Hepatitis C is an inflammation of the liver caused by a specific virus called the hepatitis C virus (HCV). The word "hepatitis" is derived from two Latin segments: "hepat" refers to the liver, and "itis" meaning inflammation. The term "hepatitis" is not specific for a particular cause of the inflammation, as hepatitis can be caused by reactions to medications, toxic drugs, poisons, alcohol, allergic reactions, autoimmune diseases (when the body attacks itself by mistake) and a variety of viruses. The most common viruses that specifically cause hepatitis include
Other hepatitis viruses also exist and cause a small number of infections. Additionally, other viruses can cause hepatitis even though they are not specifically "hepatitis viruses." These most commonly include Epstein Barr Virus (EBV), the cause of mononucleosis, and cytomegalovirus (CMV), which causes a variety of illnesses in different parts of the body, especially in patients whose immune function is depressed due to steroids, chemotherapy for cancer, and HIV/AIDS.
There are two stages of hepatitis C. The acute (early) phase occurs soon after infection. Most people have no symptoms at this stage. Roughly 75% - 85% of individuals infected go on to develop a chronic infection. At this second, chronic stage, there may be no symptoms for years or decades. Eventually, if left untreated, most people with chronic hepatitis C will become symptomatic with progressive liver disease.
There are multiple subtypes of hepatitis C, called genotypes. These include genotypes 1a, 1b, 2, 3, 4, 5, and 6. The differences between the genotypes has an important impact on how we treat HCV infection (type of medication used, dosing and duration of therapy).
In the acute stage, more than 2/3 of people who become infected have no symptoms. For those who develop symptoms (2-24 weeks after infection), the symptoms last for 2-24 weeks. The symptoms are:
In the chronic stage, patients typically go years or decades with no symptoms. This is sometimes referred to as "latent" or "dormant" hepatitis C. Eventually, the chronic hepatitis becomes active with liver inflammation and scarring. Left untreated, this can progress to cirrhosis, liver failure, liver cancer (hepatocellular carcinoma), and death. The initial symptoms of chronic hepatitis C are:
As chronic hepatitis C progresses to liver failure (hepatic decompensation), additional symptoms develop including:
These symptoms and physical changes occur because when the liver fails, it can no longer carry out its necessary functions. These functions include removing toxic substances from the blood, fighting infection, metabolizing various drugs, creating certain important proteins, manufacturing blood clotting factors, and storing vitamins, minerals, sugars and fat for use by the body.
Hepatitis C is only contracted through contact with another person who is infected with the hepatitis C virus (HCV). It is not acquired through contact with animals or insects.
Hepatitis C is present primarily in the blood, and to a lesser degree in specific other body fluids, of an infected person. Today, it is passed most commonly through the sharing of used needles by injection drug users. Prior to 1990, it was commonly passed through blood transfusions. However, since 1990, all donated blood is tested for hepatitis C virus, so it is extremely rare for hepatitis C to be acquired through a blood transfusion.
Transmission of hepatitis C occasionally occurs in healthcare settings, such as hospitals and clinics, when established infection control protocols are not followed. Health care professionals who do not follow these protocols can become infected if they sustain a needle stick from a patient who carries hepatitis C virus.
While uncommon, one mode of transmission is through organ transplantation when the donated organ comes from a person who carries the hepatitis C virus. The use of HCV-positive organs is currently reserved for the most serious cases requiring transplantation.
Sexual transmission of hepatitis C occurs, but this is quite infrequent. The frequency of sexual transmission increases if there is anal intercourse, or if intercourse takes place during menstruation. Transmission through kissing, especially if there are sores in the mouth, is theoretically possible, but has not been scientifically proven. Saliva is not infectious unless it contains blood. Sharing personal hygiene items such as toothbrushes and razors also can potentially transmit the infection.
Transmission of hepatitis C from an infected mother to a newborn does occur, but it is most common if the mother has measurable HCV in her blood. (See hepatitis C diagnosis section.) Transmission is infrequent if the mother has no detectable hepatitis C virus in her blood. Breastfeeding has not been documented as a way to transmit hepatitis C.
Hepatitis C is associated with hemodialysis, a technique used to "clean" the blood in patients with end-stage kidney disease. Careful attention to sterilization of equipment and carefully following infection control procedures should reduce or eliminate dialysis-associated transmission of hepatitis C. Likewise, hepatitis C has rarely been transmitted by the use of other incorrectly sanitized medical equipment, which is preventable using correct infection control techniques.
Tattooing and body piercing have been documented to transmit the hepatitis C virus when recommended sterilization and infection control procedures are not followed.
In the United States, having been born between 1945 and 1965, and the use of illicit injection drugs are the two most common factors associated with hepatitis C. Other risk factors include:
Population studies show that hepatitis C is more common among males, non-Hispanic blacks, those with low income, and those with less than a high school education.
People who have HIV/AIDS have an increased risk for hepatitis C, because both these diseases are transmitted in the same ways, through blood and body fluids. If someone has both infections, that person is said to be co-infected with HIV and HCV.
There are approximately 30,000 new cases of acute hepatitis C every year in the United States as estimated by the CDC. In 2015, it was estimated that approximately 3.5 million Americans were infected with hepatitis C.
