What is hepatitis?
Hepatitis means inflammation of the liver. Hepatitis can be caused by medications, herbal remedies, chemicals, toxins, alcohol, autoimmune diseases, and viruses.
Hepatitis C is a liver disease caused by a specific type of virus called hepatitis C virus (HCV). Hepatitis C virus has 6 different genotypes and more than 50 subtypes (1a, 1b, 2a, 2b, 2c, 3a, 3b, 4a, 5a, 6a,). Genotype and subtype refers to the genetic make-up and strain of the virus. In the US, 70 percent of people are infected with genotypes 1a and 1b and 10 to 20 percent with genotypes 2 and 3. A personŐs genotype is used to assess a personŐs response to HCV therapy. More specifically, genotype can often predict whether or not a person will achieve a sustained viral response, one of the main goals of HCV therapy. The most common, Genotype 1 is also the most difficult one to treat.
Diagnosis of hepatitis C is based on medical history, history of risk and opportunity for exposure to HCV. Infection is confirmed by blood tests. Often, more than one blood test is necessary to diagnose HCV. Antibody tests are used to detect the presence or absence of hepatitis C antibodies (anti-HCV) in the blood. Initially, two antibody tests are used; the EIA (enzyme immunoassay), which is usually done first. If this test is positive, meaning the test detected hepatitis C antibodies, then a second test called RIBA (recombinant immunoblot assay) is used to confirm the EIA test results. These antibody tests can not reveal whether the hepatitis C infection is new (acute), chronic (long-term) or no longer present. Polymerase chain reaction (PCR) may be used in place of or in addition ti RIBA to detect the presence of hepatitis C virus genetic material (HCV RNA) in the blood, thereby confirming active HCV infection.
Acute hepatitis C
Hepatitis C has two phases. The first one, the acute phase, lasts for 6 months and lasts from the time of viral exposure to the onset of symptoms. Often the acute phase is not recognized, as most people show no early signs or symptoms. Up to 20 percent of infected persons may experience flu-like symptoms; along with elevated liver enzymes (ALTs) that may be associated with some degree of liver injury. In some rare cases, acute hepatitis C results in a severe, and sometimes fatal liver condition called fulminant hepatitis. During the acute phase, only 15 percent of people are able to clear the hepatitis C virus.
The remaining 85% will sustain a chronic infection.
Chronic hepatitis C
For those who do not clear the virus within 6 months, Hepatitis C infection progresses to a second phase: chronic infection. During the chronic phase few people have symptoms. Some may complain of bouts of fatigue, pain or discomfort at the site of the liver (right upper side of the abdomen), nausea, and join pain. The presence of symptoms does not always indicate the degree and severity of infection to the liver.
Hepatitis C is a very slow progressing disease and its manifestation, progression and outcome vary greatly in those affected - in some cases the disease goes undiagnosed for more than 20 years. The following are possible outcomes associated with the progression of chronic hepatitis C:
25% of people mayy have no symptoms or serious liver damage while maintaining normal levels of liver enzymes (ALTs). Liver biopsy may show some degree of chronic inflammation, but the degree of injury is mild, and the overall prognosis is fairly good.
40-50% of people may have few or mild symptoms with mild to moderate elevated liver enzymes, but not enough to be severely detrimental to their health. In these people, progression of liver disease is difficult to predict.
Up to 20% of people will have severe disease, including elevated liver enzymes. They are at risk for developing cirrhosis (scar tissue in the liver), which can lead to end-stage liver disease. 1-5% of people with cirrhosis are at risk for developing liver cancer each year. Liver cancer (hepatocellular carcinoma) may develop an average 20 - 30 years after contracting chronic hepatitis C disease. In the U.S., hepatitis C is the leading cause of liver transplantion.
Although it is difficult to predict how someone will progress with chronic hepatitis C, researchers have identified factors that may influence and accelerate the progression of the disease. These factors include; male gender, age at time of exposure to HCV (greater than 40 years old), consumption of alcohol, and co-infection with hepatitis B or HIV.
Hepatitis C and HIV
People living with chronic hepatitis C and HIV are at greater risk for liver damage than people infected with hepatitis C alone. Studies have shown that HIV accelerates the progression of hepatitis C infection. The decision to treat individuals with both HIV and HCV infection is complex. For more information, refer to Hepatitis C virus (HCV) and HCV/HIV Co-infection Handbook (version IV) prepared by Jules Levin, Executive Director of NATAP.
