Hepatitis C

Diseases of liver are becoming increasingly common in Pakistan. One of the reasons for this is a very high prevalence, in Pakistan, of hepatitis caused by viruses. Although many different kinds of viruses can cause hepatitis, the most important and dangerous ones are those that spread through blood. These include Hepatitis B and C. Considering that viral hepatitis is a life threatening condition and its treatment is very difficult and expensive, this high prevalence should be a cause for serious concern.

In this article, we will, at first, describe how hepatitis B and C spread from one person to another. We will then describe its symptoms and signs and the laboratory tests through which it is diagnosed. Lastly we will discuss different options available for its treatment.

Ways of Spread

Blood Transfusion:
Hepatitis B and C pass from one person to another when the blood of a person carrying the virus somehow comes into contact with another person's blood. One very common situation in which this happens is when a person who has hepatitis virus in his blood gives blood to another person.

 

In most developed countries, before a person is allowed to donate blood, his blood is tested to make sure that it does not have hepatitis virus in it and only healthy people are allowed to act as blood donors. Unfortunately, in Pakistan and in many other developed countries, this does not happen and blood donors are not screened for hepatitis. This situation is further complicated by the tendency amongst general public to get blood from professional donors instead of from family members at times of need. The majority of these professional blood donors are intravenous drug users and their blood carries a very high probability of having Hepatitis virus in it and of causing Hepatitis C in the person who receives it.
Sexual Contact:
It is possible to transmit infection through sexual contact, although this is rare. In many cases where hepatitis C has spread from one partner to another, it is not clear whether it was the sexual intercourse which led to the transmission or whether it was through sharing some personal item such as tooth brush or a razor. The chances of transmission through sexual contact are certainly higher if intercourse occurs during menstruation.

 

Having multiple sexual partners also increases the risk. If one partner is infected and the other is not infected after many years of living together, the chances of sexual transmission are then smaller and taking extra precautions such as using condoms in such situations is probably unnecessary.

Daily Contact:
Daily routine contact for example touching the infected person or using a teacup would not cause the spread of infection; however it would be wise not to share personal items such as toothbrushes, nail cutters, scissors or razors if you are positive for hepatitis C.
Intravenous Drug Use:
According to the current evidence, it seems that 50-80% of people who use intravenous drugs or have used them in the past are infected with hepatitis C.

 

This is due to the fact that the injection gear can be soiled with small amounts of blood and sharing it can spread the virus. Sharing the needles even once can be sufficient to spread infection. In the UK, a number of people are being diagnosed with hepatitis C who had used intravenous drugs only a few times many years ago.
Acupuncture, Tattooing and Body Piercing:
Some people have been infected due to contaminated needles used in acupuncture, tattooing and body piercing clinics. The best way to prevent this is to use disposable needles.

 

Saliva:
The virus has been found in the saliva, but it is very unlikely that it can spread through kissing. It would be wise not to use someone else's toothbrush.

Mother and Baby:
Many infected mothers are worried that they may transfer the virus to the child.

However, if appropriate precautions are taken, the risk is low. During pregnancy and delivery, the risk of transfer of virus from infected mother to the child is about 6%. It is not known whether the child is infected inside the womb, during delivery or just after the delivery. Sometimes the child will have antibodies, which can last up until 12-18 months. These antibodies are acquired by the child from the mother and the child itself is not infected. The usual test for infection is by measuring the quantity of antibodies and therefore this test is not useful in the child below one year of age. Another test called PCR can, however, detect infection in the first few months. To carry the child or to kiss the child is harmless. Most doctors think that if the mother does not have any symptoms, it is not harmful to breast feed the child, however there is a possibility that if there is an abrasion in the breast or in the baby's mouth, the infection can be transmitted.

 

 

Medical Treatment:
There is evidence that the epidemic of hepatitis C in Pakistan is due to reuse of plastic or glass syringes. It should be ensured that for medical treatment only disposable syringes are used. Infection can also spread due to treatment by unqualified dentists.

Barbers:
The reuse of razor to shave the head or beard can also cause infection. Always use a separate or disposable razor. It would be better if you do not go to the barber for a shave. In the UK, usually the barbers are not allowed to use razor blades. They only use scissors or machines for hair cutting.

