What should be done for a patient with confirmed HCV infection?
HCV-positive persons should be evaluated (by referral or consultation, if appropriate) for presence of chronic liver disease, including assessment of liver function tests, evaluation for severity of liver disease and possible treatment, and determination of the need for Hepatitis A and Hepatitis B vaccination.
When might a specialist be consulted in the management of HCV-infected persons?
Any physician who manages a person with hepatitis C should be knowledgeable and current on all aspects of the care of a person with hepatitis C; this can include some internal medicine and family practice physicians as well as specialists such as infectious disease physicians, gastroenterologists, or hepatologists.
What is the treatment for acute hepatitis C?
Treatment for acute hepatitis C is similar to treatment for chronic hepatitis C. This issue was addressed in the 2009 AASLD Practice Guidance, the response rate to treatment is higher among persons with acute than with chronic HCV infection. However, the optimal treatment regimen and when it should be initiated remains uncertain.
What is the treatment for chronic hepatitis C?
Until recently, the mainstay of treatment for chronic hepatitis C virus (HCV) infection has been pegylated interferon and ribavirin, with possible addition of boceprevir (Victrelis™) and telaprevir (Incivek™) (both protease inhibitors) for HCV genotype 1 infection. After given for 24-48 weeks, this treatment resulted in a sustained virologic response (a marker for cure), defined as undetectable HCV RNA in the patient’s blood 24 weeks after the end of treatment in 50%–80% of patients (with higher SVR among persons with HCV genotypes 2 or 3 infections versus infections with HCV genotype 1, the most common genotype found in the United States).
In late 2013, The Food and Drug Administration approved two new direct acting antiviral drugs, Sofosbuvir (Sovaldi™) and Simeprevir (Olysio™) to treat chronic HCV infection. Both medications have proven efficacy when used as a component of a combination antiviral regimen to treat HCV-infected adults with compensated liver disease, cirrhosis, HIV co-infection, and hepatocellular carcinoma awaiting liver transplant. Clinical trials have shown that these new medications achieve SVR in 80%-95% of patients after 12-24 weeks of treatment.
Sofosbuvir (Sovaldi™) is a nucleotide analogue inhibitor of the hepatitis C virus (HCV) NS5B polymerase enzyme, which plays an important role in HCV replication. It is taken orally once a day at a 400-mg dose. The drug is approved for two chronic hepatitis C indications: In combination with pegylated interferon and ribavirin for treatment-naïve adults with HCV genotype 1 and 4 infections, and in combination with ribavirin for adults with HCV genotypes 2 and 3 infection. The second indication is the first approval of an interferon-free regimen for the treatment of chronic HCV infection. For more information, see prescribing information[PDF – 34 pages] .
Simeprevir (Olysio™) is a protease inhibitor that blocks a specific protein needed by the hepatitis C virus to replicate. It is to be used as a component of a combination antiviral treatment regimen of peginterferon-alfa and ribavirin for genotype 1 infections only. It is taken orally once a day at a 150-mg dose. The treatment duration is 24-48 weeks depending on prior treatment history and response to treatment. Because the efficacy of simeprevir is substantially reduced in patients infected with HCV genotype 1a with an NS3 Q80K polymorphism, screening for this mutation is strongly recommended by the manufacturer before treatment initiation. For more information, see prescribing information[PDF – 44 pages] .
For current information on approved treatments for hepatitis C, please visit the Food and Drug Administration (FDA).
How many different genotypes of HCV exist?
At least six distinct HCV genotypes (genotypes 1–6) and more than 50 subtypes have been identified. Genotype 1 is the most common HCV genotype in the United States.
Is it necessary to do viral genotyping when managing a person with chronic hepatitis C?
Yes. Because there are at least six known genotypes and more than 50 subtypes of HCV, genotype information is helpful in defining the epidemiology of hepatitis C and in making recommendations regarding treatment. Knowing the genotype can help predict the likelihood of treatment response and, in many cases, determine the duration of treatment.
- Patients with genotypes 2 and 3 are almost three times more likely than patients with genotype 1 to respond to therapy with alpha interferon or the combination of alpha interferon and ribavirin
- When using combination therapy, the recommended duration of treatment depends on the genotype. For patients with genotypes 2 and 3, a 24-week course of combination treatment is adequate, whereas for patients with genotype 1, a 48-week course is recommended.
Once the genotype is identified, it need not be tested again; genotypes do not change during the course of infection.
Can superinfection with more than one genotype of HCV occur?
Superinfection is possible if risk behaviors (e.g., injection drug use) for HCV infection continue, but it is believed to be very uncommon.
Does chronic hepatitis C affect only the liver?
A small percentage of persons with chronic HCV infection develop medical conditions due to hepatitis C that are not limited to the liver. These conditions are thought to be attributable to the body’s immune response to HCV infection. Such conditions can include:
- Diabetes mellitus, which occurs three times more frequently in HCV-infected persons
- Glomerulonephritis, a type of kidney disease caused by inflammation of the kidney
- Essential mixed cryoglobulinemia, a condition involving the presence of abnormal proteins in the blood
- Porphyria cutanea tarda, an abnormality in heme production that causes skin fragility and blistering
- Non-Hodgkins lymphoma, which might occur somewhat more frequently in HCV-infected persons
What topics should be discussed with patients who have HCV infection?
- Patients should be informed about the low but present risk for transmission with sex partners.
- Sharing personal items that might have blood on them, such as toothbrushes or razors, can pose a risk to others.
- Cuts and sores on the skin should be covered to keep from spreading infectious blood or secretions.
- Donating blood, organs, tissue, or semen can spread HCV to others.
- HCV is not spread by sneezing, hugging, holding hands, coughing, sharing eating utensils or drinking glasses, or through food or water.
- Patients may benefit from a joining support group.
What should HCV-infected persons be advised to do to protect their livers from further harm?
- HCV-positive persons should be advised to avoid alcohol because it can accelerate cirrhosis and end-stage liver disease.
- Viral hepatitis patients should also check with a health professional before taking any new prescription pills, over-the counter drugs (such as non-aspirin pain relievers), or supplements, as these can potentially damage the liver.
Should HCV-infected persons be restricted from working in certain occupations or settings?
CDC’s recommendations for prevention and control of HCV infection specify that persons should not be excluded from work, school, play, child care, or other settings on the basis of their HCV infection status. There is no evidence of HCV transmission from food handlers, teachers, or other service providers in the absence of blood-to-blood contact.
Hepatitis C and Health Care Personnel
What is the risk for HCV infection from a needlestick exposure to HCV-contaminated blood?
After a needlestick or sharps exposure to HCV-positive blood, the risk of HCV infection is approximately 1.8% (range: 0%–10%).
Other than needlesticks, do other exposures, such as splashes to the eye, pose a risk to health care personnel for HCV transmission?
Although a few cases of HCV transmission via blood splash to the eye have been reported, the risk for such transmission is expected to be very low. Avoiding occupational exposure to blood is the primary way to prevent transmission of bloodborne illnesses among health care personnel. All health care personnel should adhere to Standard Precautions . Depending on the medical procedure involved, Standard Precautions may include the appropriate use of personal protective equipment (e.g., gloves, masks, and protective eyewear).
Should HCV-infected health care personnel be restricted in their work?
There are no CDC recommendations to restrict a health care worker who is infected with HCV. The risk of transmission from an infected health care worker to a patient appears to be very low. All health care personnel, including those who are HCV positive, should follow strict aseptic technique and Standard Precautions , including appropriate hand hygiene, use of protective barriers, and safe injection practices.