HEPATITIS

C INFECTION

FACTS, DIAGNOSIS, AND INTERPRETATION

Dr.T.V.Rao MD

DR.T.V.RAO MD

WHAT IS HEPATITIS?
Hepatitis means inflammation of the liver
Can be caused by: Genetic diseases Medications (including over-the-counter) Alcohol

Hepatitis viruses (A,B,C,D,E)

HEPATITIS C
Identified in 1989
Blood test became available in 1992 Used to be known as nonA, non-B hepatitis Spread through blood-toblood contact

No vaccine available to prevent hepatitis C

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STRUCTURE OF HEPATITIS C

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HEPATITIS CA GLOBAL INFECTION

About 3 million Americans infected About 170 million infected worldwide Many do not experience symptoms
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SOURCES OF INFECTION FOR PERSONS WITH HEPATITIS C

Injecting drug use 60% Sexual 15%

Transfusion 10% (before screening) Other* 5% Unknown 10%

*Nosocomial; Health-care work; Perinatal
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Source: Centers for Disease Control and Prevention

WHAT IS HEPATITIS C INFECTION

Hepatitis C is a contagious liver disease that results from infection with the Hepatitis C virus. It can range in severity from a mild illness lasting a few weeks to a serious, lifelong illness. Hepatitis C is usually spread when blood from a person infected with the Hepatitis C virus enters

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the body of someone who is not infected

HEPATITIS C - EPIDEMIOLOGY

Before 1985
Illegal Drug Use Transfusion Sexual Other Unknown

1999

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HEPATITIS C INFECTION NATURAL HISTORY

Acute infection

Resolve 15%

Chronic infection 85%

Stable 80%

Cirrhosis 20%

Stable 75%
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Mortality 25%

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WHAT HAPPENS TO PEOPLE WITH HEPATITIS C VIRUS?

100
Infected With Hepatitis C

15
No Chronic Disease

85

17
Cirrhosis

2
Liver Cancer
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Chronic Disease
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CHRONIC HEPATITIS C FACTORS PROMOTING PROGRESSION OR SEVERITY

Increased alcohol intake Age > 40 years at time of infection HIV co-infection ? Other Male gender Other coinfections (e.g., HBV)

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ALCOHOL MAJOR CONTRIBUTOR FOR PROGRESS OF DISEASE

Chance Of Getting Cirrhosis

Non-Drinker

Hepatitis C Non-Drinker
Drinker Without Hepatitis C Drinker With Hepatitis C
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HEPATITIS C CAN PRESENT AS ACUTE OR CHRONIC INFECTION

Hepatitis C can be either acute or chronic. Acute Hepatitis C virus infection is a short-term illness that occurs within the first 6 months after someone is exposed to the Hepatitis C virus. For most people, acute infection leads to chronic infection. Chronic Hepatitis C is a serious disease than can result in longterm health problems, or even death.

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TRANSMISSION / EXPOSURE
Hepatitis C is spread when blood from a person infected with the Hepatitis C virus enters the body of someone who is not infected. Today, most people become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. Before 1992, when widespread screening of the blood supply began in the United States, Hepatitis C was also commonly spread through blood transfusions and organ transplants. People can become infected with the Hepatitis C virus during such activities as Sharing needles, syringes, or other equipment to inject drugs Needle stick injuries in health care settings Being born to a mother who has Hepatitis C
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LESS COMMONLY TRANSMITTED THROUGH

Less commonly, a person can also get Hepatitis C virus infection through Sharing personal care items that may have come in contact with another persons blood, such as razors or toothbrushes Having sexual contact with a person infected with the Hepatitis C viru s
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WHO SHOULD BE TESTED FOR HEPATITIS C?

People with risk factors for hepatitis C Those who wish to be tested

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WHO SHOULD GET TESTED FOR HEPATITIS C?

You are a current or former injection drug user, even if you injected only one time or many years ago. You were treated for a blood clotting problem before 1987. You received a blood transfusion or organ transplant before July 1992.

You are on long-term hemodialysis treatment.

You have abnormal liver tests or liver disease. You work in health care or public safety and were exposed to blood through a needle stick or other sharp object injury. You are infected with HIV.

