Hepatitis C- an appalling human disease

By Dr. Masood Akhtar, PhD
Assistant Professor
Department of Parasitology
University of Agriculture,
Faisalabad.


Liver is a vital organ of human body having different functions. It stores iron reserves, as well as vitamins and minerals; makes bile to help digest food; detoxify poisonous chemicals, including alcohol, beer, wine, and drugs; converts food we eat into stored energy and chemicals necessary for life and growth; makes blood and clotting factors to help blood clots; manufactures new proteins; remove poisons from the air, exhaust, smoke and chemicals we breathe; manufactures and export?s important body chemicals used by the body.

Hepatitis is a disorder involving inflammation of the liver. Symptoms include loss of appetite, dark urine, fatigue, and sometimes fever. The liver may become enlarged and jaundice may occur, giving the skin a yellow tinge. Hepatitis may be acute or chronic. The acute form can subside after about two months or, rarely, can result in liver failure. Chronic carriers are at risk of lasting liver disease.

The different types of viral hepatitis are A (formerly called infectious hepatitis), B (serum hepatitis), C ( formerly called non-A, non-B hepatitis), D (delta hepatitis),
E (a virus transmitted through the feces of an infected person), cryptogenic (or nonA, nonB, nonC) and G (a virus transmitted through infected blood products). More hepatitis viruses are being discovered, but may be less common. Other viruses, such as Yellow Fever, Epstein-Barry virus, Cytomegalovirus, as well as parasites and bacteria, can cause hepatitis as a secondary effect. Other types of non-viral hepatitis are: Autoimmune, Wilson's disease, hemochromatosis, drug or chemical induced, alcoholic hepatitis.

Hepatitis C virus (HCV) is a form of hepatitis caused by an RNA virus. HCV accounts for the majority of the hepatitis cases previously referred to as non-A, non-B hepatitis. The hepatitis C virus was first identified and described in 1987, and in 1990 a hepatitis C antibody test (anti-HCV) became commercially available to help identify individuals exposed to HCV. In mid-1995 the hepatitis C virus was seen for the first time ever by scientists with the aid of an electron microscope.

HCV is a major cause of acute hepatitis and chronic liver disease, including cirrhosis and liver cancer. Globally, an estimated 170 million persons are chronically infected with HCV

and 3 to 4 million persons are newly infected each year. HCV is spread primarily by direct contact with human blood. The major causes of HCV infection worldwide are use of unscreened blood transfusions, and re-use of needles and syringes that have not been adequately sterilized.

World Health Organization estimates that about 170 million people, 3 per cent of the world?s population, are infected with HCV and are at risk of developing liver cirrhosis and/or liver cancer. The prevalence of HCV infection in some countries in Africa, the Eastern Mediterranean, South-East Asia and the Western Pacific are high compared to some countries in North America and Europe. In Pakistan, the prevalence of HCV is also very high due to high frequency of unnecessary injections with dirty equipment .

The incubation period (the amount of time that elapses between infection and the
Development of symptoms) of HCV infection before the onset of clinical symptoms ranges from 15 to 150 days. In acute infections, the most common symptoms are fatigue and jaundice; however, the majority of cases (between 60% and 70%), even those that develop chronic infection, are asymptomatic.

About 80 per cent of newly infected patients progress to develop chronic infection. Cirrhosis develops in about 10 to 20 per cent of persons with chronic infection, and liver cancer develops in 01 to 5 per cent of persons with chronic infection over a period of 20 to 30 years. Most patients suffering from liver cancer who does not have hepatitis B virus infection have evidence of HCV infection. The mechanism(s) by which HCV infection leads to liver cancers are still unknown. Hepatitis C also exacerbates the severity of underlying liver disease when it coexists with other hepatic conditions. In particular, liver disease progresses more rapidly among persons with alcoholic liver disease and HCV infection.

