Hepatitis C is a common infection in the United States, with an estimated 2.7 to 3.9 million people living with chronic hepatitis C infection. Recently, the Institute of Medicine report on Hepatitis and Liver Cancer emphasized the lack of knowledge and awareness about hepatitis C among healthcare providers, social-service providers, and the general public, even among communities at risk for hepatitis C. Misconceptions and lack of awareness about this infection can lead to missed opportunities for diagnosis, prevention, and appropriate care. The following questions and answers provide a framework for counseling and educating patients about hepatitis C.
What is hepatitis C?
Hepatitis C is an infection of the liver caused by a virus. The liver is an organ in the right upper corner of your abdomen (Figure 1) that does a variety of tasks to keep you healthy: it stores nutrients, filters toxins, and produces proteins. Most people who get infected with hepatitis C virus have no apparent illness after getting infected and may never know they are infected without receiving specific testing for hepatitis C. Although some people are able to get rid of the virus after the initial infection, most (75 to 85%) do NOT clear the virus, and go on to develop chronic hepatitis C infection. This means the virus stays with them, usually for the remainder of their lives, and can be detected in their blood. Chronic hepatitis C is a long-term condition. Anywhere from 5% to 20% of people with chronic hepatitis C infection go on to develop a scarring condition of their liver called cirrhosis. This usually happens over a period of 20 to 30 years. Approximately 1% to 5% percent of people with chronic hepatitis C will die from liver failure or liver cancer.
How common is hepatitis C?
Hepatitis C is a very common infection. The Centers for Disease Control and Prevention (CDC) estimates that in the United States 1.3% to 1.9% of the population has been infected with hepatitis C, 2.7 to 3.9 million people are living with chronic hepatitis C virus (HCV) infections, and approximately 12,000 deaths occur related to chronic hepatitis C each year[1,2,3] (Figure 2). In the United States, HCV infection is especially common in persons born between 1945 and 1965—about 1 in 30 individuals in this birth cohort has been infected with hepatitis C. In recent years, approximately 20,000 new HCV infections occur each year (Figure 3), but few of these infections are associated with an acute clinical illness. Since most people with hepatitis C do not have symptoms, they often do not get tested for hepatitis C; it is estimated that about 75% of people infected with hepatitis C are unaware of their infection. Awareness of the infection allows people to seek the health care they need and to take precautions against spreading the infection to others.
What are the most common ways someone is infected with hepatitis C?
HCV is spread by direct blood-to-blood contact. A person can become infected with the hepatitis C virus any time infected blood, or blood-contaminated fluid, enters his or her body. This infection can be spread by:
Can you get hepatitis C from sex, snorting cocaine, and tatoos?
Other ways that people can get hepatitis C do not present as high a risk as the list above, but can be associated with transmission. These include:
Can you get hepatitis C from food or casual contact?
It is important to know that that hepatitis C virus is not spread through food, water, eating utensils, or casual contact (such as sneezing, coughing, or touching). Breastfeeding is considered safe for mothers with hepatitis C.
Who should get tested for hepatitis C?
In August of 2012, the CDC issues new recommendations to perform one-time hepatitis C testing for all persons in the United States born from 1945 to 1965, without prior determination of their hepatitis C risk status. This recommendation, now referred to as birth-cohort screening, arose with knowledge of the disproportionately high prevalence of hepatitis C among persons born from 1945 to 1965. Prior to this recent recommendation, the CDC had recommended a risk-based screening strategy. The recent birth cohort screening recommendation should be considered as a strategy that augments the existing risk-based strategy. The risk-based testing strategy for hepatitis C is based on identifying people who have had a risk factor for exposure to hepatitis C or are considered at high risk for developing more serious illness from hepatitis C. The following persons are recommended for risk-based screening for hepatitis C[15,16,17]:
What tests are available to detect hepatitis C infection?
