National estimates based on 1988 to 1994 NHANES indicated that African Americans which account of 12 to 13 percent of the United States population account for 22 percent of the 2.7 million people with chronic infection. From 1995 to 2001, reported HCV case incidence per 100,000 was approximately 30 percent higher among African American than among non-Hispanic whites. Prevalence as reported in the 1998-1994 NHANES showed Hispanic Americans to be 2.9 percent compared to 1.5 in non-Hispanic whites. However, the overall incidence in Hispanic Americans has decreased steadily since 1992 with incidence rates per 100,000 in 2001 being 35 percent less than that observed in non-Hispanic whites.
60%-70% have no discernible symptoms; 20%-30% might have jaundice; and 10%-20% might have non-specific symptoms (e.g., anorexia, malaise, or abdominal pain). Elevation in ALTs is evidence of liver damage The course of acute hepatitis C is variable, although elevations in serum ALT levels, often in a fluctuating pattern, are its most characteristic feature. Normalization of ALT levels might occur and suggests full recovery, but this is frequently followed by ALT elevations that indicate progression to chronic disease. People infected at a younger age and women are more likely to clear the virus. African American men appear to be least likely to clear the virus. Resolution of infection is evidenced by return of ALTs to normal level and undetectable HCV RNA
50 grams a day, 30 grams a day – 2 drinks – possible less than 10 grams a day One study – Men who drink and were infected over age 40 – 13 years median duration of progression to cirrhosis Women who did not drink and were infected under age 40 – 42 years median duration of progression to cirrhosis
Primarily large bore needles Transmission from health care worker to patient is rare.
CDC MMWR on Guidelines for laboratory testing of hepatitis C. “Persons being tested for anti-HCV are entitled to accurate and correctly interpreted test results.
Negative EIA – Not infected – Except in recently infected people and possible in immunocompromised individuals If EIA is positive and PCR is negative – Need to do another test – HCV RNA during course of infection is intermittent; a single negative PCR is not conclusive. If you have a negative PCR and a negative RIBA, there was a false positive on the EIA and the person is not infected. If you have a negative PCR and a positive RIBA, the presence of antibodies indicates either past or current infection. A single negative PCR does not rule out active infection. A positive RIBA followed by two ore more negative PCR suggests that HCV infection has been resolved and no further testing is indicated. RIBA results can also be indeterminent – anti HCV and infection status can not be determined – repeat screening test in a month or more or do NAT
Although there are both acute and chronic infections, in general clinical practice, however, acute hepatitis is uncommonly recognized; the majority of patients already have chronic hepatitis.
Fibrosis is scarring of the liver. Pathohistology – Inflammation/necrosis. There are a number of different scales for grading cirrhosis – The Metavir Scale 0 = Fibrosis, 1 Portal Fibrosis, 2 = Bridging Fibrosis, slight, 3 = bridging fibrosis, marked, 4 = cirrohsis Example: A person with genotype 1, persistently normal or slightly elevated ALTs, and minimal or no fibrosis may chose to delay treatment. An interval of 4 to 5 years between biopsies may be needed to measure a change in such patients. The presence of advanced fibrosis or cirrhosis markedly decreases response to treatment There is controversy to doing liver biopsy in all patients. Most clinicians routinely obtain a biopsy in patients with genotype 1. AASDL – After weighing the risks, benefits, and cost of existing HCV treatments and liver biopsies, most experienced clinicians routinely obtain a liver biopsy in patients with genotype 1 infection to guide recommendations for treatment. Patients with genotypes 2 and 3, however, have a high likelihood of response and therefore, some advocate treating all such patients regardless of severity of liver disease without resorting to liver biopsy. Liver biopsies may also be used to monitor progression of disease. Progress of fibrosis is non-linear. Four to five years intervals for those with mild disease? May still miss some progression. Invasive procedures – May experience pain, small number = bleeding. Death is rate. There are other laboratory tests that contribute to the monitoring of patients with HCV. There are new serum markers of fibrosis and inflammation that are currently under development. These markers are not yet able to accurately predict the severity of liver damage but they may be useful in the future
10 percent estimate – based on the assumption that there are 2.7 million persons infected with HCV and approximately 250,000 of those with HIV infection are also infected with HCV. However, 6 percent of HIV positive persons fail to developed HCV antibodies, therefore HCV RNA should be tested in HIV positive persons with unexplained liver disease who are anti-HCV negative Course of liver disease is more rapid in those co-infected. However, because factors associated with a poor treatment response (I.e., high viral load, cirrhosis, and African American race are disproportionately found in HIV infected populations, it is unclear to what extent HIV infection itself diminishes SRV rate. There are no FDA approved medications for the treatment of hepatitis C in HIV infected individuals
Hepatitis C: An Overview EIP Meeting August 12, 2005
EIA (-) No HCV (-) (-) RIBA Active HCV Infection (+) False Positive EIA No Exposure (+) (Probable) Prior HCV Infection with Recovery (+) AMA Update on the Screening and Management of Hepatitis C. Adapted From CDC Guidelines for Laboratory Testing and Result Reporting of Hepatitis C. (MMWR. 2003; 52:1-13)
EIA (-) No HCV (-) (-) RIBA Active HCV Infection (+) False Positive EIA No Exposure (Probable) Prior HCV Infection with Recovery (+ with high s/co ratio) (Probable) Prior or Active Infection (+ with low s/co ratio) (+)