Hepatitis C is primarily transmitted by direct blood-to-blood contact In the US, 60-90 percent of people infected with hepatitis C either received blood products prior to 1992 (when HCV screening of the blood supply was implemented) or shared needles and/or drug paraphernalia during injection drug use. Sexual transmission between monogamous couples is rare, but the risk may increase to 10% in individuals who have multiple sexual partners or engage in sexual practices that can result in tearing of mucous membrane tissue (the skin), such as fisting (hand in vagina or rectum) or anal sex . Transmission from mother-to-child is also a relatively low risk, less than 6 percent, but the risk increases to 17 percent if the mother is HV positive. Individuals who have undergone hemodialysis in the past may also be at risk. Finally, sharing non-sterile needles for body piercing, acupuncture, and tattooing or sharing personal items such as toothbrushes and razors are also create a risk for transmitting and contracting the virus. Up to 30 percent of HCV-infected people report no obvious risk factors. Finally, you can not get hepatitis C by hugging, kissing, shaking hands with or by having other casual contact with someone infected with hepatitis C.
Over the last decade, considerable advancement has been made in the treatment of hepatitis C. It is important to find a liver specialist called a hepatologist or gastroenterologist who is knowledgeable about hepatitis C care and treatment.
Goal of treatment
The primary goals of treatment and standards for successful completion include eradication of HCV from the body and achievement of a sustained viral response (SVR). Secondary to successful completion of therapy, a person may experience reversal of liver fibrosis and/or cirrhosis and improved quality of life.
Currently, the best treatment option for chronic hepatitis C is the combination of two medications: pegylated interferon and ribavirin. Two types of pegylated interferon are available: (Pegasys® (peginterferon alpha-2a) and peginterferon alpha-2b (Pegintron®). Both Pegasys® and Pegintron® are taken by subcutaneously (by injection under the skin) once each a week. Ribavirin, an antiviral oral medication is given twice a day according to body weight. Ribavirin is also available in two types as Rebetol® or Copegus®.
Interferon alpha monotherapy
People in whom ribavirin is contraindicated are treated with pegintron by itself (monotherapy) for a period of 48 week regardless of genotype.
The duration of treatment is based on HCV genotype, type of treatment and whether or not the individual is co-infected with HIV. In individuals with HCV genotype 1, the duration of treatment is 48 weeks and combination therapy is effective in 40-45 percent of people. In individuals with genotype 2 and 3, the duration of treatment is 24 weeks and combination therapy is effective in 70-80 percent. Treatment efficacy is defined as a sustained viral response, meaning that HCV viral load remains undetectable six months after treatment is completed.
The following factors are predictors associated with better response to hepatitis C treatment: individuals with genotype 2 and 3 respond better to treatment than individuals who have genotype 1, hepatitis C viral load less than 2 million, mild to moderate levels of ALTs adherence to therapy, and abstinence from alcohol and drug use while on treatment.
Who should be treated?
Combination therapy of pegylated alpha interferon and ribavirin are recommended to people who have documented chronic hepatitis C on liver biopsy, elevated ALTs, and no contraindication to alpha interferon and ribavirin. In addition, co-infected people with both HCV and HIV are also eligible to receive combination therapy as long as they do not have any contraindications to treatment.
Most people on interferon therapy experience flu-like symptoms, such as fatigue, fever, chills, headache, and muscle and joint aches. These symptoms tend to be more severe shortly after the injections (6-8 hours). Other side effects may include skin irritation at the injection site, hair loss, low blood count, difficulty with concentration moodiness, and depression. In cases of severe medication side effects, the dosage may be reduced. Interferon may not be offered to and may be contraindicated in people with a history of severe depression, active drug or alcohol abuse, autoimmune disease, low white or red blood cell count, or in women who are not willing or able to practice reliable birth control methods. Pregnant women and women planning to become pregnant should not undergo interferon treatment.
Most common side effects of Ribavirin are anemia (low red blood cell count), fatigue, irritability, rash, stuffy nose, and cough. Ribavirin is also known to cause birth defects. Pregnancy should be avoided during treatment. Anyone taking ribavirin, whether male or female, should continue to use effective contraception at least 6 months after the treatment is completed. When taken in combination, pegylated interferon and ribavirin may cause shortness of breath, throat irritation, itching, rash, nausea, difficulty sleeping, and loss of appetite.
Informed your doctor if you experience any of the above side effects. Your doctor may be able to lower the dosage of the drugs to reduce the side effects. Flu-like symptoms can be managed by taking low-dose acetaminophen before treatment. Always consult your physician before taking any prescribed or over-the-counter medications, herbal supplements, or vitamins.
At this point, there is no vaccine for hepatitis C. You should, however, get vaccinated against hepatitis A and B. Some prevention strategies include using condoms for vaginal, anal, and oral sex; limiting number of sex partners; abstaining from injection drug use and if unable to abstain from injecting, using new, clean needles and drug equipment every time you shoot; avoid sharing personal items such as toothbrushes, razors, and nail clippers; and when getting tattoos or body piercings, do it at a professional parlor and ask about their regulations.