VIRAL HEPATITIS C
VIRAL HEPATITIS TYPE C B
Hepatitis C virus is a RNA-virus measuring 50 nm. It is classed into a
separate genus, Hepacavirus of the Flaviviridae family.
Long-term in viremia (in the ende IP), chronic infections.
Parenteral transmission. Sporadically, vertical and
sexual transmissions were reported carrier or the sick
person.
Susceptibility is general.
The source of
infection
Route of
transmission
Susceptibility
Etiology:
Preventive measures:
The same as for HBV, exclusive immunization.
Features of Hepatitis C Virus Infection
Incubation period Average 6-7 weeks
Range 2-26 weeks
Acute illness (jaundice) Mild (<20%)
Case fatality rate Low
Chronic infection 60%-85%
Chronic hepatitis 10%-70% (most asx)
Cirrhosis <5%-20%
Mortality from CLD 1%-5%
Age-
related
Chronic Hepatitis C
Factors Promoting Progression or Severity
 Increased alcohol intake
 Age > 40 years at time of infection
 HIV co-infection
 Other
– Male gender
– Chronic HBV co-infection
Serologic Pattern of Acute HCV Infection
with Recovery
Symptoms +/Time
after Exposure
Titer anti-HCV
ALT
Normal
0 1 2 3 4 5 6 1 2 3 4
YearsMonths
HCV RNA
Serologic Pattern of Acute HCV Infection with
Progression to Chronic Infection
Symptoms +/Time
after Exposure
Titer anti-HCV
ALT
Normal
0 1 2 3 4 5 6 1 2 3 4
YearsMonths
HCV RNA
Exposures Known to Be Associated With
HCV Infection in the United States
 Injecting drug use
 Transfusion, transplant from infected donor
 Occupational exposure to blood
– Mostly needle sticks
 Iatrogenic (unsafe injections)
 Birth to HCV-infected mother
 Sex with infected partner
– Multiple sex partners
Injecting Drug Use and HCV Transmission
 Highly efficient
– Contamination of drug paraphernalia, not just
needles and syringes
 Rapidly acquired after initiation
– 30% prevalence after 3 years
– >50% after 5 years
 Four times more common than HIV
Posttransfusion Hepatitis C
0
5
10
15
20
25
30
1965 1970 1975 1980 1985 1990 1995 2000
Year
%ofRecipientsInfected
All volunteer donors
HBsAg
Donor Screening for HIV Risk Factors
Anti-HIV
ALT/Anti-HBc
Anti-HCV
Improved
HCV Tests
Adapted from HJ Alter and Tobler and Busch, Clin Chem 1997
Occupational Transmission of HCV
 Inefficient by occupational exposures
 Average incidence 1.8% following needle stick
from HCV-positive source
– Associated with hollow-bore needles
 Case reports of transmission from blood splash
to eye; one from exposure to non-intact skin
 Prevalence 1-2% among health care workers
– Lower than adults in the general population
– 10 times lower than for HBV infection
HCV Related to Health Care Procedures
United States
 Recognized primarily in context of outbreaks
– Chronic hemodialysis
– Hospital inpatient setting
– Private practice setting
– Home therapy
 Unsafe injection practices
– Reuse of syringes and needles
– Contaminated multiple dose medication vials
HCW to Patient Transmission of HCV
 Rare
– In U.S., none related to performing invasive
procedures
 Most appear related to HCW substance abuse
– Reuse of needles or sharing narcotics used for self-
injection
 No restrictions routinely recommended for
HCV-infected HCWs
Perinatal Transmission of HCV
 Transmission only from women HCV-RNA
positive at delivery
– Average rate of infection 6%
– Higher (17%) if woman co-infected with HIV
– Role of viral titer unclear
 No association with
– Delivery method
– Breastfeeding
 Infected infants do well
– Severe hepatitis is rare
Sexual Transmission of HCV
 Case-control, cross sectional studies
– Infected partner, multiple partners, early sex, nonuse
of condoms, other STDs, sex with trauma, BUT
– MSM no higher risk than heterosexuals
 Partner studies
– Low prevalence (1.5%) among long-term partners
• infections might be due to common percutaneous
exposures (e.g., drug use), BUT
– Male to female transmission more efficient
• more indicative of sexual transmission
Sexual Transmission of HCV
 Occurs, but efficiency is low
– Rare between long-term steady partners
– Factors that facilitate transmission between
partners unknown (e.g., viral titer)
 Accounts for 15-20% of acute and chronic
infections in the United States
– Sex is a common behavior
– Large chronic reservoir provides multiple
opportunities for exposure to potentially infectious
partners
Household Transmission of HCV
 Rare but not absent
 Could occur through percutaneous/mucosal
exposures to blood
– Contaminated equipment used for home therapies
• IV therapy, injections
– Theoretically through sharing of contaminated
personal articles (razors, toothbrushes)
Other Potential Exposures to Blood
 No or insufficient data showing increased risk
– intranasal cocaine use, tattooing, body piercing,
acupuncture, military service
 No associations in acute case-control or populationbased
studies
 Cross-sectional studies in highly selected groups with
inconsistent results
– Temporal relationship between exposure and infection
usually unknown
– Biologically plausible, but association or causal relationship
not established
Sources of Infection for
Persons With Hepatitis C
Sexual 15%
Other 1%*
Unknown 10%
Injecting drug use 60%
Transfusion 10%
(before screening)
* Nosocomial; iatrogenic; perinatal
Source: Centers for Disease Control and Prevention
Occupational 4%
Reduce or Eliminate Risks for
