The hepatitis C virus was first identified in 1989. It is estimated that 200,000 people in England have hepatitis C, many undiagnosed. People infected 20 to 30 years ago are now progressing to serious disease, and increasing numbers will come forward needing testing, counselling and referral for investigation and treatment.
The commonest route of infection is by sharing bloodcontaminated needles or injecting equipment during intravenous drug misuse. Many patients will deny sharing needles, but the virus is hardy and may often be transmitted through the sharing of injecting paraphernalia other than needles. Sexual transmission occurs but the frequency is uncertain and most studies indicate rates of around 5% in regular sexual partners, and a slightly increased seroprevalence in those with multiple sexual partners. Vertical (mother to baby) transmission appears to be of a similar order; there is thought to be increased risk of transmission if the mother has concomitant HIV infection. Infection may often be acquired within the first six to twelve months of injecting and many users will already be infected by the time they approach services.
The acute infection is most commonly largely asymptomatic, and jaundice only occasionally occurs. It is currently thought that in the order of 20% of new infections will resolve spontaneously, whilst the virus will persist in around 80% of cases. Although some of those with chronic hepatitis C infection experience vague, non-specific symptoms such as fatigue and aching joints, many will only develop symptoms later with the onset of complications of liver disease. Around 20% of patients with chronic infection are likely to develop cirrhosis, sometimes after 20-30 years, and about 25% of these may develop a hepatocellular carcinoma.
TESTING
Screening for hepatitis C is currently achieved by testing for the antibody, although the antigen (proof of current infection) can be detected by polymerase chain reaction (PCR). Testing, as for HIV antibodies, is only reliable 3 months after last possible exposure, and a negative antibody test performed within this period will not rule out infection. Pre- and post-test counselling, as described above under HIV testing, should occur before and after testing. Positive tests should lead to referral to a specialist centre, where confirmation (or otherwise) of active infection can be achieved by PCR. Specialist assessment may involve a period of observation and a liver biopsy to stage the disease.
TREATMENT
The National Institute of Clinical Excellence (NICE) published its appraisal of combination therapy (alpha interferon and ribavirin) for HCV, on 31 October 2000. Recommendations include:
- Combination therapy is the treatment of first choice for most patients with moderate/severe HCV who were previously untreated or have relapsed after interferon monotherapy.
- Treatment for 6 months is recommended for most patients; for genotype 1 patients with initial response, an additional 6 months is recommended.
- Treatment is generally not recommended for current intravenous drug users, heavy drinkers, those who did not respond to interferon monotherapy, those with decompensated cirrhosis.
Combination therapy clears the virus in about 40% of those treated (as compared to about 25% clearance with alpha interferon alone), at a cost of about £10,000 for one year. Treatment requires a high degree of compliance for efficacy (subcutaneous injections three times weekly for up to one year); thus many patients will be considered unsuitable for such intervention. Pergolated formulations of interferon have been developed which though more costly, reduce the frequency of administration necessary.
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The above information is copyright of Dr Bruce Trathen MBBS MRCPsych (2006). ISBN 0-9545164-0-0. The author grants permission for these guidelines to be downloaded, copied and distributed freely, but does not grant permission for their sale.
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