Hepatitis C Flashcards
What is the sexual transmission rate of HCV in heterosexual couples
Sexual transmission is extremely unlikely in heterosexual relationships
<0.1% /10years
rate increased if the index patient is HIV +ve
What factors are associated with an increased risk of sexual transmission of HCV
HIV +ve source presence of other STIs including syphilis and LGV traumatic anal sex fisting sharing sex toys communal lubricant group sex sero-sorting use of recreational drugs
Which asymptomatic patients should be screened for Hep C in the sexual health setting
Current or past injected drug users
HIV-positive individuals
MSM eligible for three monthly HIV testing
Blood product recipient pre-1991
Needlestick injury if donor HCV + or unknown
Sexual partners of HCV positive patients
Sex workers
Tattoo / piercing / acupuncture - where infection control inadequate
Migrants from high endemic countries (SE Asia, E Europe)
Alcoholics
Ex-prisoners
Patients with persistently abnormal LFTs for >3m
What test should be used to screen for HCV
anti-HCV antibody
or combined antibody/antigen test
window period for a positive HCV test after exposure
3 months + for anti-HCV test to become positive
the HCV antigen test has a much shorter window period
How often should hepatitis C testing be offered to patients eligible for it?
at least annually
Advice for reduction of risk of Hep C
Safer sex (although low risk of transmission from sex) Safer injecting practices - incl not sharing any paraphernalia Needle exchange schemes
How often should HIV+ patients be screened for Hep C
at HIV diagnosis
and every year thereafter
How often should patients be screened for Hep C who have self-cleared or been successfully treated for Hep C
annually
Management of a patient found to have acute hepatitis C?
Reassure it is treatable
Refer to a specialist centre for assessment, monitoring
and treatment
Four-weekly HCV RNA quantitation
Consider treatment if viral load does NOT reduce by at least 2 log10 by week 4 or those who remain positive at week 12
avoid UPSI
Avoid donating blood, semen or organs
PN
Contact tracing of needle sharing partners
Contact tracing of sexual contacts if patient is also HIV+
Notifiable disease
What % of patients diagnosed with HCV clear the virus in 2 - 6 months
20% clear the virus in 2-6 months
45% of all young healthy patients will clear the virus
Of the 80% of patients who do not spontaneously clear HCV infection, what % never develop liver damage or symptoms
20%
What % of patients diagnosed with HCV will develop long term symptoms /signs of liver inflammation
up to 60%
What % of patients with HCV will develop liver cirrhosis
16% develop cirrhosis - over 20 years
What % of patients with HCV will develop liver hepatocellular carcinoma?
1 - 2 %
What factors influence HCV progression
Increased alcohol consumption
Older age
Gender - male
Co-infection with HIV or hepatitis B
Management of a patient with chronic hepatitis C?
Refer to hepatology for:
- disease monitoring
- liver cancer screening
- consideration of treatment with Directly Acting Antivirals
Contact tracing = 2 weeks before jaundice / 2 weeks before suspected time of acquisition
Advise to disclose to new sexual partners
Arrange hep C screening for children born to HCV+ women
Screen for Hep A + B + vaccinate
How does HIV infection affect response to treatment for Hep C
HIV positive patients respond to treatment with DAAs as well as HIV- negative patients
bear in mind drug-drug interactions between DAAs and antiretroviral therapy
Advice for patients with chronic Hep C regarding sexual transmission risks
Advise condom use for patients with chronic HVC
very low rates of transmission outside of HIV co- infection = HIV -ve monogamous partners may choose not to use condoms
Advise sexual contacts with HIV of the risk of sexual transmission + regular testing + encourage condom use
Advise all MSM to use condoms / gloves for fisting / single person sex toys / not share lube + avoid group sex
Management of a patient presenting as a contact of Hepatitis C
Screen for evidence of past / current HCV infection
Discuss sexual transmission - low rates of transmission outside of HIV co-infection, reduce risk with condom use
No available vaccine
No immunoglobulin preparation
What is the aetiology of Hep C
Single stranded Enveloped RNA virus in the flaviviridae family Endemic worldwide
Most (90%) due to infection with genotypes 1 and 3
Prevalence of Hep C in the UK
~1%
Prevalence of Hep C in N. Africa / Middle East
~4%
Mode of transmission of HCV in UK
Most = Parenteral
- shared needles/syringes
- transfusion of blood or blood products (pre1 990s),
- re-use of needles in healthcare / tattoos / acupuncture
- renal dialysis
- needlestick injury
- sharing a razor
- sharing straws and notes for snorting recreational drugs
Sexual transmission extremely unlikely in heterosexual relationships (<0.1% /10years)
rate increases if HIV co-infected
Vertical occurs at a low rate (about 5%)
but higher rates (7%+) if woman HIV co-infected
Risk factors for HCV
Associated factors
- presence of STIs
- HIV +ve
- traumatic anal sex
- fisting
- sharing sex toys
- communal lubricant
- group sex
- sero-sorting
- use of recreational drugs
- sex workers
- current / former prisoners
- people from highly endemic countries
- tattoo recipients
- people who inject steroids
- people who snort cocaine
- alcoholics
Incubation period for HCV
4 to 20 weeks
How long does HCV serology take to become +ve after exposure
3 months after exposure in 90% - for antibody test
can take as long as 9 months
2 weeks for HCV- RNA
Impact of HIV on the appearance of HCV antibodies
may be significantly delayed
What proportion of patients with HCV are asymptomatic
> 60%
Complications of Acute Hepatitis C
<1% - acute fulminant hepatitis
50-85% become chronic carriers
What % of patients spontaneously clear acute Hep C
What % spontatnouesly clear chronic Hep C
Spontaneous clearance = 15% of acute Hep C
Spontaneous clearance = 0.02% per year for chronic Hep C
What makes symptoms / signs of Hep C worse?
