In this article, we will be focusing on one of the viral hepatitis diseases, hepatitis C infection, to
create more awareness on the occasion of the World Hepatitis Day, celebrated on 28th July
Hepatitis C is a blood-borne disease caused by a hepatitis C virus (HCV) which belongs to the
Hepacivirus genus in the family of Flaviviridae. It is potentially contagious, but curable if
diagnosed in time. Viral hepatitis progresses faster among HIV affected individuals as compared
to non-HIV individuals. There are two phases of HCV infection; acute and chronic. Acute HCV
infection is the new infection i.e. less than 6 months old and chronic HCV infection lasts more
than 6 months. Individuals with acute infection are asymptomatic, and difficult to diagnose until
later stages of the infection, leading to chronic infection. Chronic HCV infection if not managed
can cause lifelong liver damage, fibrosis, and occasionally cirrhosis. Individual with cirrhosis
have risk of developing liver failure, liver Cancer (hepatocellular carcinoma (HCC)], or even death.
There are 6 known genotypes (1, 2, 3, 4, 5 and 6) of HCV with multiple subtypes (1a, 1b, 2a, etc.).
Epidemiology
Globally, HCV infection is one of the major health burden. It is estimated that around 180 million
or 3% of the global population is living with HCV, that causes 350,000 deaths per year. The highest
prevalence is observed in developing countries like Central and East Asia, Africa and the Middle East,
while developed countries like Northern America, western Europe have a low seroprevalence. At
present, the estimated
prevalence rate of HCV in India is 1-1.9%, with genotype 1 and 3 being more prevalent. However,
genotype 1 is common in South India and genotype 3 in the North.
Hepatitis C Routes of Transmission
Hepatitis C infection spreads via blood-to-blood contact. HCV enters the body through two main
routes; parenteral (i.e. via blood) and nonparenteral (i.e. sexual or vectors). The transmission of
the virus by the parenteral route can occur through a variety of ways, the most common being
through blood transfusion and organ transplants from an infected donor. The other ways through
which the virus may be transmitted include,
- Sharing of unsterilised needles, syringes or other equipments used for injecting drugs.
- Needles used for body piercing, tattooing and acupuncture may also spread HCV.
- Unsafe sexual intercourse with an infected person, though rare.
- Sharing personalised items like toothbrushes, razors or nail files may also pose a risk.
- Birth to an HCV-infected mother.
- Other accidental exposures (occupational, hemodialysis, intranasal cocaine use) to
infected Blood.
- Outbreaks due to poor infection control.
However, HCV does not spread through sneezing, coughing, breastfeeding, hugging, sharing
utensils or drinking glasses, food, water or other casual social contact.
Risk factors for hepatitis C infection
Although, anyone can get hepatitis C infection, the risk of infection increases in individuals who
have had undergone blood transfusion or have had any surgery (especially obstetric/gynecological,
abdominal surgery or operation of the heart or eyes). Numerous other risk factors that promote
hepatitis C infections are as follows.
- Health workers exposed to infected blood or body fluids at work
- Highest incidences of infection in the age group who were born from 1945 and 1965
- Received a donated blood or an organ transplant before 1992
- Those who have certain medical conditions such as HIV, liver disease or AIDS
- Individuals who were injected or inhaled illegal drugs
- Individuals that work or live in prison
- Individuals with hemophilia and have received clotting factors before 1987
- Those who are on hemodialysis for a long period of time
- Babies born to HCV-infected mothers Individuals that work or live in prison
- Received body piercing or tattooing using non sterile equipment
- People with multiple sex partners or with history of sexually transmitted diseases and gay men
are more prone to hepatitis C infection.
Symptoms of hepatitis C
Many individuals with hepatitis C infection remain asymptomatic in the initial stages and are
unaware that they are infected. Generally, signs and symptoms will not be visible, until the
condition progresses and causes significant damage to the liver.
Symptoms of acute hepatitis C
Acute hepatitis C infection does not manifest symptoms. But, in some individuals symptoms
may occur anytime between 2 weeks to 6 months after infection. Individual with acute hepatitis
C generally show flu-like symptoms but other symptoms that may be experienced by the individual
are as follows.
- Fatigue
- Weight loss
- Fever
- Dark yellow coloured urine
- Decreased appetite
- Joint pain
- Jaundice (Yellowing of eyes and skin)
- Grey-coloured faeces
- Gastrointestinal problems such as vomiting,nausea and abdominal pain
Symptoms of chronic hepatitis C
Similar to acute hepatitis, majority of the individuals with chronic hepatitis C infection do not
show any symptoms in the early stages. Symptoms may arise often decades after exposure,
until the liver becomes severely damaged. Depending upon the type of damage to the liver,
the symptoms of chronic hepatitis C infection vary and may include,
Cirrhosis, and also produces many symptoms of acute hepatitis C which include:
� Fatigue
� Itchiness
� Abdominal bloating due to excess buildup of fluids
� Pain and tenderness in the area of the liver
� Swelling on legs, feet or ankle
� Spider angioma (spider-like abnormal collection of blood vessels beneath the skin)
Liver cancer is another issue that develops in patients who already have cirrhosis. This may lead
to symptoms like
� Jaundice
� Swollen abdomen
� Bruising and bleeding
� Abdominal pain or tenderness
Symptoms of end-stage hepatitis C
Chronic hepatitis C if not treated on time can progress to end-stage hepatitis C and can be fatal.
