Hepatitis C

If you have recently discovered that you or someone you care about has hepatitis C, there are generally three reasons to be optimistic:

• hepatitis C progresses slowly, and many people who harbour the virus will never feel sick;
• many people in South Africa have the virus; and
• treatment is already available, and researchers are at work to develop even newer treatments.

What is hepatitis C?

Hepatitis simply means ‘inflammation of the liver'. Hepatitis C usually causes little or no symptoms when people become infected. However, in approximately 80% of infected people, the virus makes itself at home in the liver, where it has the potential to cause liver damage ranging from mild to severe. During its habitation, the amount of damage by the virus to the liver varies from person to person and is countered by the liver's ability to repair itself.

An important fact to know, because it influences decisions about treatment, is that hepatitis C produces ongoing inflammation in the liver over many years. In some patients (about 20% of cases) scar tissue accumulates in the liver, which can eventually become extensive, leading to cirrhosis (a term used to describe a severely scarred liver). Patients who have developed cirrhosis are at increased risk for developing a number of complications since the liver may not be capable of performing all of its many functions to the same degree as when it was healthy.

One of the most feared complications of cirrhosis is the development of liver cancer (called hepatocellular carcinoma). It has been estimated that about 2% of people with cirrhosis (1 in 50) develop hepatocellular carcinoma each year. If you have cirrhosis, your doctor will probably do blood tests and obtain an ultrasound examination regularly to screen for hepatocellular carcinoma.

Most infected patients, even those with a progressing condition, may have no specific symptoms for many years. Some patients do complain that they are fatigued, although the fatigue's relationship to the infection is not always clear. Joint pains can occur in some patients. It is important to know that the absence of symptoms does not necessarily mean that the infection is under control.

Some symptoms for hepatitis C might be described as flu-like symptoms, for example:

• feeling tired;
• feeling sick to your stomach;
• fever;
• loss of appetite;
• stomach pain;
• diarrhoea;
• dark yellow urine;
• light coloured stools; and
• yellowish eyes and skin.

Is it contagious?

The hepatitis C virus is extremely contagious and spreads mainly through contact with blood. If you are infected by the hepatitis C virus, you should avoid activities that risk exposing another person's blood to your own. Examples include sharing a toothbrush, nail clippers, razors, needles and donating blood.

How is hepatitis C transmitted?

Sexual transmission

The virus can be spread through sexual activity. If you do not have a stable monogamous sexual partner, you should practice safe sex. If you are already infected, practicing safe sex will not only protect you from getting a new infection, but will protect your partner from being infected with hepatitis C. There is no scientific evidence that kissing, hugging, sneezing, coughing, sharing food, water, eating utensils or drinking glasses, casual contact, or other contact without blood exposure is associated with transmission of the hepatitis C virus. The risk of transmitting the virus is higher in people who are not only infected with the hepatitis C virus, but also with the human immunodeficiency virus (HIV).

Transmission during pregnancy

The risk of transmitting hepatitis C during pregnancy is about 5% to 6% (about one in 20 persons) but is increased in people who are also infected with HIV (about 12% or one in eight persons). Speak to your doctor if you are pregnant or contemplating pregnancy.

Sharing drug needles

Getting pricked with a needle that contains infected blood (hospital workers also need to be careful when giving injections and handling needles).

What happens over time?

Many researchers have studied large groups of patients with hepatitis C to find out what happens to them over time. Only about 20% (one in five persons) will develop cirrhosis 20 years after first acquiring the infection. Most patients will have some degree of inflammation in the liver, but without a significant amount of scarring.

Potential risk factors that may contribute to complications have been investigated, the most significant being:

• consumption of alcohol: People with hepatitis C who drink alcohol are at much greater risk for developing cirrhosis;
• the amount of liver inflammation and scarring: As expected, increasing amounts of inflammation make it more likely for the liver to become scarred.
• marijuana (dagga): Daily use has been associated with worsening liver disease.

The best way to determine the state of the liver is to do a liver biopsy, which involves obtaining a tiny sample of liver tissue and examining it under a microscope. A liver biopsy is commonly performed and is most often an outpatient procedure. You should discuss with your doctor whether it is required in your case.

Your doctor may obtain these two other special tests that are helpful to determine the best treatment and monitoring:

• hepatitis C virus (HCV) RNA, which is a measure of the amount of virus circulating in your blood; and
• HCV genotype, which determines the specific type of virus that you have (most people in the United States of America have type I).

Regular tests

People who have developed cirrhosis:

• should also undergo regular screening for hepatocellular carcinoma, which is typically done with an annual or bi-annual ultrasound examination and a blood test (serum alpha fetoprotein level); and

• your doctor may perform a procedure called an upper gastrointestinal endoscopy (in which a fibreoptic instrument is used to inspect the oesophagus and stomach) to evaluate for oesophageal varices (stretched veins). Varices develop in roughly 50% of cirrhosis patients.

What can I do to improve the condition of my liver?

The best thing you can do to help your liver is to avoid alcohol. In addition, all people infected with hepatitis C should be vaccinated against hepatitis A and B, unless they are already known to be immune. Pneumococcal vaccine and an annual influenza vaccination should be considered in patients who have developed cirrhosis.

Diet

Even though no specific diet is proven to improve the outcome in patients with hepatitis C, the best advice is to eat a healthy and balanced diet. It is also advisable to take a multivitamin without iron.

Exercise

Exercise is good for your overall health and is encouraged, but has no known effect on the virus.

Prescription and non-prescription drugs

Many drugs require metabolism by the liver. Thus, it is always best to check with your doctor or pharmacist before starting a new prescription. As a general rule, unless your liver is already scarred, most drugs are fairly safe. An important possible exception is paracetamol (Panado® and other tablets of the same chemical composition). The maximum dose should not exceed 2gm (in divided doses) per 24 hours.

Herbal remedies 

Although many claims about herbal remedies have been made (particularly on the internet), please beware. None has been proven to improve outcomes in patients with hepatitis C, and some have been associated with serious liver toxicity.

Support

Do not underestimate the value of sharing your concerns with other hepatitis C patients.

Tips for prevention of hepatitis C

• Don't share needles with anyone.
• Wear gloves if you have to make contact with blood.
• If you have several sex partners, use a condom during sex.
• Don't use an infected person's toothbrush, razor or any of their items that could have blood on it.
• If you get a tattoo or body piercing, ensure that it is done with clean, sterilised equipment.
• If you have hepatitis C, don't donate your blood or plasma - the person who receives it could become infected.

References:

Bonis PAL, Chopra S: Patient information sheet:
UpToDate patient information. Website: http://patients.uptodate.com/topic.asp?file=livr_dis/5071