What
is hepatitis C?
The word
hepatitis means inflammation or swelling of the liver. It
can be caused by chemicals or drugs, by drinking too much
alcohol or by different kinds of viruses. There are a number
of hepatitis viruses (including A, B, C and D) but they are
all completely different from one other. They cause different
illnesses and may require different treatments.
There are
vaccines against hepatitis A virus (HAV) and hepatitis B virus
(HBV) but not against hepatitis C virus (HCV). For people
with hepatitis C, vaccination against HAV and HBV is recommended
(see What therapies exist for hepatitis C?)
When people contract
the hepatitis C virus, their bodies produce antibodies to
try to destroy it. In most cases, a person's antibodies don't
identify the hepatitis C virus properly and the infection
becomes chronic (long-term). Most people with hepatitis C
don't know that they have it because some will never experience
symptoms while for others, symptoms take an average 10-15
years to develop. Some people may have hepatitis C for 20
years or more before realising they have it.
Hepatitis C does
not always damage the liver. If a person has symptoms, they
might feel tiredness, abdominal discomfort or nausea. It is
difficult to predict what will happen for any one person.
What is a virus?
Viruses
are minute organisms capable of infecting almost all animals
and plants. There are many different kinds. Hepatitis C virus
affects only humans.
Viruses are composed
of an outer skin that encases a core structure. They cannot
exist independently and rely on genetic material 'borrowed'
from host cells for their reproduction. Viruses are so small
that it is hard to understand. HCV is estimated to be 80 nanometers
in diameter (around 30 billion would fit on this dot . ).
Where
did the hepatitis C virus come from?
It is believed
that HCV has existed for thousands of years. Before 1990,
hepatitis C used to be called non-A non-B hepatitis. Doctors
could only guess what was causing non-A non-B hepatitis until,
in 1988, using genetic engineering, scientists discovered
the virus responsible for causing the illness and called it
hepatitis C virus.
HCV can mutate or
change slightly at a rapid rate and this is believed to be
one explanation why the human antibody response does not eliminate
the infection. By the time someone's antibodies are ready
to attack the virus, it has changed slightly and the person's
antibodies have trouble recognising it.
Although it is much
easier to talk of the hepatitis C virus as if it is a single
organism, in fact it is a group of viruses, similar enough
to be called hepatitis C virus, yet different enough to be
classified into subgroups.
Genotypes
Several identifiable families of hepatitis C virus have been
observed around the world, differing slightly from each other
in their DNA sequencing (genetic make up). The most commonly
used classification system lists these families as HCV genotype
1, 2, 3, etc.
Subtypes
Within each genotype, there is further difference between
viruses - too small to be seen as a new genotype but significant
enough and measurable, thus forming HCV subtypes. These lesser
classifications are described as HCV subtype 1a or 1b, etc.
Quasispecies
Within a person's HCV subtype or subtypes, incredibly minute
differences will exist among individual viruses. The differences
are not significant enough to form a distinct subtype. Instead
they form what's known as quasispecies. It is believed that
within an HCV subtype, several million quasispecies would
exist. Scientists predict that people who have hepatitis C
have billions of actual viruses circulating within their body.
Although there may be one or two predominant subtypes, the
infection as a whole is not a single entity and is composed
of many different quasispecies.
Australian patterns:
It is estimated that in Australia, approximately:
- 35% of people with hepatitis C have
subtype 3 (mostly being 3a)
- 35% have 1a
- 15% have 1b
- 7% have subtype 2.
The remaining people
have other genotypes.
How many people
have hepatitis C ?
Around one
in every 100 people in Australia has HCV.
More than 210,000
people in Australia are estimated to have been exposed to
HCV infection. Almost half, over 90,000 people, live in NSW.
Around 16,000 new hepatitis C virus (HCV) infections are estimated
to be occurring across the nation each year and, again, almost
half of these are in NSW. Around 90% of these new infections
occur through blood-to-blood contact between people sharing
equipment used for injecting illicit drugs.
In the period, 1990
to 2001, there were over 192,000 notifications of HCV positive
diagnoses - with over 76,000 notifications in NSW. Men comprise
around 65% of the diagnoses, women 35%. Around 65% of people
diagnosed are in the age range 20-39 years but an increasing
number of people aged 15-19 are being diagnosed.
How does hepatitis
C affect people?
Hepatitis
C affects people differently. Some are not affected by it
while others can be affected seriously. Generally
speaking, it is believed that around 75% (three quarters)
of people with chronic hepatitis C will not go on to develop
cirrhosis (scarring of liver cells).
Over a 40
year period of infection, it is believed that less than 4%
(one in 25) of people with chronic hepatitis C would develop
liver failure or liver cancer.
Hepatitis C infection
involves an acute (initial) phase of infection which is usually
not noticed and lasts up to six months. During this phase,
virus levels in the blood rise dramatically until the body's
immune response starts producing antibodies. Although our
antibodies fight the virus, in three out of four cases, the
virus is not eliminated and these people are left with a chronic
(long-term) infection.
Around 45% of people
with chronic infection don't have any noticeable liver damage
or symptoms. These people remain well but their blood is infectious
and they should take care to reduce any risk of passing the
virus on to others.
After 10-15 years,
the majority of people with hepatitis C will have developed
different levels of liver damage that will result in hepatitis
C symptoms. These could include tiredness, nausea or abdominal
discomfort (in some cases, symptoms can be disabling even
though there may be only minimal liver damage).
Over a 40 year period,
chronic infection will result in cirrhosis of the liver for
around 20% of people with chronic hepatitis C. Over this 40
year period, an additional 4% of people with chronic hepatitis
C will have developed severe cirrhosis that has led to liver
failure or liver cancer (liver failure may be treated by liver
transplant although the new liver will be affected by residual
HCV in the bloodstream).
It is important
to note that hepatitis C infection doesn't always make people
feel ill. For those people who do become ill, symptoms take
a long time to develop (approximately 10 to 15 years). Symptoms
can stay at a certain level and don't always get worse. They
can come and go with no real pattern.
What does the liver do?
The liver
is one of the largest organs in the body and plays an important
role in hundreds of vital body functions.
Some of the liver's
many functions include:
- serving as an internal chemical power
plant, converting the food we eat into stored energy and
chemicals necessary for life and growth
- acting as a filter, helping remove
alcohol and other toxic substances from the body
- processing hormones, drugs and medications
so the body can use them effectively and ultimately dispose
of them
- processing and manufacturing energy and
the many chemical substances needed by the body - and "labeling"
them so that when needed, they can be sent to specific parts
of the body.
Hepatitis C and
cirrhosis
If liver
inflammation is serious enough or continues for a long period
of time, liver cells become very damaged and may develop into
scar tissue. This scar tissue is called cirrhosis. It can
be caused by many different liver diseases. In Australia the
most common causes are excess alcohol and hepatitis C infection.
A diagnosis of cirrhosis
means that liver injury has led to the build up of fibrous
scar tissue in the liver to such an extent that the microscopic
structure or "architecture" is affected. This scar tissue
affects the blood flow through the liver and the function
of the cells in the liver. Because the scar tissue affects
the microscopic structure of the liver, it can only really
be diagnosed by liver biopsy (examining a tiny sample of liver
tissue through a microscope).
It is estimated
that between 8% and 25% of people with chronic hepatitis C
will develop cirrhosis - after 20 to 40 years of infection.
