HEPATITIS OVERVIEW

What is Hepatitis C (HCV)

Hepatitis C is a single-stranded ribonucleic acid (RNA) virus organized like the RNA of flavivirues. Several distinct strains, known as genotypes, have been identified.

Hepatitis C is a life threatening viral infection and is transmitted through infected blood and blood products. It is considered the most common chronic blood borne infection in the United States by the Centers of Disease Control. An estimated four million persons are living with HCV. Most of these are chronically infected and might not be aware of their infection because they are not clinically ill. Infected persons serve as a source of transmission to others and are at risk for chronic liver disease or other HCV related chronic disease. HCV infected persons will not experience or show symptoms for 10, 15 or even 20 years after initial infection.

Chronic liver disease is one of the leading causes of death among adults in the U. S. and accounts for approximately 25,000 deaths annually. In Texas, deaths due to liver disease rank in the top ten causes for death. Texas conducted serprevelance testing during 2000 and estimate 300,000 to 500,000 persons, in the state, have HCV.

Studies indicate that 40% of chronic liver disease is HCV related, resulting in over 10,000 to 15,000 death per year. Death due to HCV is estimated to increase over the next ten years to approximately 30,000 per year.

Hepatitis C associated end stage liver disease is the most frequent indication for liver transplantation among adults. It is estimated that 51% of all liver transplants are due to HCV infection.

Three percent or 200,000,000 people have HCV worldwide. In the U.S., 36,000 new cases are occurring each year. It is estimated that in the country less than 30% of persons with HCV know they have it.

Living With Hepatitis C, A Survivor’s Guide, Revised, Gregory T. Everson, M.D. and Hedy Weinberg; Centers for Disease Control and Prevention, MMWR, Vol. 47, October, 1998; National Institute of Allergy and Infectious Diseases, “Emerging and Re-Emerging Issues In Infectious Diseases, December, 1998; CDC: Viral Hepatitis C Fact Sheet, Dec., 2001

DISCOVERY OF HEPATITIS C

In the 1970s, available diagnostic tests indicated that 90% of posttransfusion hepatitis was not caused hepatitis A and B viruses.

Then, in the 1980s, after many years of work, investigators finally identified HCV by using specialized genetic chemistry to identify the virus, and with this discovery, they named it Hepatitis C. Discovery of HCV by molecular cloning in 1988 indicated that non-A, non-B hepatitis was primarily caused by HCV infection.

In 1990, the first test for HCV became commercially available. Blood bank screens uncovered an explosion of cases. The blood supply was not safe from HCV infection until 1992.

Hepatitis C is approximately 3 to 4 times more prevalent than HIV/AIDS in the United States. Approximately 35% of HIV infected persons are co-infected with HCV.

There is not a vaccine for Hepatitis C or a cure. There are treatments available, but it is estimated that only 200,000 to 400,000 patients have been treated.

National Institutes of Health: Hepatitis C Virus, An Introduction; Robert H. Purcell, MD, May, 2000, Hep C Alert; National Institutes of Health Consensus Statements, March, 1997; Centers For Disease Control and Prevention, Recommendations for Prevetion and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease, MMWR, Reprinted March, 1999; Hepatitis C: Moving Forward, Overview of Hepatitis C in 2001: Where Are We Going?, William Lee, M.D., University of Texas Southwestern Medical School.

ACUTE AND CHRONIC HEPATITIS C

ACUTE HCV

Persons with acute C infection typically are either asymptomatic or have a mild clinical illness. Sixty to seventy percent have no discernible symptoms; 20-30% might have jaundice; and 10-20% might have nonspecific symptoms such as malaise, abdominal pain and lack of appetite.

Clinical illness in patients with acute HCV are similar to that of other types of viral hepatitis and serologic testing is necessary to determine the etiology of hepatitis. Average time from exposure to symptom onset is 6-7 weeks; average time from exposure to seroconversion is 8-9 weeks. Anti-HCV can be detected in 80% of patients with 15 weeks after exposure, in 90% within 5 months after exposure and 97% by 6 months after exposure.

The course of acute HCV is variable, although elevation in serum ALT levels often in a

fluctuation pattern, is its most characteristic feature. Normalization of ALT levels that might occur suggests full recovery, but this is frequently followed by ALT elevations that indicate progression to chronic disease.