Acquiring HCV Infection
 Screen and test donors
 Virus inactivation of plasma-derived products
 Risk-reduction counseling and services
– Obtain history of high-risk drug and sex behaviors
– Provide information on minimizing risky behavior,
including referral to other services
– Vaccinate against hepatitis A and/or hepatitis B
 Safe injection and infection control practices
HCV Prevention and Control
MMWR 1998;47 (No. RR-19)
Reduce Risks for Disease Progression
and Further Transmission
 Identify persons at risk for HCV and test to
determine infection status
– Routinely identify at risk persons through history,
record review
 Provide HCV-positive persons
– Medical evaluation and management
– Counseling
• Prevent further liver damage
• Prevent transmission to others
HCV Prevention and Control
MMWR 1998;47 (No. RR-19)
HCV Testing Routinely Recommended
 Ever injected illegal drugs
 Received clotting factors made before 1987
 Received blood/organs before July 1992
 Ever on chronic hemodialysis
 Evidence of liver disease
 Healthcare, emergency, public safety workers after
needle stick/mucosal exposures to HCV-positive blood
 Children born to HCV-positive women
Based on increased risk for infection
Based on need for exposure management
Postexposure Management for HCV
 IG, antivirals not recommended for prophylaxis
 Follow-up after needlesticks, sharps, or mucosal
exposures to HCV-positive blood
– Test source for anti-HCV
– Test worker if source anti-HCV positive
• Anti-HCV and ALT at baseline and 4-6 months later
• For earlier diagnosis, HCV RNA at 4-6 weeks
– Confirm all anti-HCV results with RIBA
 Refer infected worker to specialist for medical
evaluation and management
Routine HCV Testing Not Recommended
(Unless Risk Factor Identified)
 Health-care, emergency medical, and public
safety workers
 Pregnant women
 Household (non-sexual) contacts of HCVpositive
persons
 General population
Routine HCV Testing of Uncertain Need
 Recipients of transplanted tissue
 Intranasal cocaine or other non-injecting
illegal drug users
 History of tattooing, body piercing
 History of STDs or multiple sex partners
 Long-term steady sex partners of HCVpositive
persons
Not confirmed as risk factor/prevalence low or unknown
Confirmed risk factor but prevalence of infection low
HCV Infection Testing Algorithm
for Diagnosis of Asymptomatic Persons
Screening Test for Anti-HCV
Negative
STOP
Positive
OR
RIBA for Anti-HCV NAT for HCV RNA
Negative
STOP
Additional Laboratory
Evaluation (e.g. PCR, ALT)
Negative PositiveIndeterminate
Medical
Evaluation
Positive
Negative PCR,
Normal ALT
Positive PCR,
Abnormal ALT
Source: MMWR 1998;47 (No. RR 19)
Medical Evaluation and Management
for Chronic HCV Infection
 Assess for biochemical evidence of CLD
 Assess for severity of disease and possible
treatment, according to current practice
guidelines
– 40-50% sustained response to antiviral
combination therapy (peg interferon, ribavirin)
– Vaccinate against hepatitis A
 Counsel to reduce further harm to liver
– Limit or abstain from alcohol
HCV Counseling
 Prevent transmission to others
– Direct exposure to blood
– Perinatal exposure
– Sexual exposure
 Refer to support group
Preventing HCV Transmission to Others
 Do not donate blood, body organs, other tissue
or semen
 Do not share items that might have blood on
them
– personal care (e.g., razor, toothbrush)
– home therapy (e.g., needles)
 Cover cuts and sores on the skin
Avoid Direct Exposure to Blood
HCV Counseling
Persons Using Illegal Drugs
 Provide risk reduction counseling, education
– Stop using and injecting
– Refer to substance abuse treatment program
– If continuing to inject
• Never reuse or share syringes, needles, or drug
preparation equipment
• Vaccinate against hepatitis B and hepatitis A
• Refer to community-based risk reduction programs
HCV Counseling
Mother-to-Infant Transmission of HCV
 Postexposure prophylaxis not available
 No need to avoid pregnancy or breastfeeding
– Consider bottle feeding if nipples cracked/bleeding
 No need to determine mode of delivery based
on HCV infection status
 Test infants born to HCV-positive women
– >15-18 months old
– Consider testing any children born since woman
became infected
– Evaluate infected children for CLD
HCV Counseling
Persons with One Long-Term Steady Sex Partner
HCV Counseling
Sexual Transmission of HCV
 Do not need to change their sexual practices
 Should discuss with their partner
– Risk (low but not absent) of sexual transmission
– Counseling and testing of partner should be
individualized
• May provide couple with reassurance
• Some couples might decide to use barrier precautions to
lower limited risk further
Persons with High-Risk Sexual Behaviors
HCV Counseling
Sexual Transmission of HCV
 At risk for sexually transmitted diseases, e.g.,
HIV, HBV, gonorrhea, chlamydia, etc.
 Reduce risk
– Limit number of partners
– Use latex condoms
– Get vaccinated against hepatitis B
– MSMs also get vaccinated against hepatitis A
Other Transmission Issues
 HCV not spread by kissing, hugging, sneezing,
coughing, food or water, sharing eating utensils
or drinking glasses, or casual contact
 Do not exclude from work, school, play, childcare
or other settings based on HCV infection
status
HCV Counseling