Cultural Factors:
Getting the children's head shaved, circumcision and ear piercing are also occasions when infection can spread. Always consult a qualified doctor for circumcision. For ear piercing it is important that needles are sterilized. In Pakistan, intravenous drips, including vitamins are very commonly used for the so called weakness. This treatment under most circumstances is unnecessary and dangerous.

Signs and Symptoms
Hepatitis can affect a person either as an acute illness or as a chronic illness.
Acute illness is self-limiting illness and usually the patient will recover in a few weeks without any lasting effects. A chronic illness lasts over a long period of time and is usually lifelong. In most patients with hepatitis C, the illness is chronic; however, it can affect different people in different ways. Many people do not have any symptoms and are not even aware of the existence of the virus. Even when there are symptoms they are not specific. Some people will feel very tired and unwell. Some people feel flu-like illnesses. Occasionally, nausea, vomiting and jaundice are seen, but this is uncommon. The following symptoms are also seen.

As some symptoms come and go, some people are diagnosed with chronic fatigue syndrome or ME. The symptoms of liver disease are not usually apparent until the disease is advanced. About 20% of the people recover completely. It is not known why some people are able to clear the virus. The remaining people continue to have the infection. The inflammation on the liver continues in some people. This inflammation is mild and is not progressive, but in others it can result in cirrhosis, which can be diagnosed 20, 30 or even 40 years after the infection. If the hepatitis C infection continues beyond six months, it is called chronic. The inflammation in the liver causes damage to the liver cells over a period of time. In some people, this damage can be serious; in others it does not cause problems. Symptoms are not an indication of damage to the liver. Sometimes, the infection remains undetected for a long period of time. Doctors cannot predict which people will have serious liver damage.
Cirrhosis is a medical term, which means excessive scar tissue in the liver. When there is acute damage to the liver, some liver cells die, but the liver restores itself to its previous condition after repairing itself and is usually not scarred. However, if the injury to the liver is continuous and recurrent, the liver can become scarred. This process starts slowly, but can continue for years without any symptoms till the scarring increases to the extent that the important functions of liver are affected and the liver cannot restore itself to its normal state. Symptoms can appear at any time, however, in this process of scarring they appear relatively late. Many symptoms appear when the liver starts to fail. The stage of cirrhosis is irreversible; however recently there is hope that new medicines may become available, which can stop scarring of liver.
Haemorrhage:
The blood draining the digestive system passes through the liver before joining the general circulation. If the liver is scarred, the resistance to this blood flow increases, which causes increased pressure in the blood vessels of the gullet and upper part of the stomach because the blood tries to find an alternative pathway through these blood vessels. If the pressure increases too much, these blood vessels can rupture and can cause dangerous loss of blood, which can become apparent in the form of vomiting of blood or through a black tarry stool. Any of these symptoms require urgent medical attention.

Effects on Consciousness:
One of the most important functions of the liver is to rid the blood of its waste products. If the liver is weak, these waste products accumulate in blood and have affect functions of the brain. The symptoms of this vary from weakness in memory to difficulty in speech, difficulty in concentrating, inattention and sometimes even coma. These symptoms can be controlled with treatment.

Swelling or Edema:
The weakness of the liver can also affect the water balance of the body and result in the accumulation of water around the legs and inside the tummy. The collection of water inside the tummy is called ascites.

Liver Cancer:
In longstanding cirrhosis, there is risk of liver cancer. One way to treat liver cancer is liver transplant as long as the cancer has not spread outside the liver.


Diagnosis
If hepatitis C is suspected, many tests are done. These tests can help in the diagnosis or in determining the progress of the disease and effectiveness of treatment.

Blood Tests:
Hepatitis C antibodies or anti-HCV is a blood test, which is widely available. This test measures the antibodies, which the body's immune system makes against the virus. This test is not a direct test of virus itself. In case of a positive antibody test, this test is repeated on the same blood sample and afterwards on another blood sample. A positive test would show that the person has been exposed to hepatitis C virus at some point; it does not prove the current presence of virus or infection. It can take some time for the antibody to appear in the blood after infection. This period is usually 8-12 weeks after infection, but sometimes it can take up to six months or more. Therefore, if the test is done too early, it would be negative. If your doctor considers appropriate, he can do another test, which is called a PCR test. A positive PCR test can confirm present and continuing infection.