high alcohol intake
other liver disease
Complications of chronic Hepatitis C
cirrhosis (5-20% after 20 years)
hepato-cellular carcinoma (after 30 years)
acute liver failure - requiring liver transplantation
death
treatment-related hepatitis B reactivation
rheumatological complications
skin lesions include porphyria, cutanea tarda and lichen planus
cryoglobulinaemia
glomerulonephritis
keratoconjunctivitis sicca (dry eyes)
Mooren ulcer (a rapidly progressive, painful ulceration of the cornea)
Diagnosis of Acute Hep C infection
HCV- RNA positive
Anti-HCV negative
Diagnosis of chronic Hep C infection
HCV RNA assay is positive 6 months after the first positive test
Further investigations for patients diagnosed with Hep C
Screen for STIs
Assess liver fibrosis - Hepatic elastography (e.g. fibroScan)
+/- liver biopsy
Liver ultrasound
Goals of HCV treatment
cure HCV infection
reduce the progression of liver fibrosis / decompensation of cirrhosis / hepatocellular carcinoma and
extrahepatic manifestations
How is HCV cure defined
negative HCV RNA in blood 12 weeks after completion of
HCV treatment
When should treatment be considered in acute Hep C
do 4- weekly HCV RNA quantitation
Treat if there is:
< 2 log10 decline in HCV RNA at week 4
or HCV RNA remains positive at week 12,
• Patients should be referred to a specialist centre for monitoring and treatment and access to clinical trials (1A) [183, 184]. See algorithm below for the management of Acute HCV (NEAT algorithm) (1A) [184].
Effect of treatment given in acute Hep C
Treatment given during the acute phase of Hep C reduces progression and will reduce the rate of chronicity
acute phase treatment has significantly higher success rates than treatment in the chronic phase
How do direct acting antivirals work>
DAAs target HCV non-structural proteins to prevent viral replication
Current DAAs target
- NS3/4A protease inhibitors (simiprevir / ritonavir boosted ombitasvir / grazoprevir / glecaprevir)
- NS5A (ledipasvir, daclatasvir, ombitasvir, velpatasvir, elbasvir, pibrentasvir)
- NS5B inhibitors (sofosbuvir, dasabuvir).
How can vertical transmission be reduced from a HCV +ve mother
No clearly demonstrated intervention to reduce HCV transmission from mother-to-child
Ribavirin is teratogenic
Treatment of HCV in pregnancy is not recommended
Inform women of small risk of transmission in pregnancy
Breast feeding - is no firm evidence of additional risk of transmission
Advice for patients treated with ribavirin for HCV
Strict use of contraception - by both men and women
during treatment and for 6 months after
Avoid any alcohol - as little as 140 g weekly can triple the rate of cirrhosis
Paracetamol is not restricted, except in people with cirrhosis, where a maximum 2 g/day is safe
Caution when taking new drugs including OTC - may interact with antiviral therapy
Why are Interferon based regimens no longer advised for treatment of HCV
oral DAAs are now considered first-line therapy.
Up to 30% of hepatitis C-infected patients receiving interferon therapy develop major depression.
Management of a neonate born to a mother with confirmed HCV
Test baby for HCV RNA NAAT at 2-3 months of age
If reactive - reported as “Evidence of HCV infection.”
- Repeat HCV RNA NAAT at 6 months of age
If non-reactive - reported as “Infection with HCV unlikely.”
- Advise anti-HCV testing at 12-18 months of age
+ Hep B vaccination
+/- HIV testing
Factors increasing HCV vertical transmission rate
HIV-HCV co-infection = increased 3 to 4 fold
prolonged rupture of membranes
Risk of HCV transmission via breastfeeding
Rare
