Hepatitis C

What is Hepatitis C?

Hepatitis C is a form of liver inflammation caused by the hepatitis C virus. You have acute or chronic disease. Chronic hepatitis C is one of the most common causes of shrinking liver (cirrhosis) and liver cancer (Hepatocellular carcinoma).

Previously, hepatitis C was called hepatitis non-A-non-B. It was not until 1989 that the causative virus was discovered and called hepatitis C virus (HCV). The virus is an RNA virus and belongs to the family of flaviviruses. It exists in many different subtypes (seven genotypes and more than 60 confirmed subtypes). The pathogen is distributed worldwide and is transmitted mainly via blood.

According to estimates by the World Health Organization, one percent of the world’s population is chronically infected with hepatitis C. That corresponds to about 71 million people. Most affected are the eastern Mediterranean and Europe.

Note: A hepatitis C infection is considered to be chronic if the genome of the pathogen (HCV RNA) can be detected in the patient’s blood for more than six months.

In Germany, about 0.5 percent of the population has ever come into contact with hepatitis C. For most people, the infection takes a chronic course.

Any suspicion of hepatitis C and any proven infection must be reported by physicians with the name of the patient to the appropriate health department. Even deaths from hepatitis C are by name notifiable, In 2016, 4,368 cases of newly diagnosed hepatitis C were registered. This means that for each 100,000 inhabitants, just over five people are newly ill with this form of liver inflammation.

Hepatitis C: transmission

Hepatitis C is mainly transmitted via blood. The most at-risk groups are drug addicts and medical staff.

Hepatitis C: transmission through drug use

The HCV transmission in the use of drugs via a vein plays a very important role. Using drugs like syringes, cannulas or spoons (in preparation for injecting drugs), drug addicts can easily infect each other.

There is also a danger when drugs are consumed via the nasal mucosa (snorting cocaine): By sharing snie tubes, hepatitis C infection is also possible.

Hepatitis C: transmission to medical staff

There is a risk of infection for medical personnel (doctors, nurses, etc.) who are in contact with hepatitis C patients or samples of such patients. For example, someone may injure themselves with a needle that is contaminated with a patient’s infected blood. Then hepatitis C viruses can be transmitted. On average, this risk is less than one percent. In individual cases, however, several factors play a role: For example, the risk of hepatitis C infection can also be greater with many viruses in the blood and a deep injury.

Hepatitis C: Transmission by blood transfusion and dialysis

Since the 1990s, all blood and plasma donations have been tested for hepatitis C. Therefore, unlike before, this transmission path hardly matters anymore.

The same applies to blood washing (dialysis). Through improved techniques, hepatitis C transmission in this way is much rarer today than it used to be.

Hepatitis C: Transmission during pregnancy and lactation

Pregnant women who are infected with hepatitis C can transmit the virus to the child via the placenta or during birth. But this risk is less than five percent.

According to experts, virus transmission via breast milk is irrelevant. Only when a lot of viruses circulate in the mother’s blood and she has bleeding wounds on the chest (for example, small cracks = rhagades) is hepatitis C transfer to the child theoretically possible. As a precaution, affected women should use nursing hats.

Hepatitis C: other transmission routes

Basically, you can also be infected with sexual intercourse with hepatitis C. This danger is generally low. Only with certain groups of people or sexual practices is there a serious risk of infection. This applies, for example, in homosexuals as well as in anal intercourse and other violent sexual practices (blood-to-blood contact!).

Whether the piercing of tattoos, piercings or ear holes carries a risk of infection for hepatitis C is a controversial topic. If contaminated cutlery is used (because it was not properly disinfected between customer appointments), virus transmission can not be ruled out.

Note: Hepatitis C viruses do not just circulate in infected people in the blood. They are also detectable in other body fluids (semen, saliva, tears, sweat etc.). However, infection via these body secretions is very unlikely.

Hepatitis C: incubation period

The time between contagion and onset of the first symptoms of hepatitis C (incubation period) may be 2 to 24 weeks. On average, six to nine weeks pass. A risk of infection for others basically exists as long as the genome of the virus (HCV-RNA) is detectable in the blood.