Liver Function Tests (LFTs):
These are blood tests, which measure those substances which are released into blood circulation in case of damage to liver cells. However, they are not reliable in measuring the extent of damage to the liver and they do not confirm the presence of virus. LFTs can fluctuate during the illness. Sometimes, they can be normal but this does not mean that the liver has not been affected.

Liver Biopsy:
One way to measure the damage to the liver is taking a small sample from the liver, which is called liver biopsy. In this test, the skin is frozen with a local anesthetic and with a very fine needle a small sample is taken from inside the liver for microscopic examination. In most UK hospitals, this test is done as a day case. Therefore, the patient can go home in the evening. Usually this test causes a little bit of pain. In case of more pain, a painkiller tablet or an injection can be given. A biopsy is evaluated to assess the degree of inflammation and scarring in the liver.

Types of Hepatitis
Hepatitis C has several different types. In Britain, Europe and America, usually genotypes I, II and III are found. Pakistani patients usually have types II and III. Repeat infection can occur from different genotype and more than one genotypes can infect simultaneously. The nature of illness is not dependent on the virus genotypes. However the efficacy of treatment can be different. Genotype I is relatively more difficult to treat. Therefore usually the genotype is determined before the start of treatment in the UK. In Pakistan most people, who have hepatitis C have genotype III and, therefore, most Pakistani specialist do not consider it essential to determine the genotype before treatment. Different tests can require complex analysis, so that specialist help is required to analyze them fully. It is important to consult a Gastroenterologist or Hepatologist before treatment of hepatitis C.

Prevention
If the blood is spilt on the floor or other work surfaces, it should be cleaned with the domestic bleach without diluting it with water. Cuts and wounds on the skin should be carefully covered with a waterproof bandage. Items of personal use, for example tooth brush, razors, scissors, should not be shared. If somebody has multiple sexual partners then barrier methods of contraception should be used (condoms). Those who have Hepatitis C should refrain from donating blood. Intravenous drugs users should never share the injection gear. Hand should be washed thoroughly should they come in contact with blood whether it is one's own or somebody else's. Before handling somebody else's blood or items soiled with blood, rubber gloves should be worn. All blood donations should be screened for hepatitis C and other infections.

Treatment
At the moment, hepatitis C is treated with a combination of two drugs. This treatment is called combination therapy. In the past, only alpha interferon was used, which was much less successful.

Interferon is a man-made drug and this drug resembles the naturally occurring interferon produced by the immune system of the human body. The aim of this drug is to stop the virus from multiplying and causing more damage to the liver. A modified type of interferon called Peginterferon is now considered to be the standard treatment. It is used in combination with a tablet called Ribavirin. This combination treatment is considered a standard treatment. Overall the chance of success with the combination treatment is 55% (45% in genotype I, 80% in genotype II and III). Those people, who cannot tolerate Peginterferon, sometimes benefit from simple interferon. In Pakistan because Peginterferon is very expensive and the usually occurring genotype is type III, which is relatively easier to treat, usually simple interferon is used for treatment rather than Peginterferon. If treatment is unexpectedly unsuccessful, Peginterferon can be used afterwards. It should be remembered that treatment is not essential, suitable or beneficial in every patient and some people just need periodic examination or tests so that the possible damage to the liver can be assessed and kept under observation. There are many factors, which can figure in the success of treatment, which include age, sex, the genotype of hepatitis C, the duration of infection, the degree of damage to the liver and presence or absence of cirrhosis. Simple interferon is given three times a week through an injection. Peginterferon is given once a week for a period of 6-12 months. Usually the patients can learn to give the injection themselves. The technique is very similar to insulin injection.

Ribavirin is also a man-made drug, which is used in the treatment of different viruses. In the treatment of hepatitis C, it is always used in combination with simple or Peginterferon. Ribavirin alone is not successful in treating hepatitis C. During treatment with Ribavirin and six months after the end of treatment, it is important that men and women both use contraceptive techniques because if conception occurs during this period, the child can be affected.