There are two types of tests for hepatitis C: (1) tests that detect antibodies produced by the body in response to HCV and (2) tests that detect the virus itself. The antibody test most often done is an enzyme immunoassay (EIA). The antibody test tells you if you have ever been infected with hepatitis C. Having antibodies does not make you "immune" to hepatitis C, nor does it necessarily mean that the infection went away. The test that will detect the actual virus in the blood is called an HCV RNA or HCV viral load. A positive HCV RNA test result means that the hepatitis C virus is still present in the body, either as an acute (very recent) or chronic (long-term) infection. Most of the commonly used HCV RNA tests can also determine the amount of HCV in the blood; this quantitative HCV RNA test measures-the number of hepatitis C virus particles in a tiny drop of blood and is often referred to as the hepatitis C "viral load" test.
What are the symptoms of hepatitis C infection?
Most people have few or no symptoms from hepatitis C, either when they are first infected or during chronic infection. If you do have symptoms with initial HCV infection, they can include a "flu-like" illness, fatigue, loss of appetite, abdominal pain, fever, jaundice, nausea, vomiting, or muscle/ joint pain. Over time, people with chronic hepatitis C who have progressed to having liver damage or cirrhosis may develop additional symptoms, including abdominal swelling, fluid retention, jaundice, easy bruising or bleeding, and loss of muscle mass.
Is there any way to prevent getting hepatitis C?
There is no vaccine for hepatitis C. Nevertheless, there are things you can do to lower your risk of getting hepatitis C infection. In the United States, injection drug use is the most common cause of new cases of hepatitis C infection. Avoiding injecting drugs or stopping the use of injection drugs can reduce your risk of acquiring hepatitis C. Even if someone is still using injection drugs, there are ways to be safer and help prevent getting hepatitis C. These precautions include using sterile needles and syringes each time you inject, not reusing needles or syringes if you can avoid it, not sharing needles or syringes, not sharing other injection materials (cookers, cottons, rinse water), and reducing the frequency that you inject. Some states have needle exchange programs that can help provide clean needles, syringes, and injection equipment. Although the risk for sexually transmitting hepatitis C is low if blood is not involved, the consistent use of condoms for sexual activity can reduce your risk of sexually transmitted diseases in general, including HIV and hepatitis B.
I have chronic hepatitis C infection. How do I prevent myself from giving this infection to someone else?
It is important to know that if you have chronic hepatitis C you are potentially contagious, even long after you first become infected. The good news is that hepatitis C transmission (passing of the virus from one person to another) can be minimized (Figure 4). For the person who has chronic hepatitis C infection, it is important to take the following precautions[18,19]:
People with chronic hepatitis C should discuss the risk of hepatitis C transmission, which is low but not absent, with their sex partners. Using latex condoms and minimizing sexual exposure to blood should presumably reduce the risk of sexual transmission.
Women with chronic hepatitis C do not need to avoid pregnancy or breastfeeding. If you are planning to get pregnant speak to your medical provider about staying healthy during your pregnancy. Approximately 5 out of every 100 infants born to women with chronic hepatitis C become infected from the mother[20,21]. This occurs at, or potentially before, the time of birth. The risk of mother to infant transmission increases with higher amounts of virus in the mother's blood, if the mother also has human immunodeficiency virus (HIV) infection, and in some cases where there are complications of delivery[21,22]. Breastfeeding is considered safe for infants of mothers infected with hepatitis C.
Persons with chronic hepatitis C should NOT be excluded from work, school, play, child-care, or other settings based on their hepatitis C infection. Hepatitis C is not transmitted through casual contact.
What happens to someone who has chronic hepatitis C?
Many people with chronic hepatitis C have no symptoms related to their infection. It is usually a "silent" condition, so they can feel fine even though the liver is being affected. But chronic hepatitis C can damage the liver very slowly over time (Figure 5). In 5% to 20% of people who do not receive treatment, chronic hepatitis C can eventually progress, usually over the course of decades, to cause cirrhosis. A normal liver has a spongy or rubbery texture whereas a liver with cirrhosis is hard and scarred and cannot function normally (Figure 6). Cirrhosis can lead to liver failure, which causes more symptoms and severe illness. People with chronic hepatitis C are also at increased risk of developing liver cancer, whether or not they have cirrhosis. Liver cancer is uncommon and generally occurs in people who have had their infection for a long time.
Are there different types of hepatitis C virus?
