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Hepatitis C (HCV): a curable disease.

Hepatitis C is an inflammation of the liver caused by hepatitis C viruses. You can become infected with the virus if it enters the bloodstream. Many of those affected become infected when using drugs via shared syringes and other equipment.

There are two forms of the disease:

  • acute hepatitis C: Infection occurred no more than six months ago.
  • chronic hepatitis C: The infection lasts longer than six months. Among other things, it can severely damage the liver in the long term.

If the infection is detected and treated in time, it can be cured before secondary diseases develop.

Chronic hepatitis C can lead to general symptoms such as fatigue, but can also cause psychological stress and significantly reduce quality of life. In cases of severe liver damage, a transplant may be necessary.

Symptoms

Hepatitis C often goes unnoticed at first. Only sometimes do symptoms occur in the first weeks or months after infection. These tend to be general symptoms such as

  • Tiredness
  • Poor performance
  • nausea
  • Pain in the upper abdomen
  • flu-like symptoms

Rarely, the skin or the white part of the eyes may turn yellow. This is known as jaundice or icterus.

If hepatitis C becomes chronic, it often takes years for the symptoms to become more severe. These are usually a sign that the liver or other organs have been damaged by the chronic inflammation.

Causes

The hepatitis C virus enters the body through direct blood contact - i.e. when the blood of an infected person enters the bloodstream of another person. In Germany, this mainly occurs through drug use - for example, when sharing syringes with others. Transmission is also possible via shared pipes, snuff tubes or other utensils if the people involved have small wounds on their lips, mouth or nose.

Hepatitis C is very rarely transmitted during sex. This is most likely to happen when there is direct contact with blood via small injuries - for example during practices where you can injure yourself (often unnoticed). Transmission is also possible during menstruation if the menstrual blood comes into contact with the partner's wounds.

Infection is also possible in healthcare professions - for example through puncture wounds with surgical instruments or syringes that have come into contact with the virus. However, the risk of infection is then less than 1%. Patients are infected much less frequently, for example during surgical procedures or dialysis.

Around 5% of infected pregnant women transmit the virus to their child - usually at birth.

In over 40 % of infected people, however, it remains unclear how they became infected. Hepatitis C is also tested for in organ donations. Hepatitis C is not transmitted by sneezing, kissing or hugging.

Frequency

Around 5 in 100,000 people contract hepatitis C every year. Most of those infected are adults.

Course

Two weeks to six months pass between infection and the onset of the disease. Most people affected do not notice the infection at first because they have no or only general symptoms, which can also have many other causes. In some people, the immune system successfully fights the virus in the first six months: around 20 to 40 % of those infected recover without treatment. However, in around 60 to 80 % of those affected, the immune system is unable to eliminate the virus. They develop a permanent (chronic) inflammation of the liver, which only very rarely heals without medication. It also often goes unnoticed for a long time. Liver damage often occurs later. You can be infected with hepatitis C several times. An infection that has been overcome does not protect against recurrence.

Consequences

Chronic hepatitis C can cause the inflamed tissue of the liver to harden and scar. This process is called liver fibrosis. As a result, the liver functions increasingly poorly. If the fibrosis progresses, a shriveled liver(liver cirrhosis) develops. The liver is then usually permanently damaged. Severely advanced cirrhosis can lead to liver failure.

Up to 20 % of people with chronic hepatitis C develop liver cirrhosis within 20 years. Around half of people with liver cirrhosis die within five years. Liver cirrhosis also increases the risk of cancer of the liver.

As a result of severe liver damage, fluid can accumulate in various parts of the body. An externally visible accumulation of water in the abdomen (ascites) is typical. If the blood can no longer flow normally through the damaged liver and therefore too much blood leaks into the small veins of the oesophagus or the entrance to the stomach, varicose veins(varices) can also form there. These often bleed easily, sometimes heavily and can even be life-threatening.

