For health professionals: Hepatitis C

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What health professionals need to know about hepatitis C

The hepatitis C virus (HCV) is transmitted primarily through parenteral exposure to infectious blood or body fluids containing infectious blood. Hepatitis C is not a vaccine-preventable infection.

Hepatitis C infection is reportable by laboratories and clinicians to local public health authorities in all provinces and territories.

Consult the national case definition for additional information.

In Canada, screening of the blood supply was implemented in 1992. This has virtually eliminated the risk of HCV transmission via transfusion. Prior to this, thousands of people contracted HCV through receiving blood or blood products.

Screening

Screen for HCV using a risk-based approach.

  • In addition to risk-based screening, testing is recommended for individuals with symptoms or clinical indications of liver disease, or abnormal liver biochemistry.
  • HCV screening is also indicated for individuals who are diagnosed with viral hepatitis B (HBV) or human immunodeficiency virus (HIV).

Risk factors

Screening for HCV is recommended for individuals with the following risk factors:

  • injection, intranasal or inhalation drug use with shared equipment, even once
  • exposure to non-sterile medical, dental or personal services equipment via:
    • hemodialysis
    • occupational injuries (e.g., health care workers exposed to blood from needle stick injuries)
    • unsafe tattooing or body piercing practices using non-sterile equipment
    • shared personal care items
    • surgical procedures
  • receipt of blood, blood products or organ transplant before 1992 in Canada
  • receipt of invasive medical procedures in countries where infection prevention and control practices are not standardized
  • engaging in sexual behaviour where blood may be present (e.g., condomless anal intercourse)
  • being born in, travelled to, or lived in a region with high prevalence of hepatitis C, such as:
    • Central, East and South Asia
    • Eastern Europe
    • North Africa and the Middle East
    • Sub-Saharan Africa
    • Australia and Oceania
  • being born to a pregnant person with hepatitis C

Some populations are disproportionately affected by hepatitis C:

  • people who inject or use drugs
  • people from countries where the prevalence of HCV is high
  • people currently or previously living in correctional facilities
  • Indigenous Peoples (First Nations, Inuit and Métis)
  • gay, bisexual and other men who have sex with men (gbMSM)

Clinical manifestations

Hepatitis C can have different clinical manifestations depending on whether it is an acute or a chronic infection.

Acute hepatitis C infection

Acute hepatitis C infection is asymptomatic in most individuals (60% to 75%).

If symptoms/signs are present, they can include:

  • nausea
  • malaise
  • anorexia
  • jaundice
  • vomiting
  • elevated serum alanine aminotransferase (ALT)
  • right upper quadrant abdominal discomfort

These symptoms may last for 2 to 12 weeks.

Chronic hepatitis C infection

Approximately 25% of those with HCV will spontaneously clear the virus within 6 months. However, in most cases (75%), the infection will become chronic. Chronic hepatitis C is often asymptomatic.

Some individuals with chronic hepatitis C infection experience:

  • nausea
  • pruritus
  • malaise
  • abdominal pain

Fluctuating alanine aminotransferase (ALT) levels are characteristic. In addition, thrombocytopenia (low platelet count) may be an indication of cirrhosis. Thrombocytopenia is known to increase with the severity of liver disease.

The late sequelae of chronic hepatitis C infection include:

  • liver fibrosis or cirrhosis
  • hepatocellular carcinoma (liver cancer)

Cirrhosis and hepatocellular carcinoma may develop over a period of 20 to 30 years depending on factors such as sex, age, and level of alcohol consumption. Approximately 1% to 5% of individuals with chronic hepatitis C infection will develop hepatocellular carcinoma.

If cirrhosis develops, individuals may experience:

  • ascites
  • jaundice
  • splenomegaly
  • oesophageal varices
  • hepatic encephalopathy

Extrahepatic manifestations are uncommon, but may include:

  • lichen planus
  • Sjogren's syndrome
  • porphyria cutanea tarda
  • non-Hodgkin's lymphoma
  • membranous glomerulonephritis
  • mixed essential cryoglobulinemia
  • membranoproliferative glomerulonephritis

Diagnostic tests

The diagnosis of hepatitis C requires 2 types of tests:

  1. hepatitis C antibody (anti-HCV) test
  2. hepatitis C ribonucleic acid (RNA) test

HCV antibody testing

HCV antibody testing is the initial screening test. A non-reactive (negative) result indicates that there is no infection. A reactive (positive) result indicates that the individual has been exposed to HCV at some point but does not distinguish between current or past infection. HCV antibody testing can be done using standard serology or a licensed point-of-care test. Reactive (positive) antibody tests require additional confirmatory RNA testing to diagnose current infection.

Window period: It may take 5 to 10 weeks for HCV antibodies to be detected in the blood following exposure. Repeat anti-HCV testing may be required.

HCV RNA testing

HCV RNA testing is used to detect the presence of virus and confirm current HCV infection (acute or chronic). It is also used to measure viral load.

Immunocompromised individuals may not develop hepatitis C antibodies and may require HCV RNA testing to confirm and diagnose infection.

Treatment

Hepatitis C is considered a curable infection.

There are 6 major strains (genotypes) of HCV and the distribution of genotypes varies by region.

In Canada, HCV genotype 1 is the most common.

The goal of hepatitis C treatment is to achieve a sustained virologic response (SVR), which is an undetectable viral load in the blood following treatment.

In recent years, hepatitis C treatment has evolved to include a combination of drugs called direct-acting antivirals (DAAs). These medications are better tolerated and more effective than previous treatment regimens.

The short-course interferon-free DAA treatments:

  • have high SVR (>90%)
  • usually range from 8 to 12 weeks, and
  • have few adverse effects

Individuals with chronic hepatitis C infection will need further assessment and should be considered for treatment, regardless of level of fibrosis. A hepatologist, gastroenterologist, infectious disease specialist, or health professional with experience in the management of viral hepatitis should be consulted.

Health professionals should consult with their provincial/territorial hepatitis C programs for more information on coverage of treatment through provincial/territorial formularies.

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