What is hepatitis C?
Hepatitis C is the disease of the liver caused due to infection by hepatitis C virus (HCV). It is one of the common causes of chronic liver disease and may to progressive liver disease. It is also the leading indication for liver transplantation.
How common is hepatitis C infection?
It has been estimated that the globally around 2% are infected with HCV. 170 million people are chronically infected the virus. Also 3 to 4 million people get newly infected with the virus each year. In India around 1-2% of people are infected with this virus. The disease is common among children who require multiple transfusions like those suffering from Thalassemia and hemophilia.
What is the natural course of the disease?
Only 20% of patients who gets infected with HCV develop symptoms of acute infection. In others the disease remains asymptomatic. Regardless of the initial symptoms 60-80% will develop chronic infection i.e. the virus remains in the liver even after 6 months of infection leading to chronic hepatitis. Without treatment one fifth of these patients in a 15-20 years will develop permanent liver damage (cirrhosis) and its manifestations. 1-3% of these patients will have the risk of developing liver cancer every year.
How does the disease spread?
Hepatitis C virus spreads through the following routes from one person to another:
Perinatal transmission: The virus is transferred from mother to her baby at the time of delivery or rarely before delivery. The infection rate among infants born to Hepatitis C infected mothers is around 5%. There is no evidence that caesarean section prevents maternal-infant transmission. Thus, caesarean section should not be routinely recommended for carrier mothers. All babies can be breast fed. Child should be tested at 18 months for antibodies to diagnose the presence of infection. If early testing is desired then at 3 months, HCV RNA PCR can be done to detect for presence of HCV. Occasionally it may be falsely negative and a second test done 6 months later will be helpful.
Blood transfusion: The risk of transfusion has significantly reduced after strict testing of donated blood. Children requiring multiple transfusions, such as those with hemophilia and thalassemia, are at increased risk of contracting HCV infection. The prevalence rate among these children is 25% and 15% respectively. Voluntary donation should be promoted as commercial donors have higher risk of being infected. Mandatory screening of blood in India for HCV has been implemented since 2001
Infected needles and syringes: This is common among intravenous drug users who share syringes and needles. Patients may be infected through reused syringes or needles. With the use of disposable syringes and needles and safe injection practice this is declining. Patients on hemodialysis are at increased risk of infection with HCV.
Sexual route of transmission: This is less common mode of spread in children. It is more common in homosexual relationship and in people with multiple sexual partners.
How does the disease manifest?
Only 10 -20% patients are symptomatic at the time of infection. These patients will develop yellowish discoloration of the eyes, pain in the upper abdomen, nausea and vomiting. Most acute infections are totally asymptomatic.
80% of infected children will develop chronic infection. They will remain normal for another 10-20 years after which they develop symptoms of liver dysfunction. During this stage patient develop jaundice, weight loss, abdominal distension due to fluid collection (ascites); blood in vomitus (hematemesis due to high pressure in portal veins and prolonged blood clotting); weight loss and altered sensorium (hepatic encephalopathy). In prolonged disease course there can be dysfunction of the kidneys (hepatorenal syndrome) or lungs (hepatopulmonary syndrome). These complications can lead to death. Some patients can develop malignancy (cancer) of the liver which can be fatal.
How can one diagnose Hepatitis C infection?
Typically antibodies take 2-3 months to appear in the blood and therefore an acute infection may be missed only if antibody (anti HCV) is tested. In case of strong suspicion, HCV RNA by PCR needs to be done. In the chronic stage, initial testing by anti HCV is followed by HCV RNA by PCR for confirmation.
How will the doctor evaluate once HCV is diagnosed?
Initial evaluation of patients with HCV infection should include:
History: One should assess for risk factors for co-infection with HBV and/or HIV, history of previous blood transfusions or iv drug abuse, family history of HCV infection, liver disease, and liver cancer.
Physical examination: The physician will assess for signs of chronic liver disease like enlargement of liver and increase in consistency, jaundice, ascites, edema (swelling of feet), wasting, and gynaecomastia (enlargement of breast nodules in boys) as well as growth parameters.
Laboratory tests: complete blood count with platelets, liver biochemical tests (AST, ALT, total bilirubin, alkaline phosphatase), albumin, prothrombin time (time taken for blood to clot). It is important to do the testing of type of HCV virus (genotype). There are six types of HCV virus. The treatment will be decided on the basis of genotype of virus.
USG abdomen: USG of the abdomen is done to look for presence of cirrhosis and evidence of portal hypertension (enlargement of the portal vein, which is the main blood supply to the liver and an enlarged spleen).
What is the treatment of HCV?
Only children older than 3 years with evidence of ongoing liver damage should be treated. The liver damage is evident by the raised liver enzymes or by doing a liver biopsy. Patients with genotype 2 and 3 are more responsive to the medication. They are the ideal candidates for treatment. The treatment includes pegylated interferon α 2a or α 2b given as once a week subcutaneous injection in combination with oral ribavarin for a duration of 6-12 months. Depending on the genotype, the clearance rate for genotype 2 and 3 is in the range of 70-80%. Vs 50-60% for genotype 1 and 4. Newer oral drugs with better response rates are available for adults albeit very expensive. Trials with drugs in children are awaited
The treatment of HCV is associated with side effects due to the drugs. Almost all children experience flu-like symptoms (eg, fever, myalgia, headache, arthralgia and anorexia), which usually remit after a few doses by prophylactic acetaminophen. Bone marrow suppression can be seen in some patients. Pegylated interferon is associated with weight loss or reduced weight gain, slowed linear growth, and decreased body mass index during the course of treatment. These effects generally reverse after cessation of therapy, but residual effects on height may be seen almost two years after the end of treatment. Eye problems are noted in 2-3% of cases, so opthalmological examinations are must at the start and during treatment if problems develop. Ribavarin can cause decrease in hemoglobin level due to damage to red blood cell (haemolytic anemia). Hence frequent monitoring of hemogram is a must.
All patients with HCV should be vaccinated against hepatitis B and hepatitis A (if antibody for hepatitis A is absent Hepatotoxic drugs and alcohol should be avoided.
How can we prevent HCV infection?
Unlike hepatitis B and hepatitis A there is no vaccine available for prevention of HCV infection. Hence high risk individuals should be screened for the presence of HCV infection. Testing of spouse can help diagnose infection in females of reproductive age group. Treatment can prevent mother to child transmission in future pregnancy. One should avoid direct contact with blood and other body fluids. Do not share razor blades and tattooing needles. Avoid iv drug abuse. People with HCV infection should not donate blood. Blood transfusions should be given only if truly indicated. Dentists need to use disposable or well sterilized instruments and wear sterile gloves.
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