Acute HCV infection has gone down consistently while chronic HCV newly diagnosed cases have risen.

Centers for Disease Control and Prevention, MMWR, Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease, Reprinted March, 1999, Harvey J. Alter, M. D., Chief, Infectious Disease Section, Department of Transfusion Medicine, National Institutes of Health; National Hepatitis C Prevention Strategy, Divisions of Viral Hepatitis, National Center for Infectious Diseases, Centers for Disease Control and Prevention, July, 2001.

CHRONIC HEPATITIS C

After acute infection, 15-20% of persons appear to clear the infection without sequelae as defined by sustained absence of HCV RNA in serum and normalization of ALT levels.

Chronic HCV infection develops in 75-85% of persons. There are no epiemiologic features among patients with acute infection that have been found predictive of either persistent or chronic infection. ALT patterns have been observed in patients during follow up and are normal in approximately 30% of chronically infected persons. A single ALT determination cannot be used to exclude ongoing hepatic injury and long-term follow up of patients with HCV infection is required.

Chronic HCV is not recognized until asymptomatic persons are identified with testing or the diagnosis of liver disease. It is estimated that in the United States, less than 30 percent of people with HCV know that they are infected.

Progression of HCV varies among patients. The course of chronic liver disease is usually insidious, progressing at a slow rate without symptoms or physical signs in the majority of patients during the first two or more decades after infection. Frequently, chronic HCV is not recognized until asymptomatic persons are identified during blood-donor screening or elevated ALT levels are detected during routine physical examinations.

Although factors predicting severity of liver disease have not been well-defined, recent data indicates that increased alcohol intake, being age 40 years at infection and being male are associated with more severe liver disease. Among persons with alcoholic liver disease and HCV infection, liver damage progresses more rapidly, among those with cirrhosis, a higher risk of liver cancer (HCC) exists. Recent studies indicate that less than 10-20 grams or only two 1 oz. of alcohol a day in patients with chronic HCV might enhance disease progression and alcohol-induced enhancement of viral replication.

Hepatitis C, M. J. Alter, PhD, Eric E. Mast, MD, MPH, Linda A. Moyer, BS, and Harold S. Margolis, MD, Centers for Disease Control and Prevention, Volume 12, Number 1, March, 1998; National Institute of Allergy and Infectious Diseases, Hepatitis C: A Meeting Ground for the Generalist and the Specialist; December, 1998, Centers for Disease Control and Prevention, MMWR, Vol. 47, Reprinted March, 1999; CDC, Hepatitis C, Frequently Asked Questions, Dec. 2001.

RISK FACTORS

Ø Blood Transfusions Prior to 1992

Ø IV Drug Use

Ø Non-Injecting Drug Use (e.g., Cocaine Use)

Ø Unprotected Sex with Multiple Partners

Ø Body Piercing and Tattooing (Especially “Street” Tattooing)

Ø Mother to Child Neonatal Transmission

Ø Perinatal-Following Obstetric Interventions or

Ø Complications (Rare)

Ø Needle Sticks and Sharps Injury

Ø Sharing Toothbrushes, Nail Files, Razors

Ø Low Birth Weight Babies Prior to 1992

Ø Household Contact

AT RISK POPULATIONS

ü HIV/HBV INFECTED

ü CHRONIC HEMODIALYSIS

ü HEALTH CARE PROFESSIONALS

ü IV DRUG USERS

ü HEMOPHILIA

ü INCARCERATED POPULATIONS

ü EMERGENCY PERSONNEL

ü VIETNAM VETERANS

ü BLOOD TRANSFUSIONS PRIOR TO 1992

ü PERSONS HAVING UNPROTECTED SEX

ü WITH MORE THAN ONE LONG TERM PARTNER

ü PERSONS WITH CLOTTING PROBLEMS TREATED PRIOR TO 1987

ü PEOPLE WHO HAVE SIGNS OF LIVER DISEASE

ü SOLID ORGAN, BONE OR TISSUE TRANSPLANTS PRIOR TO 1992

COMMONLY REPORTED SYMPTOMS

v FLU-LIKE ILLNESS

v (SORE MUSCLES, JOINTS)