Hepatitis C: symptoms

Hepatitis C infections cause in about 75 percent of cases no or only non-specific symptoms, These include, for example:

• Fatigue and tiredness
• anorexia
• nausea
• Muscle and joint pain
• light fever

Only about 25 percent of those infected develop acute liver inflammation, which is usually mild: it turns out usually moderately elevated liver values and jaundice (jaundice), so one Yellowing of the skin, mucous membranes and white dermis in the eye, Also right side upper abdominal complaints are possible.

In many patients the acute infection goes into one chronic hepatitis C above. Again, this is usually mild and with uncharacteristic symptoms such as fatigue, reduced performance and unspecific upper abdominal discomfort.

Sometimes occur in the context of chronic hepatitis C Symptoms and diseases in completely different body regions on. These include itching, joint problems, enlargement of the lymph nodes (lymphoma), special forms of vascular and renal inflammation as well as kidney failure (renal insufficiency). Other disorders are also more commonly associated with chronic hepatitis C, such as depression, diabetes mellitus, autoimmune thyroid inflammation (such as Hashimoto’s thyroiditis) and the so-called Sjögren syndrome.

Chronic hepatitis C: long-term consequences

Chronic hepatitis C can become a shrinking liver after years (cirrhosis) to lead. This means that more and more liver tissue is being transformed into functionless connective tissue. As a result, the liver function gradually decreases. However, the progression of cirrhosis can vary greatly from patient to patient. Various factors influence the course of the disease. Among others, the following factors promote the rapid development of liver cirrhosis:

• higher age
• male gender
• chronic alcohol consumption
• additional infection with hepatitis B
• additional infection with HIV
• obesity
• Insulin resistance / diabetes mellitus
• genetic factors

People with hepatitis C-related cirrhosis are at an increased risk for liver cancer.

Note: Hepatitis C is the second leading cause of liver cirrhosis and liver cancer in Germany (after chronic alcohol consumption).

Hepatitis C: examinations and diagnosis

The doctor first talks in detail to the patient, to his To raise medical history (Anamnese). Among other things, he gives a detailed description of the symptoms that occur and inquires about possible pre- and underlying diseases. He also asks about possible sources of infection (such as drug use, needlestick injuries, sexual intercourse and sexual practices, tattoos, etc.).

After that follows one physical examination: Among other things, the doctor examines the color of skin, mucous membranes and the white dermis in the skin (yellowing in jaundice). He also feels his belly. He can determine whether there are pressure pains in the right upper abdomen – a possible indication of liver disease. By palpation, he can also assess whether the liver is possibly pathologically altered. Thus, a hardened organ indicates liver cirrhosis.

laboratory tests

blood tests are an essential part of the diagnosis of hepatitis C liver function tests (as determined by GOT, GPT) – elevated levels indicate (among others) liver disease. On the other hand, in the blood Antibodies to hepatitis C virus (anti-HCV) gefahndet. Such antibodies are usually detectable seven to eight weeks after infection. Only such a hepatitis C test allows a safe diagnosis.

However, the detection of specific antibodies does not say anything about whether it is a fresh (active) infection (with a risk of infection for others) or an already healed infection in which the patient is no longer contagious. That can only be done by one direct pathogen detection clarified. In addition one searches in the blood after that Genetics of the Herpatitis C virus (HCV RNA), If one finds it, the patient has a fresh hepatitis C infection.

Note: If the (suspected) infection has occurred recently, the body may not have had enough time to produce specific antibodies. Then, regardless of the result of the antibody test, a direct pathogen detection is attempted to diagnose hepatitis C can.

If the diagnosis is hepatitis C, the exact Genotype of the pathogen be determined. In addition, the so-called viral load measured, ie the concentration of the viral genome (HCV RNA) in the blood. Both are important for therapy planning.

Ultrasound of the abdominal cavity

The doctor wins evidence of the disease state of the liver from a Ultrasound, For example, the transformation of liver tissue into connective / scar tissue (fibrosis) on the way to liver cirrhosis can be recognized. In addition, one can exclude a tumor in the liver as the cause of the complaints with the investigation.

Biopsy & Elastography

To determine more exactly how advanced the scarring (fibrosis) already is, one can Tissue sample of the liver taken and examined in the laboratory (liver biopsy).

An alternative is a special ultrasound technique, which is elastography is called. Without intervention on the body can thus determine the degree of fibrosis of the liver.

