatitis-associated cirrhosis increases the risk of liver cancer.

Prevention

There is no vaccine available to prevent hepatitis C. However, the preventive measures can be the following.

• Avoiding injecting drugs through unsterilized injection.
• Following universal precautions and safely handle needles and other sharps instruments.
• Avoiding sharing personal care items that might contain blood on them such as razors, and toothbrushes)
• Using latex condoms every time to prevent the spread of infections.
• Tattooing and piercing through sterilized needles only.
• Avoiding direct exposure to blood infected with hepatitis C.
• Educating people at high risk for infection (people infected with HIV, or immunocompromised diseases)
• Immunization with hepatitis A and hepatitis B vaccines to prevent co-infection from the hepatitis virus to protect the liver.
• Regularly monitoring and testing for the diagnosis of chronic liver disease.

Prognosis

• The prognosis for most people with hepatitis C who receives treatment is good.
• The prognosis depends on the type of virus causing it. Many people may not know they are having hepatitis C infection, half of the cases clear on their own.
• For chronic infection, the prognosis depends on a person’s overall health, the degree of liver damage, how soon treatment is received, and response to treatment.
• Drug therapies are improving the success rates of the treatment. Additionally, early diagnosis improves the prognosis.
• It can be a lifelong infection if left untreated and cause serious health problems including liver damage, cirrhosis, liver cancer, and even death.

Hepatitis C and Pregnancy

• Most women with hepatitis C who become pregnant have a healthy pregnancy in which HCV does not transmit to the fetus.
• An increased risk of undesirable consequences for the fetus including low birth weight and fetus growth restriction is associated with infection during pregnancy.
• Hepatitis C during pregnancy can cause cholestasis of pregnancy, where bile acids accumulate and lead to itching and sometimes adverse fetal outcomes.
• The chance of HCV transmission from pregnant mother to fetus is about 5%.
• HCV can be transmitted to the infant in utero or during the labor or postpartum period through contact with the blood.
• The CDC recommends screening all pregnant persons for Hepatitis C infection during each pregnancy so that risk stratification can be performed and measure is taken to reduce perinatal transmission.
• Pregnant women and nursing mothers should avoid taking any of the currently available HCV treatments.
• All the infants of HCV-positive mothers are tested when the baby is at least 18 months old because the baby will have maternal antibodies in their blood which can lead to a false positive when it is done too early.
• Babies becoming infected with HCV will need regular monitoring and ongoing medical care.

Summary

• HCV causes a liver infection called hepatitis C.
• The infection can be transmitted through infected blood or body fluids and may be transmitted during child birth, through IV drug, and sexual intercourse.
• It can cause both acute and chronic hepatitis C ranging from mild to serious, lifelong illness.
• It is diagnosed by testing for the presence of HCV antibodies and HCV RNA.
• Most people are not aware of their infection because they do not possess any symptoms.
• The best way to prevent HCV infection is by avoiding behavior that can spread the disease.

References

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2. Society for Maternal-Fetal Medicine (SMFM). Hughes, B.L., Page, C.M., Kuller, J.A. (2017, Nov 1). Hepatitis C in pregnancy: screening, treatment, and management. Am J Obstet Gynecol, 217(5), B2-B12. doi: 10.1016/j.ajog.2017.07.039. Epub 2017 Aug 4. PMID: 28782502.
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