Although cirrhosis is not life-threatening in itself, it means
people are at increased risk of developing liver failure or
liver cancer.
Although people
with cirrhosis are also less likely to enjoy a sustained response
with interferon and ribavirin combination therapy, the Australian
government does provide subsidised pegylated and standard
combination therapy (interferon & ribavirin), and pegylated
interferon therapy for those people who can not tolerate ribavirin.
How
is hepatitis C passed on?
Transmission
of the hepatitis C virus occurs when blood from someone with
the virus enters the bloodstream of someone else.
Sharing
or reusing other people's needles and syringes
extremely high risk
Sharing
or reusing other people's injecting equipment
very high risk
Unsterile
tattooing and body piercing
high risk
Mother to
baby, before or during birth
moderate/low risk
Health care
worker, needle-stick and sharps injury
moderate/low risk
Sharing
of razor-blades and toothbrushes
moderate/low risk
Blood transfusion
and blood products, before Feb 1990
low risk
Sexual activity
(without blood to blood contact)
very low risk
Blood transfusion
/ blood products, after Feb 1990
extremely low risk
Breastfeeding
extremely low risk
Sharing
injecting drug equipment
This is the most common way of transmitting HCV in Australia.
The highest risk comes from sharing needles and syringes (fits)
but all injecting equipment can potentially spread HCV, including
spoons, filters, water, tourniquets and swabs. Blood on fingers
and work surfaces also involves transmission risks. Although
it is safer to inject in the company of other people due to
the risk of drug overdose, sharing any equipment is likely
to lead to transmission of hepatitis C and other viruses.
People who are already infected can become reinfected with
different genotypes (strains) of hepatitis C and experience
another initial acute stage of infection. Because of the many
possible risk factors involved with injecting drug use, some
experts believe the safest way of taking drugs is to smoke,
drink or eat them. (Also see Injecting drug use and hepatitis
C).
Unsterile
tattooing and body piercing
Tattooing and body piercing are not always carried out under
sterile conditions. People should make sure that their tattooist
or body piercer uses standard infection control practices.
In choosing their tattoo or body piercing studio, people should
look for clean hygienic premises (such as benches, sinks and
other work areas). They should ask the tattooist whether they
use new needles each time and if they reuse needles, ask how
they are sterilised. Ideally, people should be able to watch
someone else being tattooed. While watching, potential customers
can observe whether new disposable gloves are worn for each
client, whether the tattooing equipment that is used comes
from sterile containers or bags, whether the tattooist opens
prepackaged sterile equipment in front of clients, whether
they use small separate containers of ink for each client
instead of dipping into one big container that many clients
would use and whether the tattooist explains everything to
the customer.
Blood banks
Blood banks began testing for hepatitis C virus once tests
became available in 1990. Before that, blood transfusions
and blood products carried some risk and up to 10% of people
with hepatitis C are believed to have contracted HCV through
the blood supply. Blood banks now test all donated blood and
the risk of HCV transmission through donated blood is extremely
low; less than a one in 100,000 risk.
Mother to
baby (vertical) transmission
Less than 10% of babies born to mothers with HCV actually
acquire the virus.
If a baby born to
a hepatitis C positive mother is tested at birth for hepatitis
C antibodies, the test will come back positive. This is because
the baby has its mother's antibodies, which clear naturally
over a period of months. A PCR blood test done at 4-6 weeks
will indicate whether the baby has contracted the virus, as
would an antibody blood test done at 18 months. Mothers who
contract HCV during pregnancy, or those with serious liver
damage may have a higher risk of transmitting the virus.
There is believed
to be practically no transmission risk for expectant mothers
who test PCR negative (see PCR test information, below). Overall,
the risk of vertical transmission is low and the outlook for
babies who do contract HCV is believed to be similar to that
for adults with HCV.
It is recommended
that babies born to HCV positive mothers are not antibody
tested but are given PCR tests as this can avoid months of
possible distress for the parents (see Antibody and PCR testing
information, below).
Occupational
transmission
Usually related to health care workplace, occupational transmission
can occur through needle-stick (or sharps) injuries but it
is uncommon. With needle-stick injuries involving hepatitis
C infected blood, the risk is believed to be 4% (four in every
100 such incidents). With needle-stick injuries involving
hepatitis B infected blood, the risk is believed to be 30%
(30 in 100) and for HIV the risk is estimated at 0.4% (four
in 1000). To minimise the risk of such viral infections, health
care workers are advised to practice standard infection control
precautions.
Household
transmission
This is rare and could only occur where blood-to-blood contact
happens. This might involve one person's blood spill coming
into contact with someone else's open cut. To a lesser extent,
transmission may occur through the sharing of razor blades,
toothbrushes and sharp personal grooming aids - and it is
advisable that people keep these utensils separate among household
members. To help prevent transmission of a range of bloodborne
communicable diseases in the home, all people should wear
gloves when administering first aid or cleaning up blood and
body fluid spills.
First Aid
Precautions
The skin is our first line of defence against infection. People
should make sure they have no uncovered cuts, abrasions or
dermatitis. Rubber gloves should be worn when dealing with
blood or other body fluids. Disposable materials (eg. paper
towel) should be used when cleaning up blood or other body
fluid spills or splashes. Any surfaces which have had blood
or other body fluid spills or splashes should be cleaned with
detergent and water. If contact does occur, people should
wash the blood or body fluid away as soon as possible, preferably
with soap and water; if necessary, rinse away from the eyes,
nose and mouth with plenty of water. Injuries such as cuts
and needle sticks should be washed with normal saline or soapy
water, encouraged to bleed and then covered using a waterproof
dressing. In the workplace, any accidental exposure should
be reported to the relevant workplace policy.
Sexual transmission
Sexual transmission of hepatitis C is very uncommon. If it
happens, it is believed to be as a result of blood-to-blood
contact during sex. If people have any medical condition that
involves scratching, sores or blisters in the genital region,
the possibility of blood-to-blood contact and transmission
during sex is increased. When one partner is hepatitis C positive,
couples need to reassess their sexual practices to exclude
the risk of blood-to-blood contact during sex. Using condoms
and dams when a female partner is menstruating or when having
anal sex is recommended. It is also advisable to use a water-based
lubricant to avoid condom breakage or skin abrasion during
sex. Risk of sexual transmission is thought to be influenced
by a person's viral load (amount of virus in the blood). The
risk of transmitting hepatitis C sexually is possibly increased
during the initial acute phase of infection which lasts up
to six months after catching the virus. Overall, sexually
active people should consider the benefits of safe sex in
regard to the wide range of sexually transmissible diseases.
Breastfeeding
The hepatitis C virus has not been found in samples of breast
milk taken from hepatitis C positive women. Transmission via
breast milk has not been shown to occur. There are many advantages
to breastfeeding for the mother and baby, and the choice to
breast feed or not should be left up to parents. Breastfeeding
mothers should check their nipples before each feed and avoid
breastfeeding if they are cracked or bleeding.
Blood &
organ donation
People with hepatitis C must not donate blood or organs -
except in the case of livers. People who are on the liver
transplant waiting list can use hepatitis C infected livers
as long as the donated liver is in reasonable condition. Most
people with hepatitis C do not have serious liver damage and
are considered viable donors.
Vaccination?
Currently, there is no vaccine or immunisation to protect
people against HCV infection.
Who should have
the HCV test?
