| Diagnosis
and testing
What is hepatitis C?
Is there a vaccine for the prevention of HCV infection?
What
blood tests are available to check for hepatitis C?
Can you have a "false positive" anti-HCV test result?
Can
you have a "false negative" anti-HCV test result?
How long after exposure to HCV does it take to test positive for
anti-HCV?
How
long after exposure to HCV does it take to test positive with PCR?
Who should get tested for hepatitis C?
What is the next step if you have a confirmed positive anti-HCV
test?
Can
you have a normal liver enzyme (e.g., ALT) level and still have chronic hepatitis
C?
 How
is HCV spread from one person to another?
How could a person have gotten hepatitis C?
How
long can HCV live outside the body and transmit infection?
Is
there any evidence that HCV has been spread during medical or dental procedures
done in the United States?
Can
HCV be spread by sexual activity?
Can
HCV be spread by oral sex?
Can
HCV be spread within a household?
Since
more advanced tests have been developed for use in blood banks, what is the chance
now that a person can get HCV infection from transfused blood or blood products?
Pregnancy and Breast feeding
Should pregnant women be routinely tested for anti-HCV?
What
is the risk that HCV infected women will spread HCV to their newborn infants?
Should
a woman with hepatitis C be advised against breast-feeding?
When should babies born to mothers with hepatitis C be tested
to see if they were infected at birth?
Long-term Consequences of HCV Infection
What are the chances of persons with HCV infection developing
long term infection, chronic liver disease, cirrhosis, liver cancer, or dying
as a result of hepatitis C?
Do medical conditions outside the liver occur in persons with
chronic hepatitis C?
Management and Treatment of Chronic Hepatitis C
When
might a specialist (gastroenterologist, infectious disease physician, or hepatologist)
be consulted in the management of HCV-infected persons?
What is the treatment for chronic hepatitis C?
What are the side effects of interferon therapy?
What are the side effects of combination (ribavirin + interferon)
treatment?
Can
anything be done to reduce symptoms or side effects due to antiviral treatment?
Can
children receive interferon therapy for chronic hepatitis C?
Genotype
What does the term genotype mean?
Is it necessary to do genotyping when managing a person with chronic
hepatitis C?
Why do most persons remain infected?
Can persons become infected with different genotypes?
Hepatitis C and Healthcare Workers
What
is the risk for HCV infection from a needle-stick exposure to HCV contaminated
blood?
What
are the recommendations for follow-up of healthcare workers after exposure to
HCV positive blood?
Should HCV-infected healthcare workers be restricted in their
work?
Diagnosis
and Testing
 What
is hepatitis C?
Hepatitis C is a liver disease caused by the hepatitis
C virus (HCV), which is found in the blood of persons who have this disease. HCV
is spread by contact with the blood of an infected person.
Is
there a vaccine for the prevention of HCV infection?
No.
What
blood tests are available to check for hepatitis C?
There are
several blood tests that can be done to determine if you have been infected with
HCV. Your doctor may order just one or a combination of these tests. The following
are the types of tests your doctor may order and the purpose for each:
| a) Anti-HCV (antibody
to HCV) | - EIA
(enzyme immunoassay) or CIA (enhanced chemiluminescence immunoassay)
Test
is usually done first. If positive, it should be confirmed |
- RIBA
(recombinant immunoblot assay)
A supplemental test used to confirm a positive
EIA test | | Anti-HCV
does not tell whether the infection is new (acute), chronic (long-term) or is
no longer present. |  |
| b)
Qualitative tests to detect presence or absence of virus (HCV RNA) |
| c)
Quantitative tests to detect amount (titer) of virus (HCV RNA) |
A
single positive PCR test indicates infection with HCV. A single negative test
does not prove that a person is not infected. Virus may be present in the blood
and just not found by PCR. Also, a person infected in the past who has recovered
may have a negative test. When hepatitis C is suspected and PCR is negative, PCR
should be repeated. Can
you have a "false positive" anti-HCV test result?
Yes.
A false positive test means the test looks as if it is positive, but it is really
negative. This happens more often in persons who have a low risk for the disease
for which they are being tested. For example, false positive anti-HCV tests happen
more often in persons such as blood donors who are at low risk for hepatitis C.