The HCV is neither airborne nor spread by sneezing and coughing; holding hands; kissing; using the same bathroom; eating food prepared by someone with HCV; holding a child in your arms; swimming in the same pool etc.

Anyone who received a blood transfusion or blood products before 1992 was considered to be in a high risk group. Chance of infection by transfusion today is said to be 0.12 per cent. Blood banks began screening donors for certain markers as early as 1986. Now a days, screening tests for hepatitis C came into use, and the risk is not thought to be one in 3,300 units of blood, or 0.12 per cent for the typical recipient of a transfusion. HCV acquired through blood transfusion tends to be more severe than through other modes of transmission.

Injection drug users are at high risk for contracting hepatitis B and C, and that many contract hepatitis B or C within the first year of IV drug use. Prevalence of HCV has been reported more among those who use injection drug for less than four months than among those who reported injecting drugs for 9 to 12 months.

Contaminated batches of Gammagard and Polygam, drugs used in intravenous immunoglobulin therapy, may have caused thousands across the U.S., mostly children, to contract the hepatitis C virus. Gammagard is primarily used to boost a patient's immune system. It has been documented that many women in Ireland were infected through the use of contaminated Factor D after childbirth. Those patients who received immunoglobulin therapy with Gammagard should contact their doctor immediately to have liver function tests (LFT) performed.

Physicians are not very concerned about hepatitis C transmission during birth, and many HCV positive women have given birth to children who were HCV negative. The likelihood of transmission from breast milk is also very small for HCV. Physicians do not advise against breast feeding. Neonatal transfer has been reported in 5 per cent of pregnancies, but can be as high as 25 per cent if the mother is also HIV positive.

 Japanese studies (where a much more severe HCV genotype is prevalent) showed that only 6 per cent of the babies born to HCV positive mothers contracted hepatitis C. Many showed antibodies at birth, but were clear of the virus by 18 months. This is not the case if the transmission is simultaneous with HIV or HBV infection, if the mother is infected by multiple strains. 

Mother to baby transmission of HCV may be increased if the mother is also infected with HIV (immunodeficiency virus that causes AIDS) or HBV or has a high titer of HCV in the blood. In the latter ci! rcumstances, researchers have estimated that the risk of transmission can be of the order of 10%. Full recovery from perinatal hepatitis C virus infection is rare, as chronic hepatitis generally develops even in children with prolonged intervals of remission.

Some studies have shown no risk of passing hepatitis C onto a sexual partner, others have shown only a very low risk. The United States Centers for Disease Control and Prevention (CDC) do not recommend a change in sexual practices for those engaged in a long-term relationship with one sexual partner. 

However, people with acute illness and multiple sexual partners may be at greater risk and should use condoms to reduce the risk of acquiring or transmitting hepatitis C as well as other sexually transmitted infections. The risk is increased if the HCV positive partner is immunocompromised because the virus titer in the blood may be increased under those circumstances. Sex during the menstrual period should be avoided, due to

the blood contact at that time. There is also some speculation about the possibility of transmission piggybacked on the genital herpes virus through genital lesions. The other means of acquiring hepatitis C includes health care and laboratory workers that may get stuck with an infected needle or instrument, people receiving medical/dental procedures or people that had tattoos that were performed with poorly sterilized equipment. The risk of HCV infection following a needle stick injury with HCV-contaminated blood may be as high as 10 per cent.

HCV can be spread by using something with infected blood on it such as razors, nail clippers, scissors, tweezers, tooth brushes, water pics, tattoo or body piercing needles, tampons or sanitary napkins etc. Therefore, sharing of these items is not recommended.

HCV infection is a common infection in hemodialysis units. Research reports indicate a 16 per cent prevalence rate of infection in nearly 2,500 dialysis patients without a history of blood transfusion - a rate "considerably higher" than that seen in the general population.

Alternative medical procedures involving invasive medical procedures, particularly those performed in non-medical settings, or involving autologous blood (such as the ozone-enrichment of blood) may transmit the HCV.