- People who have had blood transfusions
or blood products before February 1990
- People who have ever injected drugs
(including steroids)
- People who have tattoos
- People with body piercing
- People who have ever had a needle-stick
injury
- People with abnormal liver function
tests or who are
- experiencing hepatitis C like symptoms
but have no apparent cause
- Health care workers who perform exposure
prone procedures.
How
is hepatitis C diagnosed?
Screening
tests for hepatitis C virus are called HCV antibody tests.
These tests do not look for the virus itself, but look for
HCV antibodies (defence cells which the human body produces
to fight HCV). A positive test result implies that someone
has an HCV infection or has had one in the past. If the test
result is unclear it is repeated and, if necessary, other
types of blood tests are done.
Antibody
tests
These indicate whether a person has had an HCV infection but
cannot determine whether or not someone currently has the
virus or how long they might have had hepatitis C.
After contracting
the virus, it can take up to six months before the body seroconverts
(starts producing antibodies). During this time someone is
said to be in the window period. If they are experiencing
an active HCV infection they could still return a negative
antibody test.
People who return
a positive result but have no risk history should be advised
to have the test redone.
HCV antibody tests
are free if people take their Medicare card to a doctor who
bulk bills. As with all test results, people are advised to
ask for photocopies of the written test results. Should someone
change doctors or want to get a second opinion, they then
have their own records to show to other doctors or specialists.
HCV counselling
services
These are also known as pre- and post-test counselling, are
generally provided by a GP and have three main aims:
- to provide information and support
during what may be a period of considerable anxiety
- to help ensure good management and
treatment
- to help prevent possible transmission of
the virus.
With HCV counselling,
doctors should briefly discuss: reasons for having a test
done, the history of HCV, implication of test results (negative
or positive), routes of transmission, general outcome of infection,
treatment options, self-management strategies, implications
for life assurance and confidentiality. Doctors should also
check if people have adequate emotional support in case of
a positive test result. Doctors should provide all the information
that allows a person to make their own decision whether or
not to be tested. They should also be able to refer people
to counselling services and/or community support services.
What is a PCR test?
PCR tests
detect or measure the actual hepatitis C virus in a sample
of blood. They can tell if someone has hepatitis C virus or
just has antibodies from a past infection. There are three
types of PCR test - viral detection, viral load and viral
genotype. Each test provides different information about a
person's hepatitis C infection.
PCR stands for polymerase
chain reaction. The development of these tests over the last
few years is now being seen as a major advance in regard to
both clinical assessment of people with hepatitis C and the
monitoring of treatments. These tests assist people to:
- Determine whether they may have cleared
the virus (but still have antibodies)
- Determine their level of infectivity
- Confirm inconclusive hepatitis C
antibody test results
- Assess their response to treatment.
PCR viral
detection test
Sometimes called the "qualitative test", the PCR viral detection
test is mainly used as a confirmatory test when an antibody
test result is inconclusive. It is also used 4-6 weeks following
a risk incident, within the six month window period when antibody
tests may be unreliable, to check if someone might have contracted
HCV. The test can also be used to determine whether someone
is infectious when they have consistently normal liver function
tests. The PCR viral detection test can also be used by HCV
positive pregnant women to determine the chance of them transmitting
HCV to their child. If a mother is PCR positive, there is
up to a one in 10 chance of her baby being born with the virus.
If a mother is PCR negative, the risk of HCV transmission
to her baby is negligible.
PCR viral
load test
Sometimes called the "quantitative test", this PCR test measures
the amount of HCV circulating in someone's blood. Measuring
the level of virus in someone's blood before treatment can
help determine whether a 6 or 12 month treatment regime is
preferable. It is also believed that PCR viral load testing
as early as 2-4 weeks into treatment will identify people
who wouldn't respond over the full 12 months treatment period.
PCR viral
genotype test
PCR genotype tests can determine what HCV genotype and subtype
a person has. This may be useful information as it has been
shown that people who have particular genotypes generally
respond better to drug treatment. People who are keen for
treatment may not worry too much about PCR genotyping. For
others who aren't sure whether to try the treatment or not,
the PCR genotype test could help guide their decision (see
What therapies exist for treating hepatitis C?).
Availability
- basic viral detection test
The basic PCR viral detection test is covered under the Medicare
Benefits Schedule (under item no. 69444) for use in certain
circumstances:
- people who have had a positive HCV
antibody test and who have normal liver function test results
on two occasions six months apart, or
- people who have inconclusive HCV
antibody test results, or
- people who have weakened immune systems
(eg. HIV/AIDS) and want to confirm whether they are hepatitis
C positive or not, or
- detecting acute hepatitis C, prior to seroconversion
(production of antibodies), in those people who have signs
of acute hepatitis yet other causes have been excluded (eg.
HAV or HBV).
PCR testing is made
available in these cases (one test annually per person) where
this information is considered necessary for the clinical
management of the person's hepatitis.
Availability
- viral genotype & viral load tests
All three PCR tests are covered under the Medicare Benefits
Schedule (see Item numbers below) for use under certain circumstances.
The requests for these monitoring tests are limited to treating
specialists and are for people with confirmed hepatitis C
(by antibody or previous PCR) who may undertake antiviral
therapy depending on the result of testing.
These additional
funded access arrangements allow for:
- One PCR viral load test prior to
therapy (Item no. 69442) should someone decide to proceed
with interferon or combination therapy (one test annually
per person)
- One PCR genotype test (Item no. 69443)
- when initially considering treatment options
- Up to four PCR viral detection tests (Item
no. 69445) prior to and over a 12 month treatment/follow
up period - to help monitor treatment response.
The maximum number
of PCR viral detection tests for any course of treatment is
four, including any provided under Item 69444 (see above).
Important
note
PCR tests look for virus in the blood. Levels of virus in
people's blood can fluctuate and, at times, the level of virus
in someone's blood might be too low for the PCR test to detect
it. Therefore, a negative PCR test result may not always mean
that a hepatitis C antibody positive person doesn't have hepatitis
C. It may only mean that the test couldn't detect the virus
in that particular sample of blood. For this reason, people
should rely on a series of at least two PCR tests done over
a 4-6 month period, rather than a single PCR test.
How can someone
tell what's happening to their liver?
Liver function
tests are used to measure the general condition of the liver.
These blood tests give useful information but for a more accurate
indication of the condition of the liver, a liver biopsy would
be required.
Liver function tests
measure levels of particular enzymes or proteins in a person's
blood. If liver cells are damaged, increased levels of these
substances "leak out" into the bloodstream and show up as
raised or abnormal results in liver function tests. The tests
provide only a rough indication of possible liver damage.
ALT is the most commonly monitored enzyme in liver function
tests. Because of differences in laboratory technology, 'normal
ranges' quoted by laboratories may differ. When comparing
ALT results from different laboratories, the ALT result should
be stated against the normal upper range quoted by each lab
on the test result (eg. 70/50, meaning an ALT of 70 compared
to the laboratory's normal upper range of 50).
A doctor can offer
ongoing evaluation of people's condition by interpreting differences
in their liver function test results over time, and whether
or not they have physical symptoms or signs of liver disease.
Liver function tests may be suggested monthly or up to once
per year depending on a person's condition and whether they
have been recently diagnosed.
Liver function tests
do not provide conclusive evidence of what is happening in
the liver. Some people may feel quite ill yet have little
liver damage. For other people, damage may be occurring even
when liver enzyme levels are normal. It is important to remember
that raised liver function test results may be caused by medical
conditions other than HCV. In cases where ALT readings are
consistently high for a long time, where they fluctuate greatly
or when readings don't seem to match with how a person feels,
a specialist may suggest a liver biopsy be done. Some doctors
recommend a routine liver biopsy after 15 years of infection
and then every five years thereafter.
