The following questions have been compiled by hepatitis C educators based on their education and training experience and from other referenced sources (some information in this section has been adapted from the Hepatitis C Council of NSW website- http://www.hepatitisc.org.au/quickref/faq.html
It is believed that the hepatitis C virus has existed for thousands of years, however, scientists discovered the virus responsible for causing the illness and called it hepatitis C virus in 1988. Before then, infections with the hepatitis C virus were called non-A non-B hepatitis.
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Although it is much easier to talk of the hepatitis C virus as if it is a single organism, in fact it is a group of viruses, similar enough to be called hepatitis C virus, yet different enough to be classified into subtypes.
Several identifiable strains of hepatitis C virus have been observed around the world, differing slightly from each other in their RNA sequencing (genetic make up). The most commonly used classification system lists these families as HCV genotype 1, 2, 3, to 9.
Subtypes
Within each genotype, there is further difference between viruses - too small to be seen as a new genotype but significant enough and measurable, thus forming hepatitis C virus subtypes. These lesser classifications are described as HCV subtype 1a or 1b, etc.
Quasispecies
Within a person's hepatitis C virus subtype or subtypes, incredibly minute differences will exist among individual viruses. The differences are not significant enough to form a distinct subtype. Instead they form what is known as quasispecies. It is believed that within an HCV subtype, several million quasispecies would exist. Scientists predict that people who have hepatitis C have billions of actual viruses circulating within their body. Although there may be one or two predominant subtypes, the infection as a whole is not a single entity and is composed of many different quasispecies.
Australian patterns: It is estimated that in Australia, approximately:
The remaining people have other genotypes.
Evidence suggests that people can be infected with more than one genotype at a time. Multiple genotypes of the hepatitis C virus were detected in five of 138 HCV RNA positive injecting drug users recruited in Melbourne, Australia indicating that infection with multiple genotypes may be prevalent in people who inject drugs.
If liver inflammation is serious or continues for a long period of time, specific liver cells called stellate cells become damaged and then start producing scar tissue. When a lot ofs scar tissue is laid down it results incirrhosis. Cirrhosis can be caused by many different forms of liver disease. In Australia, the most common causes are excess alcohol and hepatitis C infection.
A diagnosis of cirrhosis means that liver injury has led to the build up of scar tissue in the liver to such an extent that the microscopic structure or "architecture" is affected. This scar tissue affects the blood flow through the liver and the function of the cells in the liver. Cirrhosis is most accurately diagnosed by liver biopsy (examining a tiny sample of liver tissue through a microscope).
It is estimated that between eight and 25% of people with chronic hepatitis C will develop cirrhosis - after 20 to 40 years of infection. Although cirrhosis is not life-threatening in itself, it means people are at increased risk of developing liver failure, other complications of advanced liver disease and/or liver cancer.
People with cirrhosis are able to access government subsidised anti-viral treatment, however rates of achieving a sustained virological response are reduced.
Liver function tests are used to measure the general condition of the liver. This blood test provides useful information about the function of the liver but for a more accurate indication of the condition of the liver, a liver biopsy is required.
Liver function tests measure levels of particular enzymes, proteins (including clotting factors)s and other chemicals such as bilirubin (causes jaundice when elevated) and glucose in a person's blood. The enzymes are used to assess liver inflammation. If liver cells are damaged, increased levels of enzymes "leak out" into the bloodstream and show up as raised or abnormal results in the blood test result. Alanine aminotransferase (ALT) is the most commonly monitored enzyme in liver function tests. Because of differences in laboratory technology, 'normal ranges' quoted by laboratories may differ. When comparing ALT results from different laboratories, the ALT result should be stated against the normal upper range quoted by each lab on the test result (eg. 70/50, meaning an ALT of 70 compared to the laboratory's normal upper range of 50).
A doctor can offer ongoing evaluation of people's liver inflammation by interpreting differences in their liver enzymesover time, and whether or not they have physical symptoms or signs of liver disease. More information on how the liver is actually working is provided by levels of proteins like albumin and prothrombin ( a clotting factor) and bilirubin. Repeat liver function tests may be suggested as frequently as weekly if disease is active and severe but are more usually done monthly or once per year depending on a person's condition and whether they have been recently diagnosed.
Liver function tests do not always match the symptoms in patients with liver disease.Some people may feel quite ill yet have little liver damage. For other people, damage may be occurring even when liver enzyme levels are normal. It is important to remember that raised liver function test results may be caused by medical conditions other than viral hepatitis. In cases where ALT readings are consistently high for a long time, where they fluctuate greatly or when readings do not match with how a person feels, a specialist may suggest a liver biopsy be done. Some doctors recommend a routine liver biopsy after 15 years of infection and then every five years thereafter.