Therefore, it is important to confirm a positive anti-HCV test with a supplemental
test as most false positive anti-HCV tests are reported as negative on supplemental
testing. Click here for
more information on Guidelines for Laboratory Testing and Result Reporting of
Antibody to Hepatitis C Virus. Can
you have a "false negative" anti-HCV test result?
Yes. Persons
with early infection may not as yet have developed antibody levels high enough
that the test can measure. In addition, some persons may lack the (immune) response
necessary for the test to work well. In these persons, research-based tests such
as PCR may be considered. How
long after exposure to HCV does it take to test positive for anti-HCV?
Anti-HCV can be found in 7 out of 10 persons when symptoms begin and in about
9 out of 10 persons within 3 months after symptoms begin. However, it is important
to note that many persons who have hepatitis C have no symptoms. How
long after exposure to HCV does it take to test positive with PCR?
It is possible to find HCV within 1 to 2 weeks after being infected with the virus.
Who
should get tested for hepatitis C? - persons
who ever injected illegal drugs, including those who injected once or a few times
many years ago
- persons
who were treated for clotting problems with a blood product made before 1987 when
more advanced methods for manufacturing the products were developed
- persons
who were notified that they received blood from a donor who later tested positive
for hepatitis C
- persons
who received a blood transfusion or solid organ transplant before July 1992 when
better testing of blood donors became available
- long-term
hemodialysis patients
- persons
who have signs or symptoms of liver disease (e.g., abnormal liver enzyme tests)
- healthcare
workers after exposures (e.g., needle sticks or splashes to the eye ) to HCV-positive
blood on the job
- children
born to HCV-positive women
What
is the next step if you have a confirmed positive anti-HCV test?
Measure
the level of ALT ( alanine aminotransferase, a liver enzyme) in the blood. An
elevated ALT indicates inflammation of the liver and you should be checked further
for chronic (long-term) liver disease and possible treatment. The evaluation should
be done by a healthcare professional familiar with chronic hepatitis C. Can
you have a normal liver enzyme (e.g., ALT) level and still have chronic hepatitis
C?
Yes. It is common for persons with chronic hepatitis C to have
a liver enzyme level that goes up and down, with periodic returns to normal or
near normal. Some persons have a liver enzyme level that is normal for over a
year but they still have chronic liver disease. If the liver enzyme level is normal,
persons should have their enzyme level re-checked several times over a 6 to 12
month period. If the liver enzyme level remains normal, your doctor may check
it less frequently, such as once a year.
How
is HCV spread from one person to another?
How
could a person have gotten hepatitis C?
HCV is spread primarily
by direct contact with human blood. For example, you may have gotten infected
with HCV if: - you
ever injected street drugs, as the needles and/or other drug "works" used to prepare
or inject the drug(s) may have had someone else's blood that contained HCV on
them.
- you received
blood, blood products, or solid organs from a donor whose blood contained HCV.
- you
were ever on long-term kidney dialysis as you may have unknowingly shared supplies/equipment
that had someone else's blood on them.
- you
were ever a healthcare worker and had frequent contact with blood on the job,
especially accidental needlesticks.
- your
mother had hepatitis C at the time she gave birth to you. During the birth her
blood may have gotten into your body.
- you
ever had sex with a person infected with HCV.
- you
lived with someone who was infected with HCV and shared items such as razors or
toothbrushes that might have had his/her blood on them.
How
long can HCV live outside the body and transmit infection?
Recent studies suggest that HCV may survive on environmental surfaces at
room temperature at least 16 hours, but no longer than 4 days. Is
there any evidence that HCV has been spread during medical or dental procedures
done in the United States?
Medical and dental procedures
done in the United States generally do not pose a risk for the spread of HCV.
However, there have been a few situations in which HCV has been spread between
patients when supplies or equipment were shared between them. Can
HCV be spread by sexual activity?
Yes, but this does not occur
very often. See section on counseling for more information on hepatitis C and
sexual activity. Can
HCV be spread by oral sex?
There is no evidence that HCV has been
spread by oral sex. See section on counseling for more information on hepatitis
C and sexual activity. Can
HCV be spread within a household?
Yes, but this does not occur
very often. If HCV is spread within a household, it is most likely due to direct
exposure to the blood of an infected household member. Since
more advanced tests have been developed for use in blood banks, what is the chance
now that a person can get HCV infection from transfused blood or blood products?
