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PHYSICIANS’ NEWSLETTER

Regional Niagara Public Health Department
An Accredited Public Health Department 2000, Issue No. 2 A copy of this newsletter is also available in print.
HEPATITIS C MEDICAL UPDATE

Hepatitis C (HCV), a blood borne RNA virus, was identified in 1989. Previously it was known as Hepatitis non-A non-B. Elusive to the immune system, there are six known genotypes with many mutating sub-types. Hepatitis C is spread through direct blood to blood contact with an infected individual and is the most common chronic blood borne infection in North America. Approximately 40 percent of chronic liver disease is a result of Hep C. It is also the most common cause of cirrhosis and the leading cause of liver transplants.

ACUTE AND CHRONIC HEPATITIS C

  • Approximately 15% of HCV infections are acute and resolve within 6 months.
  • 85% progress from acute to chronic Hepatitis C.
  • 20% of chronic cases will develop cirrhosis within 20 years and cirrhosis will develop in the rest at a rate of 10% /decade.
  • 5% will develop liver cancer within 30 years. Once cirrhosis is diagnosed, the probability of decompensation is 25% after 10 years. (The death rate for decompensated cirrhosis is 50% after 5 years.)
  • Because many HCV infected people are aged 30—50 years, death could increase substantially within the next 10 to 20 years.
STATISTICS:   Approximately 1% of Canadians (300,000) have Hep C, with 20,000 becoming infected each year. It is estimated that approximately 4,000 Niagara residents have Hepatitis C. The Canadian Liver Foundation reported receiving up to 12,000 phone calls in 1998. Of those calls, approximately 75% were Hepatitis C related.

MODES OF TRANSMISSION:  Hepatitis C virus is not easily transmitted when blood to blood contact is avoided. Modes of transmission are as follows:

Injection Drug use (IDU):  IDU is the most common risk factor, up to 80%. Intranasal cocaine use can also transmit HCV through sharing straws. The risk of contracting Hep C through IDU is also 4 times higher than for HIV.

Previous blood transfusion:  The receipt of blood products prior to 1990 was the second highest risk factor. The present risk of Hep C post-transfusion is very low, about 1 in 100,000.

Sexual Transmission:  The risk of sexual transmission is only 2.5% with prolonged sexual exposure of greater than 20 years. The risk increases with unprotected intercourse during menstruation, since the virus is present in the menstrual blood of infected women.

Needlestick Injuries:  The risk of contracting Hep C from a needlestick from a positive source is estimated to be 1.8%. Health Care Workers have no greater risk than the general population.

HCV (+) Mothers & Children:  5-10% of infants become infected regardless of mode of delivery. Breast fed babies do not appear to be at higher risk. Maternal antibodies may persist up to 18 months after birth therefore testing should be delayed.

Household Contacts:  The risk is unknown and can occur by sharing personal care items such as needles, razors and toothbrushes.

Other:  Other risks include haemodialysis, tattooing and body piercing. 10% of cases have no known risk factor. 
SYMPTOMS:   Only 5-25% of people with newly acquired HCV have symptoms. The average time from exposure to development of symptoms is 6-7 weeks and the presence of symptoms does not reflect severity of disease. Symptoms may be mild or severe and usually last only 1-2 weeks, which include: fatigue, nausea with or without vomiting, malaise, fever, itchy skin, jaundice, abdominal and joint pain. Unlike other symptoms, fatigue may persist for months. Chronic cases of Hep C may take up to 10 years to develop symptoms and 50% complain of profound fatigue.
TESTS:   HCV is diagnosed by detecting HV antibodies in the blood, produced in response to infection by the Hepatitis C virus. The average time from exposure to seroconversion is 8-9 weeks. Anti-HCV may not be positive during acute infections (less than 6 months) and may not be easily detected in immunosupressed individuals. By 6 months anti-HCV can be detected in 97% of cases. Unfortunately, the test for anti-HCV does not distinguish between acute, chronic or resolved infections.

