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Discussion

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[1]. 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[1]. 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[3]. 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[1]. 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:

  • Sharing needles with an infected person.
  • Sharing injection materials with an infected person, including syringes, "cookers", "cottons", and rinse water.
  • Receiving a blood transfusion, blood clotting factor concentrates, or organ transplant from an infected person (careful screening of the blood supply has essentially eliminated this route of transmission in the United States since 1992).
  • Passing the virus to the baby during pregnancy or at childbirth from a mother who has hepatitis C virus in the blood. (In general less than 5% of infants born to HCV-infected mothers become infected).
  • Suffering a needle stick injury or contact with infectious blood on a contaminated device through a medical procedure.

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:

  • Sexual contact with someone with hepatitis C. Transmission of hepatitis C through sexual contact appears to be uncommon, with transmission among long-term monogamous partners occurring in less than 1% of couples per year[4,5,6]. In recent years, however, there have been a number of reports of hepatitis C transmission involving persons engaging in high-risk traumatic sexual practices, most of whom also were infected with the human immunodeficiency virus (HIV)[7].
  • Inhaling drugs through the nose (intranasal drug use) when sharing equipment or materials with someone who has hepatitis C has been associated with hepatitis C infection in some studies, whereas other studies have not demonstrated this association[8].
  • Receiving a tattoo with non-sterile equipment. Some studies have found associations between tattooing and HCV infections[9,10,11,12], particularly tattooing using shared needles and/or ink, while other large studies have not[13,14].

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[15].  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]:

  • Persons who have ever injected drugs, including those who injected only once and/or many years ago
  • Recipients of clotting-factor concentrates made before 1987
  • Recipients of blood transfusions or solid-organ transplants before July 1992
  • Patients who have ever received long-term hemodialysis treatment
  • Persons who have known exposures to HCV, such as (1) health-care workers after needle sticks, sharps, or mucosal exposures involving HCV-positive blood, or (2) recipients of blood or organs from donors and the donor later tested positive for HCV
  • All persons who have HIV infection
  • Patients who have signs or symptoms of liver disease (for example, abnormal liver enzyme tests)
  • Children born to mothers who are chronically infected with HCV
Other persons at lower risk of infection but who may be considered for screening are:
  • Persons who have a history of intranasal use of drugs using shared equipment or materials
  • Long-term sexual partners of known HCV-infected persons
Liver enzyme tests are blood tests that can increase when the liver is inflamed as a result of infection, such as with hepatitis C, or with substances that are toxic to the liver, such as alcohol. Not all patients with hepatitis C have elevated liver enzyme tests. If you have a risk factor for hepatitis C, you should still get tested, even if your liver enzyme tests are normal.

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]:

  • Do not donate blood, tissues, or body organs
  • Avoid sharing razors, toothbrushes, nail clippers, or other personal care items that contain any trace of blood
  • Cover cuts or sores on the skin to keep from spreading infectious blood
  • Never share any equipment, needles, or syringes used for injecting drugs

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[23].

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.

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  • The following link will open in a new window. Figure 1 - Location of Liver in Body

    The liver is an organ in the right upper corner of the abdomen.


    Figure 1
  • The following link will open in a new window. Figure 2 - Burden of Hepatitis C in the United States

    Source: Source: CDC. Division of Viral Hepatitis-Statistic and Surveillance.


    Figure 2
  • The following link will open in a new window. Figure 3 - New Hepatitis C Infections in the United States

    Source: CDC. Division of Viral Hepatitis-Statistic and Surveillance.


    Figure 3
  • The following link will open in a new window. Figure 4 - Preventing Transmission of Hepatitis C Virus

    Source: 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.


    Figure 4
  • The following link will open in a new window. Figure 5 - Natural History of Hepatitis C Infection

    Source: Department of Health and Human Services. The ABCs of Hepatitis. Atlanta, GA: Centers for Disease Control and Prevention, Division of Viral Hepatitis. 2010 April.


    Figure 5
  • The following link will open in a new window. Figure 6 - Normal Liver and Liver with Cirrhosis
    Figure 6
  • The following link will open in a new window. Figure 7 - How to care for your liver when you have Chronic Hepatitis C
    Figure 7