Less than 1 chance per million units transfused.
Pregnancy
and Breast feeding
Should
pregnant women be routinely tested for anti-HCV?
No. Pregnant
women have no greater risk of being infected with HCV then non-pregnant women.
If pregnant women have risk factors for hepatitis C, they should be tested for
anti-HCV.
What
is the risk that HCV infected women will spread HCV to their newborn infants?
About 5 out of every 100 infants born to HCV infected women become infected.
This occurs at the time of birth, and there is no treatment that can prevent this
from happening. Most infants infected with HCV at the time of birth have no symptoms
and do well during childhood. More studies are needed to find out if these children
will have problems from the infection as they grow older. There are no licensed
treatments or guidelines for the treatment of infants or children infected with
HCV. Children with elevated ALT (liver enzyme) levels should be referred for evaluation
to a specialist familiar with the management of children with HCV-related disease.
Should
a woman with hepatitis C be advised against breast-feeding?
No.
There is no evidence that breast-feeding spreads HCV. HCV-positive mothers should
consider abstaining from breast-feeding if their nipples are cracked or bleeding.
When
should babies born to mothers with hepatitis C be tested to see if they were infected
at birth?
Children should not be tested for anti-HCV before 18
months of age as anti-HCV from the mother might last until this age. If diagnosis
is desired prior to 18 months of age, testing for HCV RNA could be performed at
or after an infant's first well-child visit at age 1-2 months. HCV RNA testing
should then be repeated at a subsequent visit independent of the initial HCV RNA
test result.
Long-term
Consequences of HCV Infection What
are the chances of persons with HCV infection developing long term infection,
chronic liver disease, cirrhosis, liver cancer, or dying as a result of hepatitis
C?
Of every 100 persons infected with HCV about:
- 55%-85% of persons may
develop long-term infection
- 70
persons may develop chronic liver disease
- 5-20
persons may develop cirrhosis over a period of 20 to 30 years
- 1%-5%
of persons may die from the consequences of long term infection (liver cancer
or cirrhosis)
Hepatitis
C is a leading indication for liver transplants. Do
medical conditions outside the liver occur in persons with chronic hepatitis C?
A small percentage of persons with chronic hepatitis C develop medical conditions
outside the liver (this is called extrahepatic). These conditions are thought
to occur due to the body's natural immune system fighting against itself. Such
conditions include: glomerulonephritis, essential mixed cryoglobulinemia, and
porphyria cutanea tarda. Management
and Treatment of Chronic Hepatitis C When
might a specialist (gastroenterologist, infectious disease physician, or hepatologist)
be consulted in the management of HCV-infected persons?
A referral
to or consultation with a specialist for further evaluation and possible treatment
may be considered if a person is anti-HCV positive and has elevated liver enzyme
levels. Any physician who manages a person with hepatitis C should be knowledgeable
and current on all aspects of the care of a person with hepatitis C. What
is the treatment for chronic hepatitis C?
Combination therapy with pegylated interferon and ribavirin
is the treatment of choice resulting in sustained response rates of 40%-80%. (up
to 50% for patients infected with the most common genotype found in the U.S. [genotype
1] and up to 80% for patients infected with genotypes 2 or 3). Interferon monotherapy
is generally reserved for patients in whom ribavirin is contraindicated. Ribavirin,
when used alone, does not work. Combination therapy using interferon and ribavirin
is now FDA approved for the use in children aged 3-17 years. What
are the side effects of interferon therapy?
Most persons have flu-like
symptoms (fever, chills, headache, muscle and joint aches, fast heart rate) early
in treatment, but these lessen with continued treatment. Later side effects may
include tiredness, hair loss, low blood count, trouble with thinking, moodiness,
and depression. Severe side effects are rare (seen in less than 2 out of 100 persons).
These include thyroid disease, depression with suicidal thoughts, seizures, acute
heart or kidney failure, eye and lung problems, hearing loss, and blood infection.
Although rare, deaths have occurred due to liver failure or blood infection, mostly
in persons with cirrhosis. An important side effect of interferon is worsening
of liver disease with treatment, which can be severe and even fatal. Interferon
dosage must be reduced in up to 40 out of 100 persons because of severity of side
effects, and treatment must be stopped in up to 15 out of 100 persons. Pregnant
women should not be treated with interferon. What
are the side effects of combination (ribavirin + interferon) treatment?