A liver biopsy provides the most accurate report on the condition of someone's liver. Using a special instrument, a specialist doctor takes a small sample which is then examined under a microscope. The actual biopsy takes about one second. People usually remain at hospital after the biopsy for at least six hours or even overnight.
Ultrasound or an x-ray can indicate certain liver-related abnormalities but have difficulty distinguishing cirrhosis from other conditions such as fat accumulation in the liver. This is particularly true in early cirrhosis. The diagnosis of cirrhosis can only really be made by liver biopsy.
The presence or absence of cirrhosis is only part of the information available from liver biopsy. Apart from showing the amount of scar tissue (an indication of what has happened to the liver in the past), the results of a liver biopsy can also show how active the hepatitis C virus is, and if there are other factors interacting with the virus that are damaging the liver. These other factors include excess alcohol, iron accumulation in the liver or evidence of autoimmune disease (when the body's own immune system attacks liver cells).
After the skin is sterilised and an injection of local anaesthetic is given, a a needle is passed between the ribs into the liver. A small sample is taken for microscopic examination. Sometimes doctors may do the procedure using an ultrasound machine to guide them. People with blood clotting disorders may be advised not to have the procedure because of the risk of internal bleeding.
Some people experience pain during the procedure while others don't even realise it has been done. Local anaesthetic is always used but if anyone is especially concerned about pain or especially anxious, they should ask for some medications for pain and to help calm them down. After the procedure, people are asked to lie still for several hours.
About one in every 300 people who have a liver biopsy could have a serious complication such as bleeding from the surface of the liver. This would usually mean staying in hospital for a day or two and may require an operation, although this is rare. About one in every 1000 people who have a liver biopsy could experience more serious complications. Although certain risks exist, they need to be balanced against the benefits of more precise knowledge of what is happening in the liver.
A liver biopsy sample is just a tiny piece of the liver but a properly taken sample is generally representative of changes throughout the liver. Hepatitis C affects the whole liver and although there may be some variation within the liver, this would be a minor, rather than major, variation.
A doctor will usually explore two major issues in looking at the liver biopsy:
Firstly, are the features consistent with hepatitis C as the cause of the liver test abnormalities? E.g. are there other liver diseases present? Secondly, if the biopsy is consistent with hepatitis C, then how badly is the liver damaged? Using the Scheuer Score (or some other scoring system such as Knodell or Metavir) model, this can be estimated by studying three main parameters:
These three features may be given scores of 0-4. When looking at fibrosis four is the worst scenario (cirrhosis).. The first two parameters (portal and lobular inflammation) are often called the grade of liver damage whilst fibrosis may be referred to as the stage of liver damage.
It is the stage of liver damage that can give an idea of the chances of progression to cirrhosis over the next 10 years or so. Stage 4 fibrosis is already cirrhosis, whilst stage 1 fibrosis may possibly only progress to stage 2 over 10 to 20 years in some patients. In others the progress can be much more rapid.
A similar liver biopsy grading, the Metavir Score, is used within prescribing guidelines for government subsidised S100 combination therapy.
On April 1st 2006 the mandatory requirement for a liver biopsy prior to access to government-subsidised hepatitis C antiviral treatment was removed. Nonetheless, doctors may still recommend that some people have a liver biopsy. Liver biopsies are not recommended lightly because there is a relatively low, but real risk associated with the procedure. Therefore, the final decision to proceed with a biopsy should be made by the individual person and their treating doctor after a full discussion of risks and benefits.
Liver biopsy will remain an important part of the treatment assessment process for the following people with hepatitis C:
Overall the decision to have a liver biopsy should be discussed between the individual, their specialist and health care team.
Sustained virological response (SVR) occurs when there is no hepatitis C virus detected in the blood using PCR technology, six months after the completion of anti-viral treatment. Recent research shows that 99% of these people maintain their viral clearance for at least fours years and it is believed their response will last indefinitely. It is also becoming clear that the majority of people who experience a SVR will experience reversal of underlying liver damage. In a percentage of patients (<30%) even cirrhosis can reverse.
In hepatitis C terms, the word “cure” is controversial because evidence suggests there is a possibility that even after a person has achieved an SVR, the virus may reappear, which is thought to occur in one percent of patients four years after completing treatment. Therefore, it is more common for health professionals to refer to clearing the virus from the body as achieving an SVR.
No. Hepatitis C is spread through blood to blood contact, therefore, it is not inherited like a genetic health condition. Unless the father’s blood gets into the baby’s blood stream there is no risk of hepatitis C transmission from father to baby.