Chronic hepatitis C can also increase the risk of other diseases. These include

  • Vascular inflammation
  • Cancer of the lymph glands
  • Metabolic diseases (for example thyroid diseases or diabetes mellitus)
  • Diseases of the kidneys
  • Skin diseases
  • Itching

Hepatitis C can also be accompanied by psychological symptoms, including depression. Complaints such as poor performance can play a role here, but also the fact that some sufferers withdraw socially.

Occasionally, hepatitis C occurs together with hepatitis B or an HIV infection because they are transmitted in a similar way. The risk of secondary damage is then particularly high.

Diagnosis

Hepatitis C can be diagnosed with a blood test. Various tests are carried out in succession:

  • Test for antibodies: Antibodies can be detected from around eight weeks after infection. They remain in the blood after an infection has been overcome. Therefore, a positive test result does not mean that you are currently ill - but that you have been infected with the virus at some point in your life.
  • Test for the virus: If antibodies are found, it is then checked whether the virus is detectable in the blood. If this is the case, you have hepatitis C and can transmit the virus to other people. Viruses can be detected just a few days after infection.
  • Test for the type of virus: The genetic characteristics of the virus are sometimes determined before treatment. This is important in certain situations in order to select effective medication - for example in people with severe liver damage.

If hepatitis C is diagnosed, further examinations follow. The doctor uses blood tests and ultrasound to check whether the liver is already damaged(fibroscan / liver stiffness / elastography).

Only rarely is it necessary to remove and examine liver tissue(liver biopsy) under local anesthesia. If hepatitis C is detected, a test for hepatitis A, hepatitis B and HIV is also recommended.

Early detection

Anyone who suspects that they have been infected with hepatitis C can be tested at any time.

If you are at increased risk of hepatitis C, it is recommended that you get tested at least once a year. This applies in particular to people who inject drugs. Medical and nursing staff are tested for hepatitis C as part of company medical examinations.

Prevention

You can protect yourself from contracting hepatitis C by avoiding getting blood from infected people into your own body. If you use drugs, you should only use your own utensils. Many cities have drug consumption rooms or other drug help facilities. Drugs can be injected there under medical supervision and used syringes or other equipment can be exchanged for new ones. There is also other help available - including help to stop using drugs.

Healthcare workers can avoid infections by following common hygiene and protective measures. These include wearing gloves, disinfecting hands and taking care when handling needles.

During sex, condoms can protect against transmission via small wounds in the mouth, on the penis, in the vagina or in the anus. Femidoms also provide protection during vaginal sex.

If a pregnant woman has hepatitis C, she rarely transmits the virus to her child. During pregnancy and childbirth, there is not much that can be done to further reduce the risk of infection for the child. This is because medication against hepatitis C is not approved for pregnant women. There is no evidence that a caesarean section reduces the risk of infection at birth. Breastfeeding is usually possible. If there are bloody sores on the nipple, nursing caps provide protection. Affected mothers can also take advantage of breastfeeding advice.

Unlike hepatitis A and B, there is no vaccination that protects against infection with hepatitis C.

Treatment

In the case of chronic hepatitis C, treatment is started as soon as possible. In the case of acute hepatitis C, it is sometimes possible to wait a few weeks to see if it heals on its own. However, as the infection often persists, rapid treatment is often advised.

There are highly effective and well-tolerated medications against hepatitis C. These are usually taken for 8 or 12 weeks and inhibit the replication of the virus. Various preparations are available. Which ones are suitable depends, among other things, on how badly the liver is damaged. The drugs are approved for adults and children from the age of three.

If the liver is severely damaged, a liver transplant is an option.

Find out more: When is treatment an option?

If the infection occurred less than six months ago, it is referred to as acute hepatitis C. In around 20 to 40 out of 100 people, an acute infection heals on its own and has no consequences. Therefore, it can sometimes be observed how it develops. This primarily applies to people who have a good chance of recovering without treatment and do not have an increased risk of transmitting the virus to others (e.g. through drug use).