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Based on increased risk for infection

HCV TESTING ROUTINELY RECOMMENDED

Ever injected illegal drugs Received clotting factors made before 1987 Received blood/organs before July 1992 Ever on chronic hemodialysis Evidence of liver disease

Healthcare, emergency, public safety workers after needle stick/mucosal exposures to HCV-positive blood Children born to HCV-positive women
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ROUTINE HCV TESTING NOT RECOMMENDED

(UNLESS RISK FACTOR IDENTIFIED)

Health-care, emergency medical, and public safety workers Pregnant women

Household (non-sexual) contacts of HCVpositive persons General population

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HCV INFECTION TESTING ALGORITHM FOR DIAGNOSIS OF ASYMPTOMATIC PERSONS

EIA for Anti-HCV
Positive (repeat reactive) Negative (non-reactive)
STOP

OR RIBA for Anti-HCV

Negative STOP Negative

RT-PCR for HCV RNA

Positive Positive

Indeterminate

Additional Laboratory Evaluation (e.g. PCR, ALT) Negative PCR, Normal ALT Positive PCR, Abnormal ALT

Medical Evaluation

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Source: MMWR 1998;47 (No. RR 19)

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HOW IS HEPATITIS C DIAGNOSED?

Blood testing 1. Hepatitis C antibody test 2. Hepatitis C PCR test to find virus in blood Liver function tests

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LABORATORY DIAGNOSIS
Serologic tests to detect HCV antibodies:

enzyme immunoassay (EIA). False negative in pts on HD, immunodeficiency; false positive in autoimmune disorder. recombinant immunoblot assay (RIBA) Target amplification technique to detect HCV RNA (molecular assay) -

polymerase chain reaction (PCR). A positive test confirms HCV infection.

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CURRENTLY PERFORMED TESTES FOR

HEPATITIS C INFECTION
Currently, the secondgeneration enzyme immunoassay (EIA-2) for antibodies to HCV (anti-HCV) is the most practical screening test for HCV infection. The diagnosis of HCV infection can be supported or confirmed by the recombinant immunoblots assay (RIBA) or tests for HCV RNA. RIBA detects antibodies to individual HCV antigens and confers increased specificity compared to EIA-2.
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MOLECULAR METHODS IN DIAGNOSIS OF

HEPATITIS C INFECTION
Qualitative reverse transcriptionpolymerase chain reaction (RT-PCR) assays for HCV RNA are simpler than quantitative tests and sufficient for confirmation of the diagnosis of HCV infection.
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ALANINE AMINOTRANSFERASE
Serum ALT testing is inexpensive and noninvasive.

Insensitive means of monitoring disease activity.

A single determination gives limited information, and serial measurements recommended.

Weak association between the degree of ALT elevation and severity of histopathological findings on liver biopsy.
Resolution of ALT elevation with antiviral therapy appears to indicate disease response.

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Serologic Pattern of Acute HCV Infection with Recovery anti-HCV

Symptoms +/HCV RNA

Titer

ALT

Normal 0
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3 4 Months

2 3 Years

4
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Time after Exposure

Serologic Pattern of Acute HCV Infection with Progression to Chronic Infection

anti-HCV
Symptoms +/HCV RNA

Titer

ALT

Normal 0
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3 4 Months

2 3 Years

4
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Time after Exposure

LIVER BIOPSY
Provides useful information about the degree of fibrosis in HCV infected patients. This information is important in management decisions. Is not used for diagnosis of HCV infection. Used for assessment of severity of inflammation, presence of fibrosis, evaluate possible concomitant disease processes, assess therapeutic intervention.

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LIVER HISTOLOGY
Activity (necro-inflammation) severity and progress. May fluctuate with disease activity or therapeutic intervention. Fibrosis implies possible progression to cirrhosis. In mild cases, is limited to portal and periportal area. More advanced changes defined by bridging fibrosis.

Cirrhosis

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DIAGNOSTIC ASSESSMENT OF INFECTED PATIENTS

In summary, the diagnostic algorithm of Hepatitis C depends on the clinical context. In asymptomatic, low-risk subjects, who are found to be anti-HCVpositive by EIA-2, the diagnosis of HCV infection needs to be confirmed, especially if the initial biochemical tests reveal normal ALT levels.
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CAN WE PREVENT HEPATITIS C INFECTION

There is no vaccine for Hepatitis C. The best way to prevent Hepatitis C is by avoiding behaviors that can spread the disease, especially injection drug use.
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REFERENCES
Centre for Disease Control (CDC) Atlanta USA, guidelines on basis of disease Diagnosis, and consequences of Hepatitis C Infection

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 Created by Dr.T.V.Rao MD for Medical and Health Care workers in the Developing world
Email doctortvrao@gmail.com

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