Patient Education

Hepatitis C virus: a silent yet deadly virus Professor Dr. Sudhamshu K.C.

Living in silence, hepatitis C virus (HCV) infrequently causes illness when first contracted as only few persons infected show the sign of acute hepatitis. It can be undetected for decades before symptoms appear. By then, it may have destroyed the liver in form of liver cirrhosis, which is an irreversible condition. From infection to noticeable or significant liver damage it can take 15-20 years. More cases are detected these days because of screening for anti HCV for overseas employment.

What is Hepatitis C virus?

Hepatitis C is one of the six hepatotrophic viruses (virus having affinity towards the liver) known to cause liver disease. This HCV virus was first identified and described in 1989, and in 1990 a hepatitis C antibody test (anti-HCV) became commercially available to help identify individuals exposed to HCV. It accounts for the majority of the hepatitis cases previously referred to as non-A, non-B hepatitis that is transmitted through blood or blood products. The hepatitis C infection causes inflammation of the liver. Unfortunately, more than 75% of infected individuals eventually progress to the chronic stage of hepatitis C that results in cirrhosis (severe scarring and hardening of liver tissue).

How it is transmitted?

In Nepal most of the cases of hepatitis are found in intravenous drug abusers. Thus, sharing needles with intravenous drug users that were infected with hepatitis C transmits it. Most people with hepatitis C contracted it either through a blood transfusion or receiving blood products (plasma, etc.) contaminated with hepatitis C. In western world the screening started from 1990. While in Nepal it started little later. Due to availability of modern sensitive methods, the risk of acquiring hepatitis C from blood transfusion is now less than 1%. Health professionals, those working in disaster prone area, fire fighters are always at risk of accidental transmission. Infected mothers can also pass the virus to the fetus in uterus, but this occurs less than 1% of the time. The likelihood of transmission from breast milk is also very small. So, it is not advised to stop breast-feeding. Tattooing or body piercing if not done with disposable or sterile needle poses the threat of transmission. Unlike hepatitis B virus HCV has minimal risk of transmission during sex. Nevertheless, there is chance of transmission if safe sex is not practiced.

If one person in a family is infected with HCV rest of the family members are panicked due to the fear that they all are exposed to the risk of transmission. But this is not true. It is not transmitted by sneezing and coughing, holding hands, kissing (in cheek), using the same bathroom, eating food prepared by someone with HCV, holding a child in your arms, swimming in the same pool. However, using common razor, nail clippers or toothbrushes are not advised, as there is chance of getting infected.

What are the symptoms of hepatitis C?

Hepatitis C often goes undiagnosed because either there is no symptoms or symptoms suggestive of a flu-like illness (sub-clinical hepatitis). Less than 25% patients present with yellow eyes suggesting acute hepatitis clinically. Acute liver failure is rare in HCV hepatitis.

A low level of infection with practically no symptoms can continue for years. Most chronic HCV patients are asymptomatic. When symptoms are present they are usually non-specific. The most common are fatigue, abdominal pain/discomfort, anorexia and weight loss. There may be mild enlargement of liver. Sometimes patient may present with features of liver cirrhosis and its complications without any idea of hepatitis C. Persons with hepatitis C can also develop liver cancer at any stage from hepatitis to liver cirrhosis. When the hepatitis C virus is a cofactor, there is an increased risk of cirrhosis in those who abuse alcohol in excess.

How it is diagnosed?

Diagnosis of hepatitis C involves confirmation of presence of HCV in the body and assessment of the severity of liver disease. In addition, evaluation of patients with hepatitis C should include determination of the patients' suitability for the treatment.

When suspected a spot test is done by commercially available kit to detect anti-HCV (antibody against HCV). If the result is positive it is confirmed by ELISA, which is more accurate. As there is some chance of false positive result, final diagnosis is made by detection of HCV RNA in the blood by RT-PCR (reverse transcriptase-polymerase chain reaction) method. Further quantitative and qualitative test is done in order to find out type of virus and severity in terms of number of viruses in the body.

Liver biopsy is done to find out the severity of liver damage. It is also done in order to rule out liver cirrhosis as in case the liver has become cirrhotic treatment against virus is not usually carried out. However, the FIBROSCAN,which is available in our center only so far, has avoided the need of liver biopsy in genotype 2 and 3 HCV CH. Beside, liver function test is performed. It may show normal results despite liver damage. Most commonly ALT (alanine aminotrasferase, a type of liver enzyme) is raised. If liver has already become cirrhotic at the time of diagnosis there may be variable results. Those who have developed liver cirrhosis need upper GI endoscopy to see if they have developed any varices or not.

What are the available treatments?

Treatment of hepatitis C started from 1990. There were very less patients who completed the treatment due to side effects. The success rate was very dismal. Real treatment started after availability of Peg-interferon in 2004. With Peg-interferon and Ribavirine we treated near about 700 patients. The success rate (SVR or sustained virological response) was 96% in genotype 3 and 80% in genotype 1. The success rate was 70% in compensated cirrhotic patients. In patients with CKD, the treatment failure was more than treatment success.

New medicines for treating hepatitis C are available in Nepal. We have DAAs (Direct acting antivirals) available for the treatment of all genotypes. SOFOSBUVIR is available since March 2015. Combination of SOFOSBUVIR and LEDIPASVIR is available since September 2015. Another medicine DACLATASVIR is available since January 2016. So, now we have complete interferon free treatment available in Nepal. For genotype 3 we are using SOFOSBUVIR and DACLATASVIR plus minus RIBAVIRIN. Genotype 1 is treated by combination of SOFOSBUVIR and LEDIPASVIR plus minus RIBAVIRIN. The duration of the treatment is usually 12 weeks and maximum upto 24 weeks. The cost of treatment has significantly decreased with newer treatments. The total cost of treatment for 12 weeks is around NRs. 1 lakh ($1000).

The side effects of newer medicines are very negligible. The side effects are more if used with interferon and ribavirine. Since the drugs may have bad effects with other drugs that you may be using for other ailments, you should tell your treating doctor in details.

Will all be virus free after treatment?

It is not true that the success after treatment is 100%. Not everyone will clear the virus after treatment. But with new DAAs, the chance of clearing virus is upto 98-99%. So far, success rate of treatment in our center for genotype 3 and 1 in non cirrhotic liver is 100%. The treatment failure increases with advancing disease. If there is chronic liver disease or compensated cirrhosis, the success rate decreases to 90%. So, the treatment should be started as soon as the disease is diagnosed.

What about anti-HCV status after treatment?

One common question from the patient is that will Anti-HCV be negative after the treatment? The answer is no. Since it is the antibody that is produced once HCV enters inside the body, it is not going to be negative even the virus is cleared from the body.