However, if the amount of virus in the blood (viral load) does not fall significantly within four weeks, there is a high probability that hepatitis C will become chronic. Treatment is then recommended.

Chronic hepatitis C very rarely heals on its own and often leads to liver damage and further illnesses. Experts therefore recommend starting treatment as soon as possible.

What should I bear in mind if I want to have children and am pregnant?

The medication is not approved for pregnant or breastfeeding women. This is because it has not been sufficiently investigated how effective and safe they are for the pregnant woman and the child.

It is therefore important to use good contraception during treatment for hepatitis C. If a woman is taking ribavirin, safe contraception is necessary until nine months after the end of treatment, as this active substance remains in the body for a long time. If her partner is taking ribavirin, safe contraception is recommended for up to six months after the end of treatment. The reason: ribavirin is also found in sperm and so far it cannot be ruled out that this could affect the development of the fetus. For women who wish to have children and have an increased risk of infection, it may be advisable to be tested for hepatitis C. If treatment is necessary, it can then be completed before pregnancy.

Who treats hepatitis C?

The disease is treated by specialists in internal medicine and gastroenterology (gastrointestinal diseases). The specialty for liver diseases is called hepatology and is part of gastroenterology. However, specialists in infectious diseases and experienced general practitioners can also treat hepatitis C. In the case of advanced liver damage, it is recommended to be treated by a specialist in gastroenterology who can also provide a hepatological assessment and further care. At Vivomed, we have experience in dealing with even the most complex situations of our patients.

What medications are available?

There are various groups of antiviral drugs. All of them inhibit the replication of the hepatitis C virus, but in different ways:

  • Polymerase inhibitors: These inhibit certain enzymes (polymerases) that are responsible for the formation of the virus's genetic information. These include the active ingredient sofosbuvir.
  • Protease inhibitors: These inhibit other enzymes (proteases) that ensure that the virus multiplies. These include the active substances glecaprevir, grazoprevir and voxilaprevir.
  • NS5A inhibitors: These also inhibit the replication of genetic information, but also work in other ways. These include the active substances pibrentasvir, elbasvir, ledipasvir and velpatasvir.
  • Ribavirin: The mechanism of action of this substance is not exactly known.

As a rule, drugs containing 2 or 3 active substances from different groups are used. Ribavirin is less well tolerated by some people than the other drugs and is therefore rarely used.

How does the treatment work?

The medication is usually taken for 8 or 12 weeks, rarely 16 or 24 weeks - once a day in the form of tablets or granules for children. Treatment usually takes place on an outpatient basis. In order for the medication to be as effective as possible, it is important to use it continuously over the recommended period.

Twelve weeks after the end of treatment (sustained virological response SVR12), a check is carried out to see whether the virus is still in the blood. If not, no further tests are usually necessary. However, people whose liver has already been severely damaged by hepatitis C are also examined regularly after treatment. This is because their risk of secondary diseases such as liver cancer (HCC) is still increased.

How is it decided which medication I receive?

Most drugs are effective against all types of hepatitis C virus. Therefore, many people can be treated with one of these drugs. Only sometimes the decision depends on certain factors. These include

  • how badly the liver is damaged
  • whether other illnesses exist, for example kidney failure
  • what other medication is being taken
  • what side effects the medication may have and
  • whether hepatitis C has already been treated.

Some medications work specifically against certain types of virus. It is then important to determine the type of virus before starting treatment. Such a determination is also important for people who have severe liver damage or severe kidney weakness (renal insufficiency) or for whom another medication has not worked sufficiently. Doctors then use a blood test to check the genetic properties of the virus and select the appropriate medication. In simple cases, pangenoypically effective drugs are used.

How effective are the drugs?

After completing treatment, most people are free of the hepatitis C virus: in around 95 out of 100 patients, the virus is no longer detectable - and they are no longer infectious . A relapse occurs in less than 1 in 100 people after initially successful treatment. Treatment can then be repeated.

Good to know:after hepatitis C has been cured, you can become infected with the virus again because you are not immune to it after contracting the disease.