HCV is diagnosed serologically by detection of specific antibodies by means of the enzyme immunosorbent assay (EIA). However, false positives are common in first generation tests whereas second generation EIAs have substantially reduced false positive results. EIAs can detect more than 95% of chronically infected patients but can detect only 50% to 70% of

acute infections. Therefore, supplementary tests such as the recombinant immunoblot assay (RIBA) must be carried out when possible. RIBA identifies antibodies which react with individual HCV antigens and is often used for confirmation of a positive EIA result. Testing for HCV circulating by amplification tests RNA (e.g. polymerase chain reaction or PCR, branched DNA assay) is also being utilized for confirmation of serological results as well as for assessing the effectiveness of antiviral therapy. A positive result indicates the presence of active infection and a potential for spread of the infection and or/the development of chronic liver disease.

The importance of Liver Function tests (LFT) in the diagnosis can not be ignored. ALT(SGPT), AST(SGOT), GTT, and Alkaline Phosphatase are all enzymes produced by the liver. When liver cells are injured, the enzymes escape and enter the blood stream. ALT and AST are often used to monitor the course of chronic hepatitis and the response to treatments such as interferon. Liver enzymes fluctuate and there are many reasons why liver enzymes may increase or decrease. 

Certain medications such as aspirin or other NSAID?s such as ibuprofen can raise liver enzymes and liver inflammation. Many people with liver enzymes that are just barely elevated may be close to cirrhosis or people with high liver enzymes might have very little damage to their livers. These tests only determine the amount of liver inflammation that is happening presently but it does not determine how much damage has been done to the liver or what stage of the disease you are in. 

The only way you can find this out is ! by having a liver biopsy. Bilirubin, Albumin, and clotting factors are also the liver function tests. When cirrhosis start to develop their level may either start decreasing or increasing. Albumin is a protein. In liver disease the level of serum albumin is a good marker of liver?s ability to produce proteins. A decrease in albumin is one of the first signs of advancing liver disease. 

Clotting factors is also a protein that helps in blood clotting. When the liver is injured and doesn?t make clotting factors, plasma levels drop within one or two days. If this occurs one may bruising easily even after minor bumps or injuries. Bilirubin is the yellow pigment responsible for jaundice. Bilirubin levels rise when there is a breakdown of too many red blood cells, a defect in liver metabolism, or a blockage of the bile system. Bilirubin accumulates in tissues, which causes yellowish coloration to skin and eyes. So, instead of just focusing on the ALT?s and AST?s it is also very impo! tant, if not more important, to check on the above mentioned tests.

Antiviral drugs such as interferon taken alone or in combination with ribavirin is often suggested for treatment of HCV but the cost of treatment is very high. Interferon is injected three times a week for 12 months and ribavirin is taken daily by mouth for 12 months. The goal of treatment is to reduce replication of the virus and eventually clear the virus from the body. Treatment with interferon alone is effective in about 10 to 20 per cent of patients. Interferon combined with ribavirin is effective in about 30 to 50 per cent of patients. The response rate is lower in those co-infected with HIV. Research on alternative HCV treatment is quite active

To date no vaccine is available against HCV. Research is in progress but the high mutability of the HCV genome complicates vaccine development. Lack of knowledge of any protective immune response following HCV infection also impedes vaccine research. It is not known whether the immune system is able to eliminate the virus.

Some studies, however, have shown the presence of virus neutralizing antibodies in patients with HCV infection. In the absence of a vaccine, all precautions to prevent infection must be taken including screening and testing of blood and organ donors; virus inactivation of plasma derived products; implementation and maintenance of infection control practices in health care settings, including appropriate sterilization of medical and dental equipment; promotion of behavior change among the general public and health care workers to reduce overuse of injections and to use safe injection practices; and risk reduction counseling for persons with high-risk drug and sexual practices.