Acute Hepatitis C (HCV)

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Hepatitis C virus (HCV) chronically infects 58 million people worldwide, and chronic hepatitis C (CHC) is a major cause of serious liver diseases such as potentially fatal hepatic cirrhosis and hepatocellular carcinoma (HCC). HCV infection accounts for one in four cases of liver cancer (Bartenschlager et al, 2018).

Although the cure rate of CHC patients has significantly improved with the use of directly acting antiviral agents (DAAs), there is currently no prophylactic vaccine available. Additionally, cured patients may still be at risk for reinfection due to lack of protective immunity (Farci et al, 1992; Page et al, 2009). Moreover, the persistent risk of HCC development post‐treatment, emergence of drug resistance‐associated substitutions (RAS) and new subtypes, as well as limited access to DAA therapy in underdeveloped regions pose significant challenges to achieving the goal of eliminating viral hepatitis as a public health threat by 2030 (Bartenschlager et al, 2018; Shah et al, 2021). Therefore, HCV infection will continue to be a global public health concern.  

The mode of infection is mainly through contaminated blood, including needle stick injuries or intravenous/intranasal drug use. Hepatitis C is not a classic sexually transmitted disease (STD), but can be transmitted through rough anal contact. It can also be transmitted through vertical contamination, but this is generally low (< 5%).

Diagnosis is made by a marked increase in transaminases, possibly accompanied by an increase in bilirubin and hepatitis C RNA that becomes positive. Hepatitis C antibodies appear after 4 to 12 weeks. 75% of infections become chronic. There is no vaccine.

Antiviral therapy is started when the disease becomes chronic.

Pathogenesis|clinical picture

In most cases (80%), HCV infection becomes chronic, despite the presence of antibodies and HCV-specific T cells. After an incubation period of 2 months (range 2 to 26 weeks), infection with HCV leads to jaundice (icterus) in only 10% of cases. In half of the HCV carriers, ALT values ​​remain more or less elevated.

The physician encounters HIV mainly in the form of chronic hepatitis and cirrhosis (20% after 20 years). The chance of developing cirrhosis is higher in men, in HCV infection at an older age and if the HCV carrier uses alcohol. Modest alcohol use and diabetes mellitus also worsen the prognosis of hepatitis C initially. In addition to liver disease, HCV infection is associated with several other conditions. A significant proportion of patients with membranoproliferative glomerulonephritis type 1 and 'mixed cryoglobulinemia' are found to be HCV positive [Mixed cryoglobulinemia can evolve into a florid B-cell malignancy in up to 11% of cases].

Treatment HCV

The highly effective oral agents used in HCV (effective in 80-100% of treated patients) cannot all be used safely in the more advanced stages of fibrosis and cirrhosis. Liver biopsy in chronic HCV infection has the main role to grade fibrosis and inflammation and to establish a competing diagnosis (alcoholic liver disease or drug hepatitis). In addition, liver biopsy can be used to document progression of liver disease over time, which is not possible with serum transaminase determination. In addition to liver biopsy, ultrasound fibroscan and various blood tests can be used. The degree of fibrosis plays a role in determining the degree of urgency to proceed with treatment. From mild to moderate fibrosis, treatment is urgently needed. In severe fibrosis, liver transplantation should be considered.

Prevention

Passive or active immunization against hepatitis C is not available. The chance of infection with HCV after a needle stick injury with HCV-positive blood is 1-10%. Depending on the type of accident and the amount of infectious material transmitted.

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