There are at least six major types of hepatitis C virus, called genotypes. Certain genotypes are more common in certain areas of the world or in certain populations. Genotypes 1a and 1b are the most common types found in the United States (about 75 percent of cases). Genotypes 2 and 3 are present in only 10 to 20 percent of patients. Genotype has little effect on how much hepatitis C affects the liver or on long-term complications from infection, but can predict responses to therapy. For example, persons with genotypes 2 and 3 are more likely to respond to interferon treatment than those with genotype 1.
What kind of treatment is there for this infection? Is there a cure?
Treatment for hepatitis C can result in permanent clearance of the virus and cure of the infection. The goal of treatment is to prevent the complications of HCV infection. Effective treatment can reduce the risk of progressing to cirrhosis and can decrease the chance the person will develop liver cancer. The medications used for treatment consist of pegylated interferon, given as an injection under the skin once weekly in combination with ribavirin, an oral medication taken twice daily. In most cases, the treatment duration is 6 to 12 months. There are some new medications for hepatitis C treatment that should be available in 2011 that can be used in combination with existing medications; these new medications are known as protease inhibitors. Your health care provider can work with you to decide whether or not you need therapy, and if so, what kind. Not all patients with chronic hepatitis C need therapy, but everyone with chronic hepatitis C should receive medical care from a health care provider familiar with this infection.
What can I do to protect my liver and stay as healthy as I can with this chronic infection?
There are a number of things people living with chronic hepatitis C can do to care for their liver (Figure 7), including seeing a doctor or other health care professional regularly for this infection. People with chronic hepatitis C should ideally avoid drinking any alcohol (beer, wine, or hard liquor). Studies have consistently shown that using alcohol can accelerate liver damage and disease due to hepatitis C, including raising the risk for cirrhosis, liver cancer, and death. Many studies have shown an increased risk of complications associated with "heavy drinking" (4 or more drinks a day), but even moderate use of alcohol intake could potentially increase the severity of liver disease. No one knows if there is a "safe" level of alcohol use in people with hepatitis C.
Recent studies have also suggested a potential link between marijuana use and increased damage to the liver in people with chronic HCV infection. This effect appears to be more prominent in those who use marijuana on a daily basis and in people with hepatitis C who also use alcohol[24,25,26].
Most medications are safe for the liver in someone with chronic hepatitis C. Health care providers and their patients with chronic hepatitis C should discuss any medications being taking to ensure they are safe, including over-the-counter medications, such as acetaminophen (Tylenol), herbs, or "natural" supplements, as some of these can be harmful to the liver.
People with chronic hepatitis C should receive immunizations against hepatitis A and hepatitis B, if they are not already immune to these viruses. Severe hepatitis A infections have been reported in people who are already infected with hepatitis C, and having both hepatitis C and hepatitis B can complicate the long-term treatment and accelerate liver disease.
1 Mitchell AE, Colvin HM, Palmer Beasley R. Institute of Medicine recommendations for the prevention and control of hepatitis B and C.Hepatology. 2010;51:729-33.PubMed Abstract
2 Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144:705-14.PubMed Abstract
3 Daniels D, Grytdal S, Wasley A; Centers for Disease Control and Prevention (CDC). Surveillance for acute viral hepatitis—United States, 2007. MMWR Surveill Summ. 2009;58:1-27.CDC and Prevention
4 Kao JH, Liu CJ, Chen PJ, Chen W, Lai MY, Chen DS. Low incidence of hepatitis C virus transmission between spouses: a prospective study. J Gastroenterol Hepatol. 2000;15:391-5.PubMed Abstract
