Introduction

First discovered in 1989, the hepatitis C virus (HCV) is blood-borne form of viral hepatitis. The incubation period is 6-9 weeks.

Transmission is usually via blood products or vertical transmission from mother to foetus. Sexual transmission is possible but rare.

HCV infection can be acute or chronic. Acute is usually asymptomatic, and often not discovered for years after infection (often discovered incidentally). Chronic infection is often discovered when patients develop serious liver disease later in life. It can cause cirrhosis, decompensated live disease, and death.

50% – 80% of those exposed to the virus will develop chronic infection. Spontaneous late clearance of the disease is very rare.

There is no vaccine available for the prevention of HCV

In many cases, chronic HCV is can be cured with antiviral combination therapy. Previously this involved genotyping of the HCV virus for each individual, and complex regimens, often involving self-administer SC injections, under the supervision of a specialist. However, in recent years, new oral agents (DAA – direct acting antivirals) which are effective against all strains (and thus don’t require genotyping) have been developed, with a cure rate of >90%, and in some cases (e.g. in Australia) can even be prescribed by a GP.

Epidemiology

  • Prevalence in the UK is about 0.02%. In Africa it is about 6%, and in Egypt is as high as 19%.
  • About 80% of those in the UK with haemophilia have hepatitis C.
  • Worldwide it is the leading cause of liver disease.
    • 180million people thought to be infected worldwide
  • 95% of new cases in UK are due to IV drug use. Sexual transmission is also possible but less common.
  • 6 genetic subtypes – genotyping for the type of Hep C is important for treatment (less so with the advent of new oral treatments)
    • 90% of cases are either type 1 or type 3

Risk factors

  • IV drug use
  • Blood transfusion before 1991
  • Haemodialysis
  • Sexual contact with an infected partner
  • Needlestick injuries in healthcare workers
  • Vertical transmission from mother to baby
  • Co-existing HIV

 

Presentation

  • 85% anicteric. 10-15% of patients will have jaundice and perhaps other general symptoms suggestive of hepatitis.
  • Jaundice, malaise, abdominal pain, nausea & fever – mild

Diagnosis

  • Diagnosis – abnormal LFTs / +ve anti-HCV
  • Acute liver failure rare – < 0.1%
  • Chronic infection very common – 85% & 1 – 4 % ® HCC

Management

  • Antiviral therapy for chronic infection
  • Treatment with Interferon has largely been superseded by use of DAA (direct-acting antivirals)
    • Cure rate>90%
    • Oral medication – usually a daily regimen (may be poor adherence)
    • Treatment usually lasts 8-12 weeks
    • Does not require intensive monitoring (unlike interferon)
    • Side effects are uncommon and usually mild and include:
      • Fatigue
      • Headache
      • Insomnia
      • Nausea

Prognosis

  • 30% of chronic HCV develop cirrhosis within 20 – 30 years
  • Male patients are more likely to develop fibrosis with chronic infection.
  • Progression from chronic hepatitis to cirrhosis takes 20-40 years. This happens more quickly in male patients, immunosupressed patients, and those who drink a lot of alcohol.
  • About 20% of Hep C patients will develop cirrhosis within 20 years.
    • 5 year survival once cirrhosis has set in is 95%. 10-year is 81%
    • ¼ of patients will develop complications, such as ascites. Once these have developed, 5-year survival drops to 50%
    • 2-5% of cirrotic patients will develop hepatocarcinoma.

References

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