In addition to the side effects due to interferon described above, ribavirin
can cause serious anemia (low red blood cell count) and can be a serious problem
for persons with conditions that cause anemia, such as kidney failure. In these
persons, combination therapy should be avoided or attempts should be made to correct
the anemia. Anemia caused by ribavirin can be life-threatening for persons with
certain types of heart or blood vessel disease. Ribavirin causes birth defects
and pregnancy should be avoided during treatment. Patients and their healthcare
providers should carefully review the product manufacturer information prior to
treatment. Can
anything be done to reduce symptoms or side effects due to antiviral treatment?
You should report what you are feeling to your doctor. Some side effects
may be reduced by giving interferon at night or lowering the dosage of the drug.
In addition, flu-like symptoms can be reduced by taking acetaminophen before treatment.
Can
children receive interferon therapy for chronic hepatitis C?
The
Food and Drug Administration has approved the use of the combination anti-viral
therapy for the treatment of hepatitis C in children 3 to 17 years old. For details
please refer to page 11 of AASLD Practice Guideline: Diagnosis, Treatment, and
Management of Hepatitis C.
Genotype
What
does the term genotype mean?
Genotype refers to the genetic make-up
of an organism or a virus. There are at least 6 distinct HCV genotypes identified.
Genotype 1 is the most common genotype seen in the United States. Is
it necessary to do genotyping when managing a person with chronic hepatitis C?
Yes, as there are 6 known genotypes and more than 50 subtypes of HCV, and
genotype information is helpful in defining the epidemiology of hepatitis C. Knowing
the genotype or serotype (genotype-specific antibodies) of HCV is helpful in making
recommendations and counseling regarding therapy. Patients with genotypes 2 and
3 are almost three times more likely than patients with genotype 1 to respond
to therapy with alpha interferon or the combination of alpha interferon and ribavirin.
Furthermore, when using combination therapy, the recommended duration of treatment
depends on the genotype. For patients with genotypes 2 and 3, a 24-week course
of combination treatment is adequate, whereas for patients with genotype 1, a
48-week course is recommended. For these reasons, testing for HCV genotype is
often clinically helpful. Once the genotype is identified, it need not be tested
again; genotypes do not change during the course of infection. Why
do most persons remain infected?
Persons infected with HCV mount
an antibody response to parts of the virus, but changes in the virus during infection
result in changes that are not recognized by preexisting antibodies. This appears
to be how the virus establishes and maintains long-lasting infection.
Can
persons become infected with different genotypes?
Yes. Because
of the ineffective immune response described above, prior infection does not protect
against reinfection with the same or different genotypes of the virus. For the
same reason, there is no effective pre- or postexposure prophylaxis (i.e, immune
globulin) available.
Hepatitis
C and Healthcare Workers What
is the risk for HCV infection from a needle-stick exposure to HCV contaminated
blood?
After needle stick or sharps exposure to HCV positive blood
, about 2 (1.8%) healthcare workers out of 100 will get infected with HCV (range
0%-10%).
What
are the recommendations for follow-up of healthcare workers after exposure to
HCV positive blood?
Anti-viral agents (e.g., interferon) or immune
globulin should not be used for postexposure prophylaxis. - For
the source, baseline testing for anti-HCV.
- For
the person exposed to an HCV-positive source, baseline and follow-up testing including
baseline testing for anti-HCV and ALT activity; and
follow-up testing
for anti-HCV (e.g., at 4-6 months) and ALT activity. (If earlier diagnosis
of HCV infection is desired, testing for HCV RNA may be performed at 4-6 weeks.) - Confirmation
by supplemental anti-HCV testing of all anti-HCV results reported as positive
by enzyme immunoassay.
Should
HCV-infected healthcare workers be restricted in their work?
No,
there are no recommendations to restrict a healthcare worker who is infected with
HCV. The risk of transmission from an infected healthcare worker to a patient
appears to be very low. As recommended for all healthcare workers, those who are
HCV positive should follow strict aseptic technique and standard precautions,
including appropriate use of hand washing. | 