Treatment also reduces the risk of secondary diseases. People with liver damage also benefit from the medication. Liver damage can even regress if hepatitis C has been successfully treated. However, as a damaged liver often cannot fully recover, the risk of certain secondary diseases such as liver cancer is still increased. People with liver damage are therefore recommended to have a check-up twice a year.

What is the reason if the medication does not work?

If a therapy does not work, this is usually because the viruses are resistant (resistant) to one or more of the active substances taken. Resistance can be detected with a blood test. Treatment can then be continued with a different combination of active ingredients.

What are the side effects of the medication?

The medication is usually well tolerated. Possible side effects are

  • Headache
  • nausea
  • Tiredness
  • Skin reactions

Around 8 out of 100 people experience mild side effects. Only very few discontinue therapy for this reason. Which adverse effects occur and how often depends on the drug. Ribavirin, for example, leads to certain side effects more frequently than other active substances, such as anemia.

Serious side effects are rare. However, doctors monitor treatment particularly carefully in the case of the following concomitant diseases:

  • Hepatitis B
  • severe renal insufficiency
  • Liver dysfunction

Interactions with other medicines are also possible. It is therefore important to inform your doctor about all the medication you are already taking. This also includes over-the-counter medicines and natural remedies. Anyone who uses drugs should also mention these.

Can medication be considered for advanced liver damage?

Medication is effective even if the liver is already damaged. In the case of advanced liver damage, the drugs no longer work quite as well and the risk of side effects is somewhat higher. Protease inhibitors are not an option for advanced liver damage, as they are likely to have more severe side effects.

How are children and adolescents treated?

Hepatitis C can also be treated effectively in children and adolescents. Some antiviral drugs are approved for children from the age of three, but the doses are lower than for adults. Children and adolescents also usually tolerate the medication well. Serious side effects are rare.

Are there alternatives to antiviral medication?

In the past, hepatitis C was treated with so-called interferons. These also inhibit the replication of the virus. However, they are less effective than antiviral drugs and have significantly more side effects. They are therefore no longer recommended for treatment. Apart from this, there are no known remedies that are effective for hepatitis C. Natural remedies are sometimes offered, but these have no proven benefit.

When is a liver transplant an option?

Hepatitis C can severely damage the liver - even to the point of life-threatening liver failure. The doctor can assess the severity of the disease based on blood values and other tests. Depending on the situation, a liver transplant may then be considered. This involves removing the diseased liver and replacing it with a donated liver or part of a liver. A liver transplant is also possible for early-stage hepatocellular cancer.

Do I need to pay attention to my diet if I have hepatitis C?

A healthy and balanced diet is generally advisable. However, a special diet is not usually necessary for hepatitis C. However, if the liver is already severely damaged by cirrhosis, this can have consequences for the metabolism. This is because the liver absorbs nutrients such as carbohydrates and proteins and processes them further. If this no longer works properly, the body lacks energy from food and deficiency symptoms occur. It may then be advisable to change your diet after consulting a doctor. For example, it is important to consume enough protein and calories. It is also recommended to eat something late at night to shorten the time until the next meal. Nutritional advice can help to ensure that you get enough nutrients despite the impaired liver function. As alcohol damages the liver, it makes sense to severely limit its consumption or, better still, to avoid it altogether.

Life and everyday life

As far as the symptoms of the disease allow, you can continue to live normally with hepatitis C. Apart from a few precautionary measures, there is no reason to restrict yourself in everyday life. The precautionary measures should prevent your own blood from coming into contact with the blood of others. People with hepatitis C can continue to work in all professions, including healthcare.

Chronic hepatitis C in particular has an impact on performance and well-being. Many people affected are ashamed of their illness or feel guilty. They fear or experience being ostracized because of their illness. Some therefore withdraw from other people. In addition, many are afraid of infecting others and therefore avoid contact.

Summary of hepatitis C:

HCV is now a curable disease. Above all, the good treatment options offer hope. Protective measures can also prevent infection.