The symptoms that occur due to this debilitating illness include:
� Extreme fatigue
� Abdominal swelling
� Pruritus (Severe itching of the skin)
� Cachexia (weakness and wasting of the body)
� Gastrointestinal bleeding due to hemorrhaging and enlargement of the veins
� Mild cognitive impairments such as confusion,
irritability, memory and concentration problems due to the brain and nervous system damage,
caused by accumulation of toxins in the bloodstream (hepatic encephalopathy).
How is hepatitis C diagnosed?
Majority of the individuals with Hepatitis C infection remain asymptomatic during acute HCV
infection and only a few get diagnosed at the initial stages. Individuals who develop chronic
HCV infection unknowingly carry the virus and often remain undiagnosed for decades after
exposure. Many individuals are diagnosed with HCV infection only when they undergo any
blood screening or other examination for reasons unrelated to hepatitis C.
However, timely diagnosis of HCV plays a vital role in therapeutic decision-making and
assessment of effective antiviral treatment. Also, early detection along with lifestyle
modifications and proper counseling may reduce the risk of transmission of infection
to the other people. Different platforms are available for detection of HCV infection which
include:
Hepatitis C tests:
A liver function test is the primary screening test which aids in assessing the health of liver.
This panel of tests includes serum alanine transaminase (SGPT), aspartate aminotransferase
(SGOT), alkaline phosphatase, gamma glutamyl transferase (GGT), bilirubin, total protein,
etc., which in conjunction with other tests aid in diagnosis of liver disease or monitoring its
progression.
Serologic antibody assay:
Anti-HCV antibody testing is the initial test used for diagnosis of hepatitis C. It detects the
presence of antibodies generated against the virus. This test indicates exposure to the HCV
but cannot distinguish whether an individual has active or previous HCV infection. Anti-HCV
can be identified by using enzyme-linked immunosorbent assay (ELISA) and it detects antibodies
that bind to recombinant antigens derived from core as well as nonstructural regions. Other
techniques used for antiHCV testing are chemiluminescence immunoassay (CLIA), rapid
immunoassays and recombinant immunoblot assays (RIBA).
HCV RNA detection: It is a molecular diagnostic assay that can detect and
quantify the HCV RNA using the process called nucleic acid amplification test or nucleic acid test
(NAT). NAT is considered as the Gold standard' supplemental test for detection of active HCV
infection. This test can be used for confirmation as well as follow-up of patient's treatment
response. There are two types of HCV RNA tests; qualitative and quantitative. Qualitative
test distinguishes current or past infection, while quantitative test detects and measures
the viral load in the patient's blood. Molecular
technologies that are currently used for HCV RNA detection include reverse transcriptase PCR (RT-PCR),
transcription-mediated amplification (TMA) and branched deoxyribonucleic acid (DNA).
HCV genotyping: This method will determine which HCV genotype is present in the patient. As there are 6
different genotypes of HCV and each of these genotypes have various subtypes. Finding out the genotype of
the virus before initiating treatment is important, because it will aid in selection of both the type and
length of treatment, and helps to predict the likelihood of curing the infection. Also, there are different
assays available for HCV genotyping such as reverse hybridisation, direct DNA sequencing which are based on
nucleotide sequences.
Biopsy:A procedure in which a small tissue sample is removed from the liver using a special
biopsy needle to examine the presence of cirrhosis or cancer.
Treatment and prevention modalities of Hepatitis C
HCV infection can be treated successfully with proper medications and lifestyle modifications. Treatment may
not be needed in some cases of acute infection and chronic infection without any liver damage. The infection
will be clear on its own due to body's strong immune response. The goal of treatment is to fight the infection,
progression and its remission. However, the type of treatment and duration depend on number of factors such as
damage to the liver, HCV genotype, past treatment experience, ability to tolerate the drugs, etc.
Until recently,
the standard treatment for hepatitis C infection involved pegylated interferon and ribavirin therapy. Nowadays,
new antiviral drugs have been developed which are more effective, safer and better
tolerated. These medications are prescribed in combination with or without ribavirin or pegylated interferon
and a few other newer drugs. Also, liver transplantation is recommended in some cases of liver damage caused
due to infection. Currently, there is no vaccine available for hepatitis C infection and getting vaccinated
for hepatitis A and B will reduce the risk of co-infection.
Lifestyle modifications such as abstinence from alcohol and smoking, regular exercise, eating healthy and
balanced diet will limit the liver damage. While other preventive measures that need to be taken care of
are avoiding unsafe blood transfusion, sharing personal items, unprotected sex, etc. which will help reduce
risk of spreading the infection. With every advancing day the treatment of disease is getting costlier, which
in turn increases the disease burden on healthcare. However, appropriate and timely diagnosis is vital in
reducing the severe complications caused from the disease. Also, proper education and awareness programs
will increase our understanding about the disease condition and its transmission. The best way to curb these
health problems is to prevent a disease. As disease prevention would give dual benefits of saving your health
as well as your wealth!