What
is a liver biopsy?
A liver
biopsy provides the most accurate report on the condition
of someone's liver. Using a special instrument, a specialist
doctor takes a small sample which is then examined under a
microscope. The actual biopsy takes about one second. People
usually remain at hospital after the biopsy for at least six
hours or even overnight.
Ultrasound and other
x-rays can indicate certain liver-related abnormalities but
have difficulty distinguishing cirrhosis from other conditions
such as fat accumulation in the liver. This is particularly
true in early cirrhosis. The diagnosis of cirrhosis can only
really be made by liver biopsy.
The presence or
absence of cirrhosis is only part of the information available
from liver biopsy. Apart from showing the amount of scar tissue
(an indication of what has happened to the liver in the past),
liver biopsies also show how active the hepatitis C is now,
and if there are other factors interacting with the hepatitis
C to damage the liver. These other factors include excess
alcohol, iron accumulation in the liver or evidence of autoimmune
disease (when the body's own immune system attacks liver cells).
After the skin is
sterilised and an injection of local anaesthetic given, a
special instrument passes a needle between the ribs into the
liver. A small sample is taken for microscopic examination.
Sometimes doctors may do the procedure using an ultrasound
machine to guide them. People with blood clotting disorders
may be advised not to have the procedure because of the risk
of internal bleeding.
Some people experience
pain during the procedure while others don't even realise
it has been done. Local anaesthetic is always used but if
anyone is especially concerned about pain or especially anxious,
they should ask for some medications for pain and to help
calm them down. After the procedure, people are asked to lie
still for several hours. It's a good idea to take a favourite
book or music (don't forget the headphones).
A week or two later,
people are given results to take back to their GP. It's a
good idea to ask for a photocopy in order to keep a set of
personal records. Some doctors recommend a routine liver biopsy
after 10 to 15 years of infection and every five years thereafter.
About one in every 300 people who have a liver biopsy could
have a serious complication such as bleeding from the surface
of the liver. This would usually mean staying in hospital
for a day or two and may require an operation, although this
is rare. About one in every 1000 people who have a liver biopsy
could experience more serious complications. Although certain
risks exist, they need to be balanced against the benefits
of more precise knowledge of what is happening in the liver.
Liver biopsies are
not recommended lightly. Because of the relatively low, but
none the less real risk associated, the final decision to
proceed with biopsy should be made by the individual person.
Anyone interested should discuss the procedure and possible
risks with their doctor.
Is biopsy
an accurate guide to what is happening in the whole liver?
A liver biopsy sample is just a tiny piece of the liver but
a properly taken sample is generally representative of changes
throughout the liver. Hepatitis C affects the whole liver
and although there may be some variation within the liver,
this would be a minor, rather than major, variation.
How do doctors
make sense of a biopsy result?
A doctor will usually explore two major issues in looking
at the liver biopsy:
Firstly, are the
features consistent with HCV as the cause of the liver test
abnormalities? ie. are there other liver illnesses present?
Secondly, if the
biopsy is consistent with HCV, then how badly is the liver
damaged? Using the Scheuer Score model, this can be estimated
by studying three main parameters:
- the amount of portal inflammation
- this is the inflammation around liver cells, bile ducts
and veins in parts of the liver
- the amount of lobular inflammation - this
is the amount of inflammation in separate lobules (the left,
right and smaller subdivisions of the liver)
- the amount of fibrosis - this is an early
stage in the development of liver cell scarring (cirrhosis).
These three features
may be given scores of 0-4, where four is the worst scenario.
Thus the overall biopsy may be scored out of 12. The first
two parameters (portal and lobular inflammation) are often
called the grade of liver damage whilst fibrosis may be referred
to as the stage of liver damage.
It is the stage
of liver damage that can give an idea of the chances of progression
to cirrhosis over the next 10 years or so. Stage 4 fibrosis
is already cirrhosis, whilst stage 1 fibrosis may possibly
only progress to stage 2 over 10 to 20 years.
A similar liver
biopsy grading, the Metavir Score, is used within prescribing
guidelines for government subsidised S100 combination therapy,
although Australian clinicians most commonly use the Scheuer
score (above).
What
therapies exist for treating hepatitis C?
The best
course of treatment currently available involves a combination
of two drugs: pegylated interferon and ribavirin.
Current
government subsidised treatment involves pegylated combination
therapy. Conditions apply to both this treatment (see below).
People wanting
to access drug treatment outside of the government subsidised
scheme can purchase treatment drugs at full price or may be
able to access them through industry-sponsored Special Access
Schemes (see Alternative access to treatment).
Some people
with hepatitis C use complementary or alternative treatments
to counter symptoms of hepatitis C. For example, traditional
Chinese medicine which includes a mixture of acupuncture or
Chinese herbs or both; homeopathy and herbalism. If people
decide to try alternative therapies, it is important they
see a qualified natural therapies practitioner.
Whatever
treatment choice is made, it is important that people find
out as much as possible about the different options. Natural
or complementary therapists should work alongside GPs who
can monitor progress and possible side effects.
Many doctors
advise people with hepatitis C to have the hepatitis A and
B vaccinations. Although the viruses are unrelated, such vaccinations
will help prevent possible additional liver complications
caused by having more than one viral infection at the same
time.
Antiviral
drug therapies for treating hepatitis C
The best course of therapy currently available involves a
combination of two drugs: pegylated interferon and ribavirin.
Interferon is a natural substance made by the body to help
defend itself against infection. Synthetically manufactured
interferon in large doses can help reduce the amount of hepatitis
C virus in the body and slow down the disease process. Pegylated
interferon has an altered molecular structure which ensures
it remains circulating in the bloodstream for a much longer
period of time compared to standard unpegylated interferon.
Thus, pegylated combination therapy involves a once-weekly
injection instead of three-times-a-week injections for standard
interferon.
Ribavirin is a drug which helps to cut down the rate of hepatitis
C virus (HCV) replication. With HCV, it has been shown to
work best in combination with pegylated interferon rather
than as a therapy on its own.
The Australian government offers subsidised anti-viral therapy
to people fulfilling certain criteria.
While not a criteria for access to subsidised HCV S100 treatment,
liver biopsy is the most accurate report on the condition
of a person’s liver and is often recommended by specialists.
People wanting to access anti-viral drug therapy outside of
the government subsidised scheme can purchase anti-viral therapy
at full price or may be able to access them through industry-sponsored
compassionate-use schemes (see Alternative access to treatment).
Peg combo therapy
The currently preferred therapy for hepatitis C involves a
combination of once-weekly injections of pegylated interferon
and twice-daily ribavirin tablets marketed under the names
“Pegatron” and “Pegasys RBV”. The
cure rate for pegylated combination therapy is related to
a person’s hepatitis C genotype.
People with HCV genotype 1 or 4 are given 48 weeks of
therapy and have a 50% (approx) chance of cure.
People with HCV genotypes 2 or 3 are generally given 24 weeks
of therapy and have an 80% (approx) chance of cure.