EIA Testing:  The initial test is the EIA (enzyme-linked immunosorbent assay), an anti-HCV.

RIBA Testing:  A more sensitive test is RIBA (recombinant immunoblot assay) anti-HCV and can identify false positive results.

HCV-RNA Testing:  More sensitive than EAI and RIBA are the HCV-RNA tests by RT-PCR (polymerase chain reaction). HCV-RNA (RT-PCR) tests are either Qualitative or Quantitative.

Qualitative results, which can detect the virus within 8-9 weeks after exposure, are given as either positive or negative. If HCV RNA is negative, the client may have spontaneously cleared the virus. Those with a negative HCV RNA may still have HCV since 12% will test negative because the sample taken may be below detection limits of the assay. It is unlikely that these clients will progress to cirrhosis.
Qualitative can only be ordered in the following:
     
  • immunocompromised clients; needlestick injuries from a known positive Hep C source, infants born with HEP C positive mothers at 12 weeks, to assess response to treatment if given
**NOTE: Hep C literature also recommends HCV RNA qualitative tests for all positive HCV clients with a normal ALT to confirm chronic infection. The Public Health Laboratory in Toronto which does all HCV RNA testing can not do a qualitative RNA for this reason due to strict criteria and limited funding.
Quantitative gives the amount of circulating virus and can identify the genotype. The cost of doing a quantitative test is about $400.
Quantitative testing can only be ordered:
     
  • to assess suitability and optimal duration of therapy
  • if liver enzymes are elevated 1.5 times higher than the upper normal range and client is being referred to a specialist.
ROLE OF A SPECIALIST ~ Clients who are symptomatic, with persistent or intermittent abnormal liver chemistry and those under treatment should be referred to a gastroenterologist or hepatologist.
TREATMENT ~ At present, there is no cure for Hepatitis C. Treatment is recommended for clients with chronic HCV who are at greater risk for progression to cirrhosis. Clients are likely to respond when treated early. Treatment may slow the progression of liver disease and prevent cirrhosis and carcinoma. Those treated with established cirrhosis in the absence of hepatic decompensation have a prognosis which may exceed 10 years. A liver biopsy is the best way of confirming cirrhosis and assessing prognosis, but it is not considered mandatory in order to start treatment. 

High risk individuals for treatment considerations are those with:

  • Persistently elevated ALT levels (more than 1.5 times normal limit)
  • Detectable HCV RNA (qualitative)
  • Liver biopsy indicating moderate degrees of inflammation
Treatment should not be given to:
  • Those with advanced cirrhosis 
  • Autoimmune disorders
  • Pregnant women
  • History of severe depression
  • Clients < 18 of age as treatment is not FDA approved
  • Those who drink alcohol excessively or who inject legal drugs until behaviours have been discontinued for > 6 months
HEP C—CHOICE OF TREATMENT

Interferon Monotherapy is an antiviral and immunostimulant substance given subcutaneously 3 million units, three times a week. Duration of therapy for those with genotypes 2 or 3 is six months and often respond very well. Duration of therapy for genotype 1 and other genotypes is 12 months. 60% have genotype 1. 15-19% have a sustained response greater than 1 year after therapy is stopped with normal serum ALT and loss of detectable HCV RNA. The chances of liver cancer decreased by 13% and mortality by 16% with treatment. Persistent abnormal ALT levels and detectable HCV RNA after 3 months of treatment are unlikely to respond and should be discontinued. The approximate cost of Interferon treatment is $6,000. Side Effects of Interferon: Most have flu-like symptoms and weight loss early in treatment but symptoms diminish within 1-2 weeks. 5-10% must be discontinued due to side effects.

Interferon and Ribavirin Combination therapy is now available in Canada as REBETRON. Rebetron has a response rate of 43% compared to 19% with interferon treatment alone. The dose of Interferon is 3 million units, 3 times per week, subcutaneously, and a dose of Ribavirin is 1000mg per day < 75 kg or 1200 mg > kg orally. Approximate cost of Rebetron is $20,000—$25,000 per year. Side Effects of Rebetron: Common complaints are anemia, rashes, nausea, headache and flu-like symptoms.

