Ask the expert: All about hepatitis C

May 8, 2018 Kris Kowdley, MD

Baby boomers and people with certain risk factors should be screened for hepatitis C. Getting tested is easy; current treatments are simple and have a high cure rate.

By 2030, the World Health Organization wants to have hepatitis C eliminated from the planet. A key to reaching that goal is to create awareness of the disease among baby boomers, who suffer from it in larger numbers compared to the rest of the population, as well as those with increased lifestyle risks. But what is hepatitis C, and what can be done to reduce its numbers? Kris Kowdley, MD, director of the Liver Care Network and Organ Care Research at Swedish Medical Center in Seattle, WA, discusses hepatitis C in detail.

What is hepatitis C, and how does it differ from hepatitis A or B?

Nature of hepatitis C

“Hepatitis C is an RNA virus. What makes hepatitis C different from some other viruses is that the vast majority of patients who are infected with the virus go on to develop chronic infection. And that’s the problem — the body does not develop immunity to this virus and, as a result, hepatitis C is associated with chronic infection and lack of immunity and clearance in 60 to 90 percent of patients.

On the other hand, another unique aspect of hepatitis C is that it there is no reservoir in the nucleus. Therefore, the virus needs to replicate in order to survive, which allows for the option for a cure with sustained suppression of viral replication.  Thus, recently available direct-acting antiviral agents provide high rates of success in curing this chronic viral infection.”

Lack of signs or symptoms in hepatitis C

“This is a very important point to emphasize — hepatitis C infection, and any other liver disease, doesn’t necessarily result in symptoms or signs. The liver is an abundantly oversupplied organ in terms of the body’s needs, so many people can go for decades with no symptoms or signs until they develop late-stage disease. By the time a patient develops jaundice, muscle wasting, abdominal distension, fluid overload or internal bleeding, the patient may have lost anywhere from 80 to 90 percent of liver function. Since there may be no symptoms or signs of hepatitis C, or many liver diseases, it’s particularly important for individuals to identify if they may be at risk and be screened.

“Now, sometimes patients with liver disease may have symptoms such as fatigue and joint pain, some patients have cognitive issues that they call a ‘brain fog.’ But these symptoms are very nonspecific and can be attributed to depression, to fibromyalgia, or to other things and do not necessarily target the liver. Most patients come to recognize liver disease either by screening or if they have routine tests and their liver enzymes are noted to be abnormal. Our goal should be never to have a patient diagnosed with chronic liver disease when they show symptoms. If they do have symptoms specific to the liver, they may include jaundice, yellow eyes, color changes to the urine and stool, muscle wasting and fluid overload where the belly gets swollen.”

Comparison to hepatitis A

“The vast majority of patients who are exposed to hepatitis A have it transmitted by what we call the fecal-oral route, so through the gastrointestinal tract, food, etc. With hepatitis A the vast majority of patients who are exposed to the virus will become immune after clearing the virus; a very small subset of patients with hepatitis A may develop severe liver injury and may even need a transplant but that is extraordinarily rare.”

Comparison to Hepatitis B

“Hepatitis B has a similar mode of transmission as hepatitis C through exposure to blood products or sexual contact. Unlike hepatitis C, hepatitis B causes chronic infection depending on the age at which the person was infected. So, a newborn exposed to hepatitis B has a very high likelihood of developing chronic infection, whereas an adult exposed to hepatitis B has less than a 5 percent of infection.”

Who needs to be tested for hepatitis C?

“Individuals who have experimented currently or in the past with intravenous drugs are a high-risk group. We are seeing a resurgence in acute hepatitis C cases because of the injection drug and opioid epidemic. Many people who may have experimented with drugs a few times in their youth may have forgotten about it and may discover in routine testing 30 years later that they have hepatitis C.”

“Certainly, exposure to contaminated blood is an important risk factor. The blood supply was tested for hepatitis C starting in 1992, so anyone who received a blood transfusion prior to 1992 is at increased risk. And anyone who’s ever been incarcerated, there’s a very high rate of hepatitis C in prison populations. Certain populations have increased risk of hepatitis C, such as African Americans and Native Americans, and so do patients who have had organ transplantation or tattoos in an unregulated setting through contaminated needles.”

And what about baby boomers - why should they be tested?

“There are a number of reasons why baby boomers, those born from 1945 to 1965, represent 85 percent of the hepatitis C population.

There may be a variety of reasons why baby boomers are at increased risk, but the key point isn’t to target the risk factor but to screen the patient. It’s important to screen patients without stigmatization. One of the major advantages that I think has changed public perception is that now we are able to do age-based screening instead of risk-based screening. Certainly, there remains stigmatization of some individuals with hepatitis C who may not want to come forward with any potential risk factor, so the ability to say, ‘Oh, you were born in this age cohort , you are at increased risk, would you like to be tested,’ I think has made a lot more patients willing to be tested.”

How do I get screened for hepatitis C?

“It’s just a standard antibody blood test. It’s available everywhere and covered by insurance for patients in the appropriate age group or who have risk factors. If patients test positive, they need a confirmatory RNA test to directly look for the virus in the blood. Patients who test negative can be reassured they don’t have chronic hepatitis C. The occasional patient who tests positive but has no measurable virus in the blood is likely to have a false positive or have been previously exposed and in the small group who does clear the virus.

“There’s really no reason for a patient not to be screened. We have the ability at Swedish and Providence St. Joseph Health to send a message to patients in the electronic medical record informing them that they should be screened for hepatitis C. And once they get tested, we now have the pathway for them to be referred to specialists or treated directly after they’ve had the appropriate staging to determine the stage of the disease, counseling about lifestyle health and management and then link to a provider who can offer them treatment.”

What are some of the new therapies to treat hepatitis C?

“If you go back through the history of hepatitis C, we have made an unbelievable amount of progress in 15 years, a very short amount of time. The initial therapies for hepatitis C were based on improvement in liver enzyme levels; we didn’t even have a test to monitor the virus directly. We used to treat patients with an injection of interferon three times a week for six months, which led to a lot of side effects and response rates in terms of a viral cure of only 3 to 4 percent.

Fast forward to 2014, where we now had the ability to treat patients with a single pill once a day for as little as eight weeks, achieving a cure rate of 95 percent or higher. In the last year or two we’ve made even further progress, where we now have single-tablet treatments for patients regardless of what particular strain of virus they have. So we are now able to achieve in most patients a cure with oral therapy, just pills, with as little as eight weeks of treatment in well over 95 percent of patients. And we have data showing that once patients are treated and achieve cure—meaning that 12 weeks after therapy the virus is still not measurable in the blood — their liver tests improve, liver scarring regresses and they practically eliminate the risk of needing a liver transplant.”

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This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.

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