In hepatitis C terms, the word “cure” is defined
as clearing the hepatitis C virus from the body. GPs and specialists
often refer to this as a sustained viral response (SVR)
To define whether
a person has cleared the virus, PCR blood tests are done at
the end of therapy and then repeated six month later. If both
tests return a negative result, the person is deemed to have
cleared their hepatitis C infection and..
is no longer infectious (has no risk of transmitting
the virus)
is not likely to experience further liver damage
is likely to see an improvement in liver condition,
and
is likely to experience a reduction in symptoms.
Even where people
may successfully clear the virus, their past chronic hepatitis
C infection may have caused liver damage (eg. cirrhosis) which
will remain. Some of these people will have a gradual reversal
of liver damage and symptoms associated with hepatitis C may
improve. People with cirrhosis should seek specialist advice
about medical follow-up and managing their liver damage. If
cirrhosis is present, there is still a small ongoing risk
of liver cancer.
Subsidised therapy is available to people who satisfy a range
of conditions (called S100 criteria). The criteria change
from time to time and are becoming more relaxed. Additionally,
there has been an increase in the number of clinics offering
treatment. It is advisable to check for the most up-to-date
listing of criteria and treatment centres by phoning the Hep
C Helpline.
After successful anti-viral therapy, people do not have immunity
and can get reinfected with hepatitis C, so it is important
to avoid blood-to-blood contact with other people. Additionally,
people who have cleared HCV will continue to manufacture antibodies
and will continue to return positive results to the HCV antibody
test. This does not mean you still have the virus, it simply
shows that you had a recent past infection. To confirm HCV
infection or clearance of the virus, a PCR test needs to be
performed rather than an antibody test.
Anti-viral therapy side effects
Most people undergoing therapy experience some level of side
effects. The most common side effects are flu-like symptoms
such as chills, fever, malaise, muscle pain, and loss of appetite.
Other common side effects include depression, sleep disturbance,
tingling or crawling of the skin, impaired concentration and
cognitive dysfunction such as memory loss, apathy, and a slowing
down of mental processes.
The most common side effect of ribavirin is anaemia. People’s
blood counts are monitored closely, especially in the first
few weeks. The ribavirin dose may be lowered if necessary.
Nearly everyone experiences some level of side effects at
first although for most people, side effects do settle down
and lessen. In many cases, they can be managed by adjusting
dosing or prescription of additional medication. Very few
people have to stop taking therapy early because of side effects.
It is important to note that management of some side effects
has improved significantly over the last couple of years.
Over 90% of people now complete their therapy.
Improved management of side effects has allowed therapy to
become available to people who may have been previously excluded.
It is important to speak to your treating doctor or nurse
about any side effects when they occur, as they will most
likely be able to help you manage them better or help reduce
them.
More information on side effects can be found in the factsheet,
‘Side effects of antiviral drug therapy’.
S100 treatment co-payments
Although S100 drugs are free, a monthly administrative co-payment
is required. The level of co-payment ranges from $3 to approximately
$25 and depends on whether someone is attending a private
or public treatment centre, and whether they are a health
care or seniors card holder, pensioner or war service veteran.
Alternative access to treatment
People wanting to access interferon-based therapy outside
of the government subsidised S100 scheme can purchase treatment
drugs at full price through a specialist or seek access through
industry-sponsored compassionate-use schemes. For more information,
people should contact their nearest treatment centre.
Assessing/monitoring therapy
Because of possible side effects, close monitoring is required.
This includes regular return visits to the treatment centre
or to a doctor for blood tests and general assessment. PCR
testing is an important part of treatment monitoring and involves
blood tests that look for the actual virus. These tests play
a major role in regard to clinical assessment for therapy
and ongoing monitoring of therapy.
PCR viral detection tests. These tests are sometimes called
“qualitative testing” and simply show if the hepatitis
C virus is present in the blood. They are used during therapy
to help monitor whether interferon therapy is working well
or not.
PCR genotype testing. These tests are used before therapy
to determine what “type” of hepatitis C virus
a person has. A person’s HCV genotype helps determine
their chance of being cured.
PCR viral load tests. These tests are sometimes called “quantitative
testing” and measure the amount of hepatitis C virus
circulating in someone’s blood. They are used for monitoring
response to therapy. PCR viral load tests can also help in
determining the likelihood of response to therapy, particularly
in regard to people with genotype 1.
After therapy
Following successful therapy, it is important that people
avoid further infection risk and have follow up visits at
six months and one year with their GP.
After successful
anti-viral therapy, people do not have immunity and can get
reinfected with hepatitis C, so it is important to avoid blood-to-blood
contact with other people. Additionally, they will continue
to manufacture antibodies and will continue to return positive
results to the HCV antibody test.
People who do not respond to therapy or relapse after therapy
(those who do not clear the virus and are not cured) should
maintain regular follow up visits with their GP. Further developments
in hepatitis C therapies occur over time, especially in regard
to experimental trials of new drugs and combinations of drugs.
Complementary
therapies
To date, there have been few HCV research trials in Australia
to check the effectiveness of complementary therapies,
also known as natural or alternative therapies.
Good results have been reported by some people using complementary
therapies but others have found no observable benefits. Some
people may choose complementary therapies as a first or a
last resort. Others may not use them at all. Some may use
them together with pharmaceutical drug treatments. Whatever
people choose, they should be fully informed. It's advisable
that people ask searching questions of the practitioner they
go to:
- How has their therapy helped people with
hepatitis C?
- Is the treatment dangerous if you get the
prescription wrong?
- What are the side effects?
- Is the practitioner a member of a recognised
complementary therapies organisation?
- How much experience have they had of working
with people with hepatitis C?
- How have they measured the health outcomes
of their therapy?
- How do they aim to help?
People have the
right to ask any question of any health practitioner and expect
a satisfactory answer. If not satisfied, a person should consider
shopping around until they feel comfortable with a practitioner.
A Medicare rebate cannot be claimed when visiting a complementary
therapist. Some private health insurance schemes cover some
complementary therapies. It pays to ask a therapist about
costs and payment before visiting them.
As with any treatment,
wrongly prescribed medicines can be harmful - some can even
damage the liver. If deciding to use complementary therapies,
it's vital that people see a practitioner who is properly
qualified. It is also advisable for people to talk to their
medical doctor or specialist and complementary therapist about
the treatment options under consideration - and it's best
if they are all able to consult directly with one another.
It's also important for someone to continue having their health
monitored by a GP. If a complementary therapist suggests that
someone stops seeing their medical specialist or doctor, or
stop a course of pharmaceutical medicine, the person should
consider changing their therapist.
What is meant
by the term, response?
Response can have several different meanings in regard
to treatment.
Non response
No significant reduction in viral load after 12 weeks of treatment.
End of treatment
response
Measurement values (ALT, PCR, etc.) at the end of a treatment
period.
Sustained
response
A sustained response is where no presence of the virus can
be detected immediately after therapy, and for six months
afterwards. Recent research shows that 99% of these people
maintain their viral clearance for at least fours years and
it is believed their response will last indefinitely.
It is also becoming
clear that the majority of people who experience a sustained
response will enjoy a reversal of their underlying liver damage,
even from the stage of cirrhosis.
Self-management
People with
hepatitis C should consider the following self-management
actions:
- Stop drinking alcohol or cut down alcohol intake
- Consider having hepatitis A and hepatitis B vaccinations
(see treatments section)
- Eat a well-balanced diet to help maintain good health
- Learn how to manage stress, rest when feeling unwell and
seek counselling if needed
- When taking prescription or over-the-counter drugs, check
with a GP and follow the directions carefully
- Lessen stress levels by talking to close friends or close
family members about their feelings or problems
- If injecting drugs, use safer injecting methods (see Harm
reduction).