Liver Transplant may be the treatment of choice if Hep C is life threatening. Liver transplants have an 80% success rate; however, HCV will return to the transplanted liver. Most will develop recurrent Hepatitis and 20-30% will develop cirrhosis.
Hep C - Recommended Follow-up for Patients With Chronic HCV

 
PATIENT STATUS  RECOMMENDED FOLLOW-UP
Normal aminotransferases (ALT), repeatedly negative HCV-RNA  Most of these patients have recovered from a remote HCV infection and simply require follow-up with ALT testing every 6—12 months
ALT are persistently normal (I.E. on 3 to 4 serial tests within 1 year) ALT test every 6—12 months
ALT elevated and treatment not currently indicated  6-monthly bilirubin, albumin, international normalized ratio of prothrombin time (INR) and ALT tests
Established cirrhosis  Specialist follow-up due to risk of liver failure
Not currently immune to HBV/risk of Hepatitis A  Discuss with pt possibility of immunization for HBV/HAV
Patients on treatment 

 

 ALT and HCV-RNA monitored early during treatment, since these tests will indicate who is unlikely to respond in the long term, in which case treatment should be stopped.

Source: Hepatitis C medical information updated from the Canadian Liver Foundation.

NOTE: Hepatitis B vaccine can be obtained free of charge from the PHD BIOS (Bio-Inventory System) at 688-5238. Hepatitis A vaccine can only be obtained free of charge from the Ministry of Health through a Section 8 Letter for those on social assistance or disability that have an Ontario Drug Benefit card. (See Section 8 letter insert) (See next page for more information)
Hepatitis C Information:  Compensation for Blood Transfusion Recipients

Clients need to obtain a Hepatitis C compensation package through the Federal or Provincial government based on year of blood transfusion. Physicians are required to complete part of the claim form. Canadian Blood Services will initiate an investigation with a Transfusion Related Infection (TRI) form completed by the Public Health Department or family physician with approximate date and location of blood transfusion. Federal Government offers compensation if blood products were received between Jan.1/86-July 1/90. Clients need to obtain the Federal compensation package at 1-888-726-2656. On April 25/00, 6,400 applications were mailed to elegible Canadians (2500 in Ontario). There are 6 levels of payment based on severity of illness ranging from $10,000 to $225,000. Claim forms often require a PCR RNA test. Physicians ordering this test need to include the client’s Federal claim form # on the requisition. Clients can also apply every 2 years if illness has progressed. To date (June 2000), new applications are taking about 1 year to process and disbursement of payment has recently begun. Provincial Government offers compensation to those who contracted Hepatitis C from blood products prior to December 31, 1985 and between July 2, 1990—September 28, 1998. Clients need to obtain the Ontario Hepatitis C Assistance Program Compensation Package (OCAP) at 1-877-222-4977. From Jan/99—May/00, approximately 2,500 people have been compensated $10,000 and will receive an additional $15,000. Recently, about 100 people per week have been applying. 
HEPATITIS C BLOOD DONORS

Hep C clients may have donated during the “window period” (up to 10 weeks). The RNA-PCR test is used to screen blood, which can detect HCV within 1-2 weeks post expsosure. A TRI (Transfusion Related Infection) form should be forwarded to the Canadian Blood Services if the donation was given in Canada.
RESOURCES
 
  • Public Health Department part-time Hep C nurse Linda Warkentin (BScN) at 688-3762, extension 558
  • Hepatitis C Society of Canada (1-800-652-4372) has monthly meetings in Niagara.
  • Canadian Liver Founation (1-800-563-5483). In March 2000 a 9 page “Hepatitis C medical information update” was distributed to all family physicians, surgeons and gastroenterologists. If you did not receive this update, please contact the Canadian Liver Foundation
WEBSITES Submitted by: Linda Warkentin, RN, BScN