By: Rishi K. Agarwal, MD
What is hepatitis? Hepatitis is a general term for inflammation of the liver, which can occur from a number of different sources including toxins, medications, heavy alcohol use, and viruses. Hepatitis C (HCV) is the most common viral hepatitis in the US with an estimated 3.2 million individuals with chronic HCV. There are an estimated 17,000 new cases of HCV per year.
Hepatitis C is classically known as a chronic disease, though there is a phase of acute HCV which occurs during the first 6 months of exposure. In the vast majority of cases this acute phase will lead to chronic hepatitis C. Why is the chronicity of this disease so important? It is because until recently, hepatitis C was considered a lifelong illness, and one of the leading causes of cirrhosis and liver cancer. Different patient populations are considered to be at high risk for hepatitis C. Those are namely current or former injection drug users, recipients of blood transfusions or solid organ transplants prior to 1992, chronic hemodialysis patients, persons with known exposure to HCV (healthcare works after needle sticks with HCV-positive blood), persons with HIV, and children born to HCV-positive mothers. Hepatitis C can be transmitted sexually but the risk is significantly lower compared to those listed above.
Given how common hepatitis C is in our population, the next obvious question is: “what symptoms should we be looking for?” That is a bit more challenging since approximately 70-80% of patients with acute hepatitis C, and a large percentage of patients with chronic hepatitis C, do not have any symptoms. For acute hepatitis C, some patients may have mild to severe symptoms including fever, fatigue, loss of appetite, nausea, vomiting, abdominal pain, joint pain, and jaundice. For chronic hepatitis C, the majority of patients will not have symptoms until they begin to have liver damage, even in the setting of normal liver function tests. With this being said, asymptomatic patients can still spread the virus to other individuals.
Chronic hepatitis C is a serious disease than can lead to long-term health problems. Of every 100 people infected with hepatitis C, 75-85 people will develop chronic hepatitis C. Of those, 60-70 people will go on to develop chronic liver disease, 5-20 will go on to develop cirrhosis over a 20-30 year period, and 1-5 people will die from cirrhosis or liver cancer. With this data, approximately 15,000 people die every year from hepatitis C related liver disease.
Because HCV infection is frequently asymptomatic, screening patients who may have an increased likelihood of being infected with HCV is an important step toward improving the detection and ultimately the treatment of infected individuals. Screening for HCV generally focuses on testing those who have an individual risk factor for exposure, who have evidence of liver disease, and who belong to certain demographic groups that have a high-prevalence of infection-including individuals born in the United States between 1945 and 1965. Several organizations have provided guidelines for who should be tested/screened for HCV infection.
Screening is performed initially via a hepatitis C antibody test. A positive antibody test is followed by an RNA test. If positive, it is important to discern the genotype, as treatment regimens are tailored to the genotype the patient has. It is important to avoid alcohol if diagnosed with hepatitis C, as alcohol and hepatitis C can have a synergistic effect on disease progression. Vaccinations are very important as well, thus patients should be vaccinated against hepatitis A and B, as well as against the flu (once a year), pneumonia (at least once), diphtheria and tetanus (once every 10 years) and pertussis (once during adulthood).
Treatment for hepatitis C has come a long way from where we started. Approximately 20% of patients with hepatitis C will spontaneously clear the virus; however the remaining 80% of patients will be looking for treatment options. In the early days, our options were limited, typically committing patients to 2-drug (and even 3-drug) therapy from anywhere between 6 and 12 months with the primary medications being interferon and ribavirin. In some cases, we were only able to offer successful treatment ~50% of the time. These medications were noted to have multiple side effects ranging from anemia, to fatigue, to depression, which decreased compliance. Over the last few years great strides have been made in the treatment of hepatitis C, to the point that depending on the genotype, we can potentially offer non-interferon treatment regimens (i.e. an all-oral regimen) and have a near 90% chance of clearing the virus – thus providing not only treatment but a cure.
In summary, hepatitis C is a global health problem that can progress to cirrhosis and end stage liver disease in a substantial proportion of patients. Screening can play a major role in identifying patients and ultimately treating them with ever-evolving and improving therapies.