Hepatitis C: treatment

The acute hepatitis C Cures in 10 to 50 percent of patients within weeks without treatment. Therefore, physicians generally do not immediately prescribe antiviral drugs, but wait for a while.

Only in certain cases should be started early with a drug hepatitis C therapy. This is the case, for example, with patients who have been infected with hepatitis C during a needle stick injury as part of their work (for example as a doctor or nurse in the hospital). So that those affected can carry out injury-threatening activities as soon as possible, they receive medicines for the rapid elimination of viruses in their bodies. Even with acute hepatitis C with severe symptoms or severe comorbidities, it may be useful to treat the infection with antiviral drugs.

First and foremost, however, such drugs are included chronic hepatitis C used. They are designed to prevent the liver disease from progressing further. They also lower the risk of cirrhosis and liver cancer as a long-term consequence of chronic hepatitis C.

Medicines for hepatitis C

The infection is generally treated with two or three different drugs (combination therapy). The details of this drug-based hepatitis C treatment depend on the individual case. For example, when selecting medicines, the doctor will consider which viral genotype the patient has been infected with. The severity of liver damage, existing kidney damage and concomitant infections (such as HIV or hepatitis B) as well as any pretreatments influence the treatment planning.

Today, hepatitis C is usually prescribed medications that prevent the pathogens in different ways from the proliferation. They are called “directly antiviral agents “(DAA) designated and taken in tablet form. Side effects hardly occur. The DAAs used include:

• protease inhibitors like Grazoprevir (GZR) or Simeprevir (SMV)
• Polymerase inhibitor like sofosbuvir (SOF)
• NS5A inhibitor like ledipasvir (LDV) or elbasvir (EBR)

Many of these drugs are not available individually, but only in a fixed tablet combination. For example, there are ledipasvir / sofosbuvir tablets and elbasvir / Grazoprevir tablets.

Also approved for hepatitis C therapy PEG interferon α (pegylated interferon-alpha) and Ribavirin (RBV), They are effective against all genotypes of hepatitis C. Until 2013, the two active substances were therefore the standard agents for hepatitis C treatment: PEG interferon was administered once a week as a syringe into the subcutaneous fat tissue. Ribavirin was taken daily in tablet form, sometimes in combination with a direct antiviral agent (DAA).

This old standard therapy was quite effective, but had various side effects and interactions (flu-like symptoms, sleep disorders, depression, etc.). Therefore, PEG interferon is hardly used in hepatitis C therapy today. Ribavirin is still prescribed in certain cases in combination with “direct antiviral agents” (DAA).

Note: Interferon-free hepatitis C therapy is not recommended during pregnancy and lactation.

Duration of use of the medication

The drug hepatitis C treatment usually extends over 12 weeks. In some cases, the doctor prescribes the medication for only eight weeks. However, some patients may need to take them for more than 12 weeks, for example 24 weeks.

At least 12 weeks after the end of the drug treatment, the doctor again examines the blood of the patient to check the success of the therapy. If genotypes of hepatitis C virus can still be detected in the sample, either the therapy has not worked sufficiently or the patient has re-infected. Then a re-treatment (usually with other agents than the first time) may be useful.

liver transplantation

Chronic hepatitis C can lead to cirrhosis after years. In severe cases, the diseased liver can no longer fulfill its tasks. For the affected then a liver transplant is the last treatment option.

Hepatitis C: course and prognosis

Above all, many patients want to know one thing: Is hepatitis C curable? The answer is: in most cases yes.

Acute hepatitis C spontaneously heals in 15 to 40 percent of patients. Conversely, 60 to 85 percent of all infected individuals develop chronic hepatitis C. Spontaneous healing is rarely observed here. However, in many cases, the right therapy leads to success in chronic hepatitis C. Healing here means that no viruses are detectable in the blood. This will be checked with follow-up examinations after the end of treatment. The patient is then considered cured. Later relapses are rare. However, after a healed infection, you can also re-infect with hepatitis C!

In 16 to 20 percent of patients with chronic Hepatitis C develops liver cirrhosis after 20 years as a late consequence. Those affected are more susceptible to liver cancer: a malignant liver tumor is detected every year in two to four percent of them.