As with any chronic
disease, maintaining physical and psychological health will
help people cope with any symptoms and illness. Controlling
alcohol use, eating a healthy balanced diet, sensible exercise,
managing stress, discussing and sharing emotions, getting
adequate rest and giving up smoking will all help to keep
a person as healthy as possible. Although there is no proven
link between diet and progression of hepatitis C, some people
with the condition do report feeling better when they avoid
particular foods (eg. fatty or highly spiced).
Alcohol
The risk of developing cirrhosis appears to be higher for
people with HCV if they also are heavy drinkers (see definition,
below). A reduction in alcohol intake should be the first
step in any attempt to reduce the possible risk of serious
liver damage. This is also an important step before considering
treatment options.
Alcohol
recommendations
Generally speaking, people who have hepatitis C would benefit
from cutting out alcohol use altogether, or reducing it in
line with the specific guidelines that have been developed
by the Commonwealth Department of Health and Ageing (for people
with health conditions including hepatitis C): guideline
4.
Alcohol
tips
People who find it difficult managing their alcohol intake
should seek advice from the Alcohol & Drug Information
Service (phone 9361 8000 or 1800 422 599). The following tips
may also be useful:
- Try low alcohol drinks
- Alternate non-alcoholic drinks with alcoholic
ones
- Avoid places where there may be pressure
to drink heavily
- Avoid drinking in rounds by purchasing
own drinks
- To keep track of how many have been consumed,
finish each drink before the next.
Heavy drinkers
When we use this term we are referring to people who regularly
drink more than five standard drinks in a day, and who regularly
have less than two alcohol-free days per week.
Standard
drink
This is the equivalent of one middy of full strength beer,
one standard glass of wine or one nip of spirits. For further
information, see the Commonwealth Department of Health and
Ageing's standard
drink guide.
Prescribed
medications
Some prescribed and over-the-counter medications can be harmful
to the liver if taken in high doses or for too long. It is
therefore important for people to consult a GP or pharmacist
about their current or any proposed medications, and follow
the directions. People with serious liver disease (ie. cirrhosis)
should consult a specialist about all medications.
Hepatitis
C and diet
It is common for
people with hepatitis C to worry about what they eat and whether
their diet affects their liver. Generally speaking, there
are no particular foods that people need to avoid or seek
out, aside from avoiding certain herbs and plants that can
cause liver damage.
This pamphlet provides a brief introduction to healthy eating
for people with hepatitis C who do not have serious liver
damage. It is meant to complement more detailed information
resources which are listed in “ Further nutritional information.
” If you are unsure about whether you need specialised dietary
advice, please speak to your doctor.
The role of the liver
The liver is one of the most important organs of your body.
It is the factory that converts raw materials from your digestive
system into substances that your body needs. It detoxifies
harmful substances such as alcohol and helps remove waste
products. The liver also makes bile which helps in the digestion
and absorption of fats.
What HCV does to your liver
The hepatitis C virus (HCV) often causes damage to people's
livers, although many with hepatitis C remain quite well.
Even if someone's liver is not significantly damaged they
may still feel tired or ill. This may be due to the way the
human body fights HCV.
Healthy eating & lifestyle
Healthy eating is important as you generally feel better when
you eat well. Healthy eating involves choosing a variety of
foods. In the right balance, these foods will meet your body's
need for energy, growth and repair. To get a good daily intake
of vitamins and minerals you need to eat some food from all
the food groups every day, varying your choices from day to
day.
Exercise may also make you feel better and improve your appetite.
You don't have to take it seriously, only regularly. Over
consuming alcohol or other drugs can disrupt your day-to-day
eating patterns and this may have a negative impact on your
health.
Hepatitis C and body weight
Evidence is mounting that excess body fat contributes to liver
disease (as well as cardiovascular disease). People with HCV
are advised to avoid becoming overweight.
The best way to manage your weight is a long term approach
of increasing the exercise you do along with maintaining a
lower-fat high-fibre diet. Avoid rapid weight loss as this
can be damaging to the liver. Contact a dietitian to discuss
the best strategy for you.
Alcohol & HCV
The risk of developing cirrhosis is higher for people with
HCV if they also are heavy drinkers (for more information,
contact the NSW Hep C Helpline or speak to your doctor). A
reduction in alcohol intake should be the first step in any
attempt to reduce the possible risk of serious liver damage.
Fats & HCV
You don't need to cut out all fats and oils just because you
have hepatitis C - everybody needs some fats to make hormones
and for body cells to function properly. But many people in
Australia eat too much fat which is a risk factor for heart
disease, diabetes and becoming overweight. People are generally
advised to eat less fat.
If you feel sick or nauseous (ie. feel like vomiting) and
find that fatty food doesn't agree with you, try avoiding
such foods while you feel nauseous. Reintroduce individual
foods gradually to see which ones cause the problem.
Dairy foods
Dairy foods are an excellent source of essential nutrients.
It is hard to get enough calcium if you exclude milk products
from your diet. Some dairy foods contain high levels of fat
and if you want to reduce your fat intake, choose reduced-fat
dairy products or calcium-enriched soy milk products.
Red meat
Lean red meat is a valuable source of iron, protein and B
group vitamins. There is no published scientific evidence
to suggest that people with hepatitis C are adversely affected
by eating red meat.
Sugar
We are born with a strong liking for sweet tasting foods.
Although sugar is a source of energy (calories, kilojoules),
it is better to obtain your energy from nutrient rich foods
such as wholegrain breads and cereals, meats, fruits, nuts,
fish, tofu or vegetables.
Sugar enhances the flavour of many foods and it is often found
as an additive. Such foods consumed in moderation should not
pose a health problem. There is no published scientific evidence
to suggest that people with hepatitis C have particular problems
metabolising (processing) sugar.
Tea and coffee
Tea and coffee have been enjoyed in many cultures for thousands
of years. The active ingredient, caffeine, produces effects
on the body (such as increased alertness) but these are usually
temporary. There is no published scientific evidence suggesting
that tea, coffee or caffeine-containing drinks, consumed in
moderation, cause particular problems for people with HCV.
Salt
All people in Australia are advised to eat less salt whether
they have hepatitis C or not. You can do this by using less
salt in cooking and reducing salt use at the table. Many manufactured
or processed foods such as canned vegetables or sauces are
high in salt. Try using low-salt or salt-reduced varieties
of these foods.
Food colours and preservatives
There is no published scientific evidence to suggest that
people with hepatitis C have particular problems metabolising
artificial colours or preservatives in foods. Avoiding all
artificial colours, flavours and preservatives would severely
limit your shopping choices and could add unnecessary stress
to your life without any significant health benefits.
Any people with proven sensitivity to particular colours,
preservatives or foods should be vigilant, whether they have
hepatitis C or not.
Vitamin & mineral supplements
There is evidence that antioxidant nutrients (such as vitamin
C and E) can play a role in limiting the damage that HCV causes
to the liver. Most people get their vitamins and minerals
from fruit and vegetables. Additional supplements may be useful
for people who do not eat a variety of foods from each food
group. People with illness or injury have increased vitamin
and mineral requirements and may benefit from taking supplements.
If you take supplements, be careful not to exceed the recommended
dose as this may be harmful. Seek advice about whether you
need nutritional supplements from an Accredited Practicing
Dietitian (see DAA, Further Information ).