Side Effects of Treatment
Simple and Peginterferon and Ribavirin can all cause unwanted side effects especially at the start of treatment, although their intensity can vary among different patients. These side effects include flu-like symptoms, tiredness, headaches, nausea, anemia and depression. There can be other side effects as well. Flu-like symptoms can be treated with paracetamol and most people start feeling better after a few weeks.

Some people, who have severe side effect cannot take the whole quantity of medication or cannot take it for the full duration of treatment. In view of these side effects, different blood tests are required during the course of treatment. It is, therefore, necessary to visit the doctor regularly so that these tests and side effects can be carefully reviewed. During treatment with these two drugs, the patient will require a lot of encouragement and support. People who are infected with hepatitis C, even if they are not being treated should stay in contact with a specialist doctor. This strategy is beneficial as the disease progress or damage can be kept under review and, if new treatments become available, a suitable treatment can be started.

Liver Transplant:
In people with cirrhosis, in case of deterioration and liver failure, liver transplant is an option, although this is a very major operation and is done only in people who are very unwell. The percentage of success is between 60-80%. The virus affects the new liver and sometimes can cause serious illness after a few years.

Complementary Treatments
For symptomatic relief, some people consider unconventional or complementary treatments in addition to the conventional treatment. There are many complementary treatments available such as massage, reflexology, aromatherapy, Tai-chi and medication. It has been seen that these treatments are helpful in trying to relieve tiredness and aches and pains and can also promote a feeling of well being and calm. The traditional Chinese medicines and herbal medicines are similar treatments.
When considering complementary therapies, it is important to bear in mind potential risks. All complementary treatments are not harmless or beneficial. It is important to ensure that complementary treatment practitioner belongs to a recognized organization and has understanding of hepatitis C.

Diet
Patients with hepatitis C often want to know whether or not they should use any special diet. For most people who are otherwise in good health, the answer is no. Like other people, they should also use a balanced diet in which everything is taken in moderation and nothing in excess. This would mean that regular meals are taken, fruits and vegetables are abundantly used, and the use of fat and sugar is reduced. In addition, most people should take two portions of foods per day, which provide good source of protein for example pistachio, almonds walnuts, meat, chicken, fish, eggs, lentils, beans, cheese, milk and dairy products. One advantage of taking a varied diet is that food will be pleasant to take and vitamins and minerals will be included. Most people who eat or are taking a good diet do not require additional vitamins. Those people who have symptoms of hepatitis C may require additional advice regarding suitable diet. In case of nausea and loss of appetite, referral to a dietitian may be helpful.

Alcohol
As far as possible, people who have hepatitis C should not use alcohol or use it only in minimal quantities. According to the advice given by the Department of Health of the UK, the maximum advisable limit of alcohol is 3-4 units for men and 2-3 units for women. This should never be exceeded. Please also see our information regarding alcohol and liver disease.



Considerations before the Test
If you are thinking of getting a test then some issues should be considered. It may be advisable to consult a professional for example a doctor, counselor or a drug worker in the UK. In addition to this in some British hospitals Nurses, who specialize in advising people with hepatitis C, can also give advice.
Insurance and Mortgage:
Most insurance companies will ask the applicants whether they have been tested for hepatitis B, C or HIV. In case of a positive result, life insurance or mortgage that is linked to life insurance can be refused or the premium can be increased. In this case, consult your doctor because many UK consultants can write to the Insurance or Mortgage Company and can advise them regarding your health and life expectancy.

Whom to take into Confidence:
This is a difficult decision. A positive result can affect the family and spouses. It is possible that affected people may want to get tested. This should borne in mind as even now there are misunderstandings in people's minds regarding this illness. There are instances that people had to leave their job or they were refused medical or dental treatment or the children received discriminatory treatment in school. It is always possible to get medical or dental treatment from another place. Simple precautionary measures can protect medical workers and near relatives.
Confidentiality:
It can be an issue for some people. Most addiction treatment services or GUM Clinics can do tests for blood borne viral diseases in confidence. However if a local GP does this test, the result will be registered and he may be required to disclose the result on certain inquiries, for example in case of medical examination for employment or insurance.

   

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