v LOW GRADE FEVER

v GENERAL MALAISE

v IRRITABLE BOWELS

v FATIGUE (MILD TO SEVERE)

v DIARRHEA

v NIGHT SWEATS

v LACK OF CONCENTRATION

v “LIVER PAIN”

v ITCHY SKIN

v INDIGESTION

v DEPRESSION/MOOD SWINGS

v ABDOMINAL BLOATING

v HEADACHES

v “BRAIN FOG”

v LOSS OF APPETITE

v COGNITIVE DYSFUNCTION

v DIZZINESS & PERIPHERAL VISION PROBLEMS

Symptoms can be slight and not noticeable until severe liver damage has been detected. A general “just not feeling myself and I have a lot of tiredness” are sometimes the earliest reported symptoms.

Living With Hepatitis C, A Survivor’s Guide, Gregory T. Everson, MD and Hedy Weinberg; Centers for Disease Control, Viral Hepatitis C Fact Sheet, Dec. 2001; Hepatitis C Support Project of San Francisco.

WHO SHOULD BE TESTED ABSENT SYMPTOMS?

§ Persons who ever injected illegal drugs, including those who injected once or a few times many years ago;

§ Persons who were treated for clotting problems with a blood product made before 1987 when more advanced methods for manufacturing the products were developed;

§ Persons who were notified that they received blood from a donor who later tested positive for Hepatitis C;

§ Persons who received a blood transfusion or solid organ transplant before July, 1992 when better testing of blood donors became available;

§ Patients on long-term hemodialysis;

§ Persons who have signs or symptoms of liver disease (e.g., abnormal liver enzyme tests);

§ Healthcare workers after exposures (e.g., needle sticks or splashes to the eye) to HCV positive blood on the job;

§ Children born to HCV-positive mothers;

§ Persons who have tested positive for HIV.

Centers for Disease Control: Viral, Hepatitis C Fact Sheet, Dec. 2000

THE HEPATITIS ALPHABET

There are at least seven distinct hepatitis viruses, identified as A though G. Although the public tends to lump all of them together, each is diagnosed with blood tests and are easily distinguished.

Hepatitis A (HAV)

Outbreaks of HAV occur due to poor hygiene, contaminated water supply, and inadequate hand washing in food preparation, such as in day care facilities. It is excreted in feces and is called “fecal-oral”. The virus is more easily spread in areas where there are poor sanitary conditions and where personal hygiene is not observed. Most infections result from contact with a household member or sex partner with HAV. Casual contact, as in the work place and school settings does not spread the virus. Adults will have signs and symptoms more often than children.

HAV will cause flu-like symptoms within 10 to 40 days of exposure, low-grade fever, fatigue, loss of appetite, nausea, diarrhea, headache, malaise, and mild abdominal pain. Often but not always jaundice will appear. About 15% of people infected with HAV will have prolonged or relapsing symptoms over a 6-9 month period. In most cases, the persons infected with HAV will completely recover with immunity to reinfection. HAV does not persist after the acute stage and does not develop chronic hepatitis, cirrhosis, or liver cancer.

Hepatitis A vaccine is available and should be administered starting at age 2. Protection against HAV begins four weeks after the first dose of Hepatitis A vaccine and protection will last for at least 20 years.

Hepatitis B (HBV)

Hepatitis B spreads through transfusions of blood and blood products, body fluids, sharing of needles through intravenous drug use, hemodialysis, accidental needle-stick or sharps and by sexual contact. It can also be transmitted from mother to infant at delivery. There are an estimated 1.2 million chronically infected Americans, of whom 20-30% acquired their infection in childhood. Chronic infection occurs in 90% of infants at birth, 30% of children infected at 1-5 years old and 6% of persons infected after 5 years old. Death from chronic liver disease occurs in 15-25% of chronically infected persons. Patients can develop liver failure from severe acute HBV, and 5 to 10% do not clear the virus. They are carriers and can develop chronic hepatitis and progression to cirrhosis or liver cancer. There are several antiviral agents that appear to be effective and there is a vaccine. HBV symptoms are the same as HAV and HCV. Hepatitis B vaccine has been available since 1982 with routine vaccination starting at birth.