Herbal treatments
Some herbal treatments have been shown as beneficial to the
liver (eg. silymarin). Other herbs can damage the liver (eg.
germander, Teucrium chamaedrys ) and some can interfere with
prescribed medications (see Further Information ).
Complementary health practitioners can advise on possible
herbal treatment options. For further information and referrals,
please contact the NSW Hep C Helpline . It is recommended
that you discuss all treatments you are considering with your
medical practitioner.
Nausea & loss of appetite
Here are some tips to help when you feel nauseous or have
lost your appetite:
Eat small amounts, often
Eat most when you feel hungry
Try ginger ale or other ginger products
Choose foods that contain lots of vitamins and minerals. You
can meet your requirements in a smaller amount of food by
eating foods like milkshakes or smoothies, yoghurt, nuts,
tofu, dried fruit, soy drinks, flavoured milk or cheese.
Try different tastes to stimulate your appetite, eg. bitter,
sour, salty, sweet.
Special nutritional supplements may be useful if you are not
eating well or if you are losing too much weight.
Talk to a dietitian if nausea and loss of appetite persist.
Dietitians can also provide advice on nutritional supplements.
Further
nutritional information
Most people with hepatitis C will not experience serious liver
damage. They need only take care about their food choices
and alcohol intake to ensure their diet keeps them as healthy
as possible.
If you have a level of liver damage or symptoms that require
more specialised dietary advice, your GP or specialist should
be able to refer you to a dietitian.
For more detailed information on hepatitis C and diet, see
ASC Nutrition & Hep C
For dietary advice, contact the Dietitians Association of
Australia: www.daa.asn.au
(02 6292 9555).
Also read, The
Guide to Healthy Eating for People with Hepatitis C
, AHC (2001).
For information about helpful and harmful herbs, see Info
on Herbs.
Injecting
drug use and hepatitis C
In Australia,
past or present injecting drug use is the most common risk
factor for HCV. The majority of people who have injected drugs
have hepatitis C. Those people who inject and don't have hepatitis
C are at great risk of infection.
Anyone who has ever
shared injecting equipment may have possibly caught hepatitis
C. It doesn't matter what was injected - heroin, methadone,
pills, speed or steroids. It is the possible blood-to-blood
contact during injecting that is a potential risk for transmitting
infection.
People who inject
drugs will benefit from a good medical follow-up after a hepatitis
C diagnosis is made. Knowing about hepatitis C status is important
in helping to maintain good health through recommended lifestyle
changes (see Self-management).
For those people
who already have hepatitis C, it's important to inject as
safely as possible to avoid passing the virus on to others
or becoming reinfected with a different HCV genotype or subtype.
It is believed that reinfection may cause increased illness
or place a greater strain on the liver.
Those people who
previously contracted HCV but cleared it naturally would not
be so lucky a second time around and would most likely develop
a chronic infection.
Methadone
and hepatitis C
People on a methadone program may be able to access hepatitis
C antibody testing and ongoing liver function test monitoring
through their prescribing clinic. If the clinic does not offer
such services, a person can ask for a referral to a GP who
does.
The effects of methadone
can alleviate painful symptoms of hepatitis C. Relief of pain
can be helpful, but it may also camouflage early signs of
liver damage (if it develops). Flu-like hepatitis C symptoms
may give the impression that someone is using prescription
pills or going through withdrawal. If this causes problems
with staff at the clinic, it may be useful if they're reminded
of the complicating effect of hepatitis C symptoms. People
should be careful with methadone dosages and aware of their
tolerance for drugs. This is especially important if liver
damage is severe. People who inject drugs can obtain information
on HCV and injecting drug use from the NSW Users & AIDS
Association (NUAA) or the NSW
Hep C Helpline .
Harm reduction
There are a number of health risks associated with injecting
drug use. These include the variability of the strength of
street drugs, differences in people's capacity to tolerate
drugs, the potential for street drugs to contain impurities
and the possibility of infection or reinfection with hepatitis
C and other bloodborne infections. People who inject drugs
should consider the following:
- Swallow, snort or smoke the drugs (but
don't share the straws if snorting)
- Wash hands before and after shooting up,
preferably using soapy water
- Wipe down all surfaces where hit is being
prepared
- Avoid all contact with anyone else's blood,
including traces not able to be seen
- Use a new fit for every hit
(as a last resort, use fits cleaned as described below)
- Don't share any equipment when preparing
and injecting drugs - use personal gear
- Don't inject hits prepared by other people
at some other time
- Immediately after use, flush fits with
clean cold water even if it's not thought they'll be used
again. This helps remove blood from the fit and has the
added advantage of removing traces of whatever drug has
been used
- Dispose of fits safely - eg. put them in
sharps bins, back in fit packs or as a last resort, put
into empty plastic resealable drink bottles
- Avoid binge drug use and heavy alcohol
use when using.
Cleaning
fits
If people have to reuse fits, disinfecting or cleaning them
will reduce the chances of HCV and HIV transmissions, septicaemia
and other infections. People should play it safe and use all
new equipment every time they hit up. Reusing fits should
be a last option only. If anyone has to reuse fits, they should
remember the following guidelines:
- After previous use: wash
your hands then rinse fit with cold tap water. Repeat this
until all signs of blood are gone. Squirt water down sink
or safe fluid disposal area (eg. empty plastic drink bottle).
Do this as soon as a fit is used as dried or clotted blood
is hard to wash out and can block the fit. Always use cold
water as hot water will clot blood in the fit and block
it.
- Before current
use: wash hands and prepare three containers:
one filled with clean cold tap water for rinsing the fit;
one filled with full strength bleach for soaking/bleaching
the fit; and one filled with clean cold tap water for flushing
bleach from the fit.
- Rinsing: Draw clean cold
tap water from the first container into the fit. Squirt
the water out into your sink or safe fluid disposal area.
Repeat until you cannot see any traces of blood.
- Bleaching: Use full strength
bleach (at least 5.25% sodium hypochlorite), having checked
the use-by date. Take the fit apart and cover it completely
with bleach, soaking it for at least two minutes. If you
can't soak it, draw bleach into the fit and shake for at
least 30 seconds. (Count "one thousand, two thousand" ...
up to "thirty thousand".) Squirt the bleach out into your
sink or safe fluid disposal area. Repeat this process at
least once again.
- Flushing: Draw up fresh
water from the third container into the fit. Don't use water
from the first container as this has been contaminated.
Squirt the water into your sink or safe fluid disposal area.
Repeat this flushing process at least six times, until all
the bleach has been removed.
Taking time with
the above steps improves the chances of avoiding transmission
of hepatitis C, but ideally use a new fit for every hit.
Hepatitis
C and women
Hepatitis
C can affect women differently from men - possibly due to
effects on female hormonal balances. Women with hepatitis
C who are considering hormone treatment or related medications
should discuss any possible complications with their doctor.
There is no evidence that HCV adversely affects a pregnant
woman or her unborn child - but there is a low risk of transmission
from mother to baby depending on the mother's PCR status.
Hormonal
effects
Hepatitis C can involve menstrual irregularities, particularly
if a woman is experiencing significant hepatitis C symptoms.
This may be because the liver plays a role in regulating hormones
in the body.
Birth control
If women are experiencing significant hepatitis C
symptoms, using the oestrogen-based contraceptive pill may
be inadvisable. In these cases, the progesterone-only pill
or Depo-Provera may be preferable. In any case, women should
consult a gynaecologist or other women's health specialist.