5 Marincovich B, Castilla J, del Romero J, García S, Hernando V, Raposo M, Rodríguez C. Absence of hepatitis C virus transmission in a prospective cohort of heterosexual serodiscordant couples. Sex Transm Infect. 2003;79:160-2.PubMed Abstract
6 McMahon JM, Pouget ER, Tortu S. Individual and couple-level risk factors for hepatitis C infection among heterosexual drug users: a multilevel dyadic analysis. J Infect Dis. 2007;195:1572-81.PubMed Abstract
7 van de Laar TJ, Matthews GV, Prins M, Danta M. Acute hepatitis C in HIV-infected men who have sex with men: an emerging sexually transmitted infection. AIDS. 2010;24:1799-812.PubMed Abstract
8 Scheinmann R, Hagan H, Lelutiu-Weinberger C, Stern R, Des Jarlais DC, Flom PL, Strauss S. Non-injection drug use and Hepatitis C virus: A systematic review. Drug Alcohol Depend. 2007;89:1-12.PubMed Abstract
9 Haley RW, Fischer RP. Commercial tattooing as a potentially important source of hepatitis C infection. Clinical epidemiology of 626 consecutive patients unaware of their hepatitis C serologic status. Medicine (Baltimore). 2001;80:134-51.PubMed Abstract
10 Hellard ME, Aitken CK, Hocking JS. Tattooing in prisons--not such a pretty picture. Am J Infect Control. 2007;35:477-80.PubMed Abstract
11 Samuel MC, Doherty PM, Bulterys M, Jenison SA. Association between heroin use, needle sharing and tattoos received in prison with hepatitis B and C positivity among street-recruited injecting drug users in New Mexico, USA. Epidemiol Infect. 2001;127:475-84.PubMed Abstract
12 Ko YC, Ho MS, Chiang TA, Chang SJ, Chang PY. Tattooing as a risk of hepatitis C virus infection. J Med Virol. 1992;38:288-91.PubMed Abstract
13 Silverman AL, Sekhon JS, Saginaw SJ, Wiedbrauk D, Balasubramaniam M, Gordon SC. Tattoo application is not associated with an increased risk for chronic viral hepatitis. Am J Gastroenterol. 2000;95:1312-5.PubMed Abstract
14 Murphy EL, Bryzman S, Glynn S, et al. Risk factors for hepatitis C virus infection in United States blood donors. NHLBI Retrovirus Epidemiology Donor Study (REDS). Hepatology. 2000;31:756-62.PubMed Abstract
15 Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep. 2012;61(RR-4):1-32.CDC and Prevention
16 Ghany MG, Strader DB, Thomas DL, Seeff LB; American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: an update. Hepatology. 2009;49:1335-74.PubMed Abstract
17 Alter MJ, Seeff LB, Bacon BR, Thomas DL, Rigsby MO, Di Bisceglie AM. Testing for hepatitis C virus infection should be routine for persons at increased risk for infection. Ann Intern Med. 2004;141:715-7.PubMed Abstract
18 Centers for Disease Control and Prevention. Recommendations for the prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR. 1998;47(RR-19):1-39.CDC and Prevention
19 Alter MJ. Prevention of spread of hepatitis C. Hepatology. 2002;36(5 Suppl 1):S93-8.PubMed Abstract
20 Conte D, Fraquelli M, Prati D, et al. Prevalence and clinical course of chronic hepatitis C virus (HCV) infection and rate of HCV vertical transmission in a cohort of 15,250 pregnant women. Hepatology. 2000;31:751-5.PubMed Abstract
21 Mast EE, Hwang LY, Seto DS, Nolte FS, Nainan OV, Wurtzel H, Alter MJ. Risk factors for perinatal transmission of hepatitis C virus (HCV) and the natural history of HCV infection acquired in infancy. J Infect Dis. 2005;192:1880-9.PubMed Abstract
22 Roberts EA, Yeung L. Maternal-Infant transmission of hepatitis C virus Infection. Hepatology. 2002;36(5 Suppl 1):S106-13.PubMed Abstract
23 National Digestive Diseases Information Clearinghouse. Chronic Hepatitis C: Current Disease Management. NIH Publication No. 10-4230, January 2010.NDDIC
24 Hézode C, Roudot-Thoraval F, Nguyen S, et al. Daily cannabis smoking as a risk factor for progression of fibrosis in chronic hepatitis C. Hepatology. 2005;42:63-71.PubMed Abstract
25 Hézode C, Zafrani ES, Roudot-Thoraval F, et al. Daily cannabis use: a novel risk factor of steatosis severity in patients with chronic hepatitis C. Gastroenterology. 2008;134(2):432-9.PubMed Abstract
26 Ishida JH, Peters MG, Jin C, Louie K, Tan V, Bacchetti P, Terrault NA. Influence of cannabis use on severity of hepatitis C disease. Clin Gastroenterol Hepatol. 2008;6:69-75.PubMed Abstract