Except for blood-to-blood contact, the virus is quite difficult to pass on. Within normal daily contact, family members, friends and work colleagues are not at risk of contracting hepatitis C.
Partners, families and friends can play an important role providing emotional and practical support for people with hepatitis C.
Most babies are not at risk of catching hepatitis C, and sexual transmission of hepatitis C is very uncommon.
If parents feel it is necessary to test their babies and toddlers, it is important to discuss with the testing process with their GP or specialist. A PCR viral detection test done at 4-6 weeks will indicate whether the baby has contracted the virus, as would an antibody blood test done at 18 months.
It is not believed that hepatitis C physically affects children any differently from adults. Although many studies have examined hepatitis C's affect on adults, particularly people who have had blood transfusions, there have been few studies done on infants and children. Emerging research suggests hepatitis C infection has a lesser impact when contracted by children.
Having hepatitis C should not have impact on people in the workplace. Risk of hepatitis C transmission is so low that people with hepatitis C have no obligation to inform employers, work colleagues or customers that they have the virus. The one exception is for health care workers who carry out exposure prone procedures.
Looking for work
In pre-employment health checks, employers should ask questions relevant only to the advertised job. Types of work where someone might be precluded because they have hepatitis C are limited to those specialised health care workers who carry out exposure-prone procedures (operating with sharp instruments within body cavities). Unless a person with hepatitis C is applying for such work, employers have no valid legal reason to know about their infection. If someone is specifically asked when filling out a pre-employment medical questionnaire to tell about hepatitis C or such things as liver illnesses, they would probably need to decide whether to disclose or not on the basis of whether such information is relevant to the job, and whether possible discrimination may result from the disclosure.
Becoming sick at work
Working people who develop illness are able to take sick leave and possibly long-service leave, but additional time off can cause problems. Employers do have a legal responsibility, though, to make reasonable modifications to the workplace to accommodate people's disabilities. Amongst other options, employers may be able to:
Workplace disclosure
People who tell employers or work colleagues may unfairly lose their job or face some other form of discrimination as a result of ignorance or ill-feeling towards perceived injecting drug use. In such cases a person's union or the Anti-Discrimination Board of the relevant state or territory may be able to assist. The Anti-Discrimination Board can attempt to negotiate a return to work for sacked workers. If this is not possible or not appropriate, it can attempt to gain fair compensation on behalf of the unfairly sacked worker.
Health care workers
In Australia, health care workers who perform exposure prone procedures are obliged to monitor their hepatitis C status and abstain from performing exposure-prone procedures if they are HCV PCR positive. They are encouraged to inform employers of their hepatitis C status if they perform exposure prone procedures. Health care workers who do not perform exposure prone procedures are under no legal obligation to disclose their status to their employer, colleagues or patients. An employer may be breaching anti-discrimination legislation if it requires employees to disclose their hepatitis C status.
What is an exposure prone procedure?
An exposure-prone procedure is characterised by the potential for direct contact between skin (usually finger or thumb) of a health professional and a sharp surgical instrument, needle or sharp tissue in body cavities or in poorly visualised or confined body sites (including the mouth). An exposure-prone procedure refers to any situation in which the risk of transmitting blood borne viruses from health professionals to patients or vice versa during medical or dental procedures is high.
Hepatitis C virus can survive outside the human body forsome time. However, hepatitis C virus survival is dependent on virus titre, the volume of blood, ambient temperature and exposure to sunlight and humidity. The risk of hepatitis C transmission from syringes discarded in the environment appears to be very low. In May 2007, there has been only one documented case of hepatitis C transmission occurring after a community acquired needlestick.
Bowden, S., McCaw, R., White, P.A., Crofts, N. & Aitken, C.K. (2005). Detection of multiple hepatitis C virus genotypes in a cohort of injecting drug users. Journal of Viral Hepatitis; 12(3): 322-324.
Dore, G. Removal of liver biopsy – what will it achieve? Australian Hepatitis Chronicle 2006; issue 16 (October): 4-5.
Communicable Diseases Network of Australia (CDNA), National Public Health Partnership (NPHP), and Australian Health Ministers' Advisory Council (AHMAC). Infection control guidelines for the prevention of transmission of infectious diseases in the health care setting 2004; Canberra: Australian Government, Department of Health and Ageing.
Thompson, S.C., Boughton, C.R. & Dore, G.J. (2003). Blood-borne viruses and their survival in the environment: is public concern about community needlestick exposures justified? Australia and New Zealand Journal of Public Health; 27(6): 602-607.
Libois, A., Fumero, E., Castro, P. et al. (2005) “Transmission of hepatitis C virus by discarded needle injury”. Journal of Infectious Diseases, 41(1 July); 129.