Hormone
Replacement Therapy
If women have severe hepatitis C symptoms they may need to
discuss with their doctor or specialist whether hormones should
be used for menopausal symptoms. In some cases, doctors may
recommend external vaginal creams and skin patches rather
than pills.
Issues for partners,
families and friends
Except for
blood-to-blood contact, the virus is quite difficult to pass
on. Within normal daily contact, family members, friends and
work colleagues are not at risk of contracting HCV (see Household
transmission).
Partners,
families and friends can play an important role providing
emotional and practical support for people with hepatitis
C.
Most babies
are not at risk of catching hepatitis C, and sexual transmission
of hepatitis C is very uncommon.
If parents feel
it is necessary to test their babies and toddlers, it is important
to discuss with their GP the tests involved. A PCR viral detection
test done at 4-6 weeks will indicate whether the baby has
contracted the virus, as would an antibody blood test done
at 18 months. It is recommended that babies born to HCV positive
mothers are not given antibody tests until at least 18 months
of age (see Mother to baby transmission).
At some point in
time, people who have hepatitis C may decide to tell their
current sexual partner/s. It may be useful to have hepatitis
C booklets or brochures on hand. For more information on disclosing
HCV status to others, or to obtain written resources, people
can phone the NSW Hep
C Helpline.
How does hepatitis
C affect children?
It is not
believed that hepatitis C physically affects children any
differently from adults.
Although many studies
have examined hepatitis C's affect on adults, particularly
people who have had blood transfusions, there have been few
studies done on infants and children. Emerging research suggests
hepatitis C infection has a lesser impact when contracted
by children. For more specific information, contact the NSW
Hep C Helpline.
Telling
others
Coping with
an illness like hepatitis C can be easier when friends, family
and others know what's happening - but people with hepatitis
C should be careful about telling others as they may react
with prejudice.
Some health
care workers - such as GPs or surgeons - may need to know
about a person's hepatitis C so they can give the best treatment
for injuries or other illnesses (eg. providing medicines that
may be less harmful for the liver).
Most people
with hepatitis C are not obliged to inform anyone of their
HCV status. HCV positive health care workers who perform 'exposure
prone procedures' should be guided by their State or Territory
health department's guidelines and by the policy of their
professional body and relevant Board (see Health care workers
in NSW).
People who
are unsure of who to tell, or how to tell them, should contact
the NSW Hep C Helpline
or a counsellor.
Hepatitis C is a
notifiable condition for GPs, hospitals and blood pathology
laboratories. They pass on basic information about an HCV
positive test result to the health department. Such information
is kept very brief and treated confidentially. It is used
to provide statistics about hepatitis C.
Within workplaces
and health care settings, government-endorsed standard blood
and body fluid precautions are used to prevent transmission
of viruses such as HCV. Because these precautions are based
on the assumption that anyone could have HCV, precautions
should be applied equally for everybody.
Most health care
workers have non-judgmental attitudes and are aware how HCV
is transmitted. People with HCV should consider whether health
care workers that they see need to know about their HCV -
from the point of view of providing best quality health care,
rather than infection control considerations.
Health care workers
who perform exposure prone procedures should be guided by
their State or Territory health department policies. Hepatitis
C positive health care workers in NSW who perform exposure-prone
procedures should seek advice from a medical specialist
in the management of HCV. Infected health care workers should
also seek advice from their professional organisation and
registration board regarding the implications for their career.
NSW Health has established the Blood Borne Virus Advisory
Panel from which advice can be sought anonymously by
infected health care workers and their treating medical specialists.
The NSW Hep C Helpline
can provide contact details for the Blood Borne
Virus Advisory Panel.
What
can be done about discrimination?
How people
might have caught the virus is not important. Those who have
hepatitis C are covered by anti-discrimination laws and should
be treated equally by other people.
Anti-discrimination
legislation covers people with hepatitis C as viral infections
such as HCV are classified as a disability.
It is important
to remember that people with HCV should not be treated differently
from anyone else. This applies to all of their everyday life
- including buying or renting goods or services, obtaining
health care services, applying for a job, getting a promotion
at work or maintaining privacy where someone works or lives.
If something happens
that seems to be against the law, people should first discuss
it with the person or organisation that they feel is discriminating
against them. People can usually access advice and help from
work-related or legal organisations - eg. the workplace union,
an Equal Employment Opportunity officer, a community legal
centre or the Anti-Discrimination Board of NSW.
The Anti-Discrimination Board has the legal power
to investigate a complaint, and if it appears to be against
the law, to try to reach a private settlement. Most complaints
are settled successfully but those that are not go to the
Equal Opportunity Tribunal. For general information
on what to do, people can phone the NSW Hep
C Helpline.
What
can people do in regard to work?
Having hepatitis
C should not have any great implications for people in the
workplace. Risk of HCV transmission is so low that people
with HCV are under no obligation to inform employers, work
colleagues or customers that they have the virus. The one
exception is for health care workers who carry out exposure
prone procedures (see Telling others, and Health care
workers in NSW).
Looking
for work
In pre-employment health checks, employers should ask questions
relevant only to the advertised job. Types of work where someone
might be precluded because they have hepatitis C are limited
to those specialised health care workers who carry out exposure-prone
procedures (operating with sharp instruments within
body cavities). Unless a person with hepatitis C is applying
for such work, employers have no valid legal reason to know
about their infection. If someone is specifically asked when
filling out a pre-employment medical questionnaire to tell
about hepatitis C or such things as liver illnesses, they
would probably need to decide whether to disclose or not on
the basis of whether such information is relevant to the job,
and whether possible discrimination may result from the disclosure.
Becoming
sick at work
Working people who develop illness are able to take sick leave
and possibly long-service leave, but additional time off can
cause problems. Employers do have a legal responsibility,
though, to make reasonable modifications to the workplace
to accommodate people's disabilities. Amongst other options,
employers may be able to:
- Change a position from full-time to part-time
- Adopt flexitime arrangements
- Allow working from home where appropriate
- Reduce the amount of physical activity
required within a job.
Workplace
disclosure
People who tell employers or work colleagues may unfairly
lose their job or face some other form of discrimination as
a result of ignorance or ill-feeling towards perceived injecting
drug use. In such cases a person's union and the Anti-Discrimination
Board of NSW may be able to assist. The Anti-Discrimination
Board can attempt to negotiate a return to work for
sacked workers. If this is not possible or not appropriate,
it can attempt to gain fair compensation on behalf of the
unfairly sacked worker.
Health care
workers in NSW
In NSW, health care workers who perform exposure prone procedures
(see glossary) are obliged to monitor their HCV status and
abstain from performing exposure-prone procedures if they
are HCV PCR positive. They are encouraged to inform employers
of their HCV status, and should do so if it is likely that
they have exposed patients to risk of infection by performing
exposure prone procedures while infectious. For further information,
see the NSW Health department circulars, 2003/39
and 99/88.
What about insurance
& superannuation?
People with
hepatitis C should not necessarily be refused life assurance
or other insurance products but may expect to pay higher annual
premiums. Superannuation providers can legally ask if someone
has hepatitis C or whether they have injected drugs but they
are not able to use that information to then treat the person
less favourably than others.
Insurance
Companies rely on skilful calculation of risk in order to
carry out their business. Risk classification calculation,
based on medical, statisti | 
