Chronic hepatitis C infection is a treatable condition. The two main consequences of chronic infection with hepatitis C virus are cirrhosis and hepatocellular carcinoma. It usually takes many years for these to develop and there is an opportunity for early treatment.
Chronic hepatitis C infection may cause non-specific symptoms, such as fatigue, but diagnosis relies on a willingness to consider it as a possibility and test accordingly.
Around half of all chronic hepatitis C infections are undiagnosed. Tragically this means many infections will not become apparent until the patient presents with cirrhosis or hepatoma.
The prevalence of hepatitis C in the UK is estimated to be 0.4-1 per cent or approximately 250,000-600,000 individuals in total. It is estimated that around 30 per cent of those infected will develop cirrhosis 20-30 years after infection.
1. Risk groups and detection
In acute hepatitis C infection only around 20 per cent will show any symptoms in the early stages and in most patients these symptoms are usually non-specific.
Nearly 90 per cent of chronic hepatitis C infections are found in injecting drug users. Screen the following groups:
- Patients who have ever injected drugs (less than one-third will be current injectors and ex-injectors may be less keen to disclose previous substance use).
- Patients with abnormal LFTs.
- Patients who received a blood transfusion before September 1991 or other blood products before 1986 in the UK.
- People who were born or lived in regions where hepatitis C is endemic, such as south Asia.
- Any exposure to medical or dental treatment, tattoos, piercings or acupuncture where infection control may have been poor.
- Sexual partners of infected people.
- Children of infected mothers.
Take blood to test for hepatitis C antibodies. This will identify anyone who has ever been exposed to the hepatitis C virus.
In this group 75 per cent will have active infection but the other 25 per cent will clear the virus spontaneously. A further blood test is needed for anyone who has hepatitis C virus antibodies to check for hepatitis C virus RNA by PCR. Some labs will test from the same sample but many will require a second sample to be taken and sent.
Anyone at risk of hepatitis C should also be tested, with consent, for hepatitis B and HIV.
3. Management and referral
Early referral is advantageous and NICE guidance recommends that 'mild' chronic hepatitis C virus is treated. Ongoing substance misuse should not be a barrier to referral and treatment.
Many patients that test positive will be concerned about transmission to family and sexual partners. There is less than a 1 per cent per year risk of sexual transmission in a relationship but the risk is much higher in rough or anal sex where there is a risk of contact with blood. Patients should avoid sharing toothbrushes or razors with family members.
Encourage anyone with chronic hepatitis C infection to stop drinking alcohol.
Alcohol is associated with an increased risk of progression to cirrhosis.
4. Treatment of chronic infection
The two drugs used to treat hepatitis C are pegylated interferon and ribavirin. The interferon is given as weekly injections. Interferons are produced by the body as part of the immune response to a virus. Ribavirin is given daily as an oral medication.
The recommended length of treatment is 24 or 48 weeks depending on a number of factors including the hepatitis C virus genotype, the viral load at the start of the treatment and initial response.
The aim is to achieve a sustained virological response, which is defined as undetectable serum hepatitis C virus RNA, six months after treatment.
This can sometimes lead to confusion for patients who are expecting a 'cure'. Typical success rates are around 80 per cent in genotypes 2 or 3 and 50 per cent in genotype 1.
There can be considerable side-effects during hepatitis C treatment and primary care is in a good position to offer monitoring and support during treatment.
Interferon can cause influenza-like symptoms and up to 50 per cent will report fatigue, headaches, fever, myalgia, insomnia and nausea. Up to 25 per cent may suffer hair loss, pruritus, and depression. Interferon can also cause thyroid dysfunction.
The most common blood test abnormalities are anaemia and thrombocytopaenia. Ribavirin can also lead to anaemia, as well as rashes, insomnia and dyspnoea.
6. Harm reduction and reducing transmission
Reinforce the need to not share any injecting or snorting equipment. Sharing spoons or straws can also result in infection.
There is no vaccination against hepatitis C but it is important to vaccinate against hepatitis B. Injecting drug users or those who test positive for hepatitis C should also have a hepatitis A vaccine. These should be given immediately - use an accelerated schedule at zero, one and two months with a booster at 12 months.
- Dr Lawson is a GP in Cumbria and RCGP lead for the certificate in the detection, diagnosis and management of hepatitis B and C in primary care.
- The Hepatitis C Trust www.hepctrust.org.uk
- NICE. Peginterferon alfa and ribavirin for the treatment of chronic hepatitis C. TA200. London, NICE, 2010.
- Nash KL, Bentley I, Hirschfield GM. Managing hepatitis C virus infection. BMJ 2009; 338: b2366.
- Health Protection Agency. Hepatitis C in the UK: 2009 report. HPA, December 2009. www.hpa.org.uk/hepC2009.