On a global scale, the prevalence of hepatitis C is greatest in Central and East Asia, North Africa, and the Middle East. In 2016, it was estimated that 177 million people worldwide had antibodies to hepatitis C virus.
Hepatitis C is diagnosed using careful questioning, a thorough physical examination, and through laboratory and imaging tests. Your healthcare professional will ask about your symptoms and how long you have been having them. You may also be asked about your history of risk factors such as:
Laboratory blood tests will be done to evaluate the patient's liver function (liver blood tests) and to look for hepatitis C antibodies (serologies). If these tests indicate that the person has hepatitis C, a hepatitis C "viral load" test will be done. This looks for genetic material from the hepatitis C virus (HCV) and measures the quantity of hepatitis C virus that is circulating in the patient's blood. This is helpful in determining if treatment is appropriate and to monitor the success of the treatment (how well the patient responded).
Individuals who had hepatitis C in the past and cleared the virus on their own will have a positive HCV antibody test, but there will be no hepatitis C virus genetic material (undetectable viral load) in the blood. If a person is immunosuppressed due to an immunological condition, cancer chemotherapy, immunotherapy or HIV/AIDS, the test results may be different and need to be evaluated accordingly.
Once the diagnosis of hepatitis C is established, other tests may be done to determine whether the patient has developed liver fibrosis or scarring (cirrhosis). This can be done with a needle biopsy of the liver, and examining the biopsied liver tissue under the microscope. Liver biopsy is less commonly done today because noninvasive tests (without invading the liver) are more readily available, more easily accomplished and less costly.
Liver imaging can evaluate fibrosis using ultrasound and MRI scans. Additionally, calculations using a variety of blood tests (FibroSure, FibroTest, Hepascore, FibroSpect, APRI) also can predict the degree of inflammation and fibrosis present. Genotype testing will typically be done to determine what subtype of hepatitis C the patient has, as this will impact what drugs are used for treatment.
Testing for other infections including HIV, hepatitis A, and hepatitis B is typically done to determine if the patient might have other conditions that could impact patient's treatment and prognosis.
With the newest forms of antiviral treatment, the most common types of chronic hepatitis C can be cured in most individuals.
The treatment of chronic hepatitis C has gone through several generations of medications. Not long ago, treatment was limited to interferon alpha-2b (Intron A) or pegylated interferon alpha-2b (Pegetron), and ribavirin (RibaPak and others). Interferon and pegylated interferon need to be injected under the skin (subcutaneously), while ribavirin is taken by mouth. This combination therapy is infrequently used today, being recommended for only the least common genotypes of hepatitis C virus (HCV).
Since 2010, direct-acting antiviral (DAA) drugs have been in use. The second generation of antivirals for HCV was the protease inhibitors telaprevir (Incivek) and boceprevir (Victrelis), both taken by mouth. These were used in combination with the earlier drugs to increase effectiveness (efficacy). These drugs are also no longer in common use, and have been replaced by better options.
As more has been learned about how hepatitis C virus multiplies (reproduces) within the liver cells, new drugs continue to be developed to interfere with this multiplication at different stages. As such, we no longer think in terms of generations of drugs, but rather categories of action. Research and development of these direct-acting antivirals continue, with new agents coming to market every few months. Each category is improved and expanded by the addition of new drugs, which are safer and more effective.
As previously mentioned, there are multiple genotypes of HCV. Different antiviral drugs are approved and recommended for different genotypes, based upon the demonstrated effectiveness in clinical trials. This is especially true because the recommended therapy for any given genotype changes frequently as new drugs and new research become available. A detailed description of all the recommendations, options, and how they work is beyond the scope of this article. All of these drugs should be used only under the management of a medical specialist.
Currently available and commonly used direct-acting antiviral drugs include:
Some of these (those without a brand name in parenthesis) are only used in fixed combination drugs:
Many people are living with hepatitis C. If you have hepatitis C, there are several important things that you can do to help yourself and others such as:
Although often uncomfortable, you should notify your partner of your hepatitis C prior to having sex. You also must notify all your health care professionals of your infection, so they can take precautions.
Hepatitis C can be passed from a mother to her child during pregnancy and during delivery. Per the Centers for Disease Control and Prevention (CDC), approximately 6 of every 100 infants born to HCV-infected mothers become infected with the virus. The risk is 2-3 times greater when the mother has HIV as well.
You and your doctor should discuss and decide if you should receive treatment for hepatitis C during your pregnancy.
Hepatitis C can be prevented by avoiding close contact with a person who has the hepatitis C virus, and by avoiding situations which can increase your risk of getting hepatitis C. These situations include:
In a healthcare setting, it means following all procedures for infection control to minimize risks due to needle sticks, hemodialysis, and contaminated equipment. There is no protective vaccination for hepatitis C at this time, although research continues in this area.
The outlook for a person with hepatitis C depends upon the stage of the disease when it is discovered and how it is managed.
You can die from hepatitis C under two circumstances:
Fortunately, with better diagnostic tests, better drug treatment options, liver transplantation, and ongoing research, death from hepatitis C is becoming less common in the United States.
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Like the slow, silent serial killers found in society, this disease, hepatitis C, slowly and methodically has infected many people. Symptoms of hepatitis C include:
