Hepatitis C

Basic facts
Hepatitis C is a liver disease caused by the hepatitis C virus: this virus can cause both acute and chronic hepatitis infection, which varies in severity from mild illness, lasting several weeks, to a serious lifelong disease.
The hepatitis virus is transmitted with blood, and infection usually occurs as a result of exposure to a small amount of blood. This can happen with the use of injecting drugs, unsafe injections, unsafe medical care and transfusion of untested blood and blood products. Throughout the world, chronic infection of hepatitis C affects 71 million people.
A significant number of people with chronic infection will develop cirrhosis or liver cancer.

Approximately 399,000 people die each year from hepatitis C, mainly from cirrhosis and hepatocellular carcinoma (1).
With the help of antiviral drugs, more than 95% of people with hepatitis C infection can be cured and thus reduce the risk of death from cancer and cirrhosis, but access to diagnosis and treatment is low.

Currently, hepatitis C vaccine does not exist, but scientific research is being carried out in this area.
The hepatitis C virus (HCV) causes both acute and chronic infection. Acute HCV infection usually occurs without symptoms and is only very rarely associated with a life-threatening disease. Approximately 15% -45% of infected individuals spontaneously dispose of the virus within 6 months after infection without any treatment.
The remaining 60% -80% of individuals develop chronic HCV infection. In persons with chronic HCV infection, the risk of liver cirrhosis is 15% -30% within 20 years.

Geographical distribution

Hepatitis C is found all over the world. The most affected regions are the Eastern Mediterranean Region and the WHO European Region - prevalence rates are 2.3% and 1.5%, respectively. The prevalence rates of HCV infection in other WHO regions range from 0.5% to 1.0%. The hepatitis C virus has numerous strains (or genotypes), and their distribution depends on the region.

Broadcast

The hepatitis C virus is transmitted through the blood. Most often it is transmitted:

as a result of injecting drug use when sharing devices for injections;
in medical institutions due to repeated use or insufficient sterilization of medical equipment, especially syringes and needles; and
with transfusion of untested blood and blood products.
HCV is also transmitted sexually and can be transmitted from an infected mother to her infant; but these types of transmission are much less common.

Hepatitis C is not transmitted through breast milk, food, water, or with safe contacts, such as hugs, kisses and the use of foods or drinks in conjunction with an infected person.

Estimates from the simulation suggest that, in 2015, there were 1.75 million cases of HCV infection worldwide (23.7 cases of HCV infection per 100,000 people globally).

Symptoms

The incubation period of hepatitis C is from 2 weeks to 6 months. After initial infection, approximately 80% of people do not have any symptoms. People with acute symptoms can experience high fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, darkening of the urine, gray feces, joint pain and jaundice (yellowing of the skin and eye proteins).

Screening and diagnostics

Due to the fact that acute HCV infection usually occurs without symptoms, it is rarely diagnosed at an early stage. In people at the stage of developing a chronic HCV infection, the infection also often remains undetected because it remains asymptomatic for decades, while the symptoms develop to severe liver damage.

HCV infection is diagnosed in two stages:

Persons infected with this virus are identified by serological screening for HCV antibodies. If the test confirms the presence of HCV antibodies, a test for ribonucleic acid (RNA) of HCV should be performed using the nucleic acid amplification (MANK) test to confirm chronic HCV infection, since about 30% of HCV infected persons spontaneously get rid of the infection due to a strong immune response without needing in treatment. Despite the cessation of infection, the results of their testing will continue to be positive for HCV antibodies.

After diagnosing a chronic infection of hepatitis C in a person, it is necessary to evaluate the degree of liver damage (fibrosis and cirrhosis). This can be done with a liver biopsy or various non-invasive tests.

In addition, such people should be subjected to a laboratory test to establish the genotype of the hepatitis C strain. There are six HCV genotypes, and they respond differently to treatment. In addition, a person can be infected with viruses of more than one genotype. The extent of liver damage and the genotype of the virus are taken into account in the decision-making process for the treatment and management of the disease.

Testing

Diagnosis at an early stage can prevent health problems that may arise from infection and prevent the transmission of the virus. WHO recommends screening among people who may be at increased risk of infection.

Populations at higher risk for HCV infection include:

  • people who inject drugs;
  • people using intranasal drugs;
  • people receiving blood products or invasive procedures in medical institutions with inadequate infection control practices;
  • children born to mothers infected with HCV;
  • people with sexual partners infected with HCV;
  • people with HIV infection;
  • people who are or were in prison; and people who have tattoos or piercings.

Of the estimated 36.7 million people with HIV in the world, about 2.3 million people have in the past or currently have a serologically established HCV infection. Conversely, among all HIV-infected people, the prevalence of antibodies to HCV was 6.2%. Diseases of the liver are one of the main causes of morbidity and mortality among people with HIV.

Treatment

Hepatitis C does not always require treatment, because some people, thanks to an immune reaction, stop the infection, and in some people with a chronic infection, liver damage does not occur. If treatment is necessary, then the goal of treating hepatitis C is a cure. The cure rate depends on a number of factors, including the strain of the virus and the type of treatment provided.

The standards of treatment for people with hepatitis C are changing rapidly. Sofosbuvir, daklataswir and the combined drug sophosbuvir / lepidasvir are part of the treatment regimens preferred by the WHO guidelines, and can contribute to achieving a 95% cure rate.

These drugs are much more effective, safe and are better tolerated by patients than old treatments. Due to PAP, a larger number of patients with HCV infection can be cured, as well as making treatment shorter (usually 12 weeks). WHO is currently updating its treatment guidelines to include panthenotypic DPP treatment regimens and simplified laboratory monitoring. At the same time, in certain situations, pegylated interferon and ribavirin continue to retain some significance. Although the cost of producing PPE is low, in many high and middle income countries these drugs remain very expensive. In some countries (mainly low-income countries) prices have declined significantly due to the introduction of generic versions of these drugs.

Access to HCV treatment is improving, but remains limited. In 2015, out of 71 million people with HCV infection in the world, 20% (14 million) knew about their diagnosis. In 2015, 7.4% of people with diagnosed (1.1 million people) started treatment. In 2016, treatment received 1.76 million more people, and global coverage of hepatitis C treatment increased to 13%. To achieve the goal of reaching 80% of the people in need by 2030, significant efforts are needed.

Prevention

Primary prevention

Hepatitis C vaccines do not exist, so the prevention of HCV infection depends on reducing the risk of exposure to the virus in health facilities and in high-risk populations, for example, among injecting drug users at risk of sexual intercourse.

The following limited list contains examples of primary preventive interventions recommended by WHO:

  • hand hygiene: including surgical treatment of hands, washing hands and using gloves;
  • safe and proper implementation of medical injections;
  • provision of comprehensive services aimed at harm reduction to injecting drug users, including sterile injecting equipment;
  • testing of donated blood for hepatitis B and C (as well as HIV and syphilis);
  • training of medical personnel; and promoting the proper and consistent use of condoms.
Secondary and tertiary prevention

For people infected with the hepatitis C virus, WHO recommends the following activities:

education and counseling on options for medical care and treatment;
immunization with hepatitis A and B vaccines to prevent co-infection of these hepatitis viruses with hepatitis viruses to protect the liver of such people;
appropriate treatment at an early stage, including antiviral therapy, if indicated; and
regular monitoring for the purpose of early diagnosis of chronic liver disease.
Screening, care and treatment of people with hepatitis C infection
In April 2016, WHO updated its "Guidelines for Screening, Providing Medical Care and Treating People with Hepatitis C Infection." These guidelines complement the existing WHO guidelines for the prevention of transmission of blood-borne viruses, including HCV.

They are intended for policy-makers, government officials and other workers in low- and middle-income countries who are developing screening, medical care and treatment programs for people infected with HCV. These guidelines will help to expand services for the treatment of patients with HCV infection, as they contain important recommendations in these areas and address issues related to their implementation.

Screening, care and treatment of people with hepatitis C infection - in English
Access to HCV treatment is improving, but remains limited. In 2015, out of 71 million people with HCV infection in the world, 20% (14 million) knew about their diagnosis. In 2015, 7.4% of people with diagnosed (1.1 million people) started treatment. Approximately 50% of people who started treatment in 2015 received PAP. Over the years, the cumulative number of people receiving treatment on a global scale has reached 5.4 million people in 2015. Most patients who received treatment before 2015 used old therapies, mainly interferon-based therapy.

Summary of main recommendations

Recommendations for screening for HCV infection

1. Screening for the identification of persons infected with HCV
It is recommended that serological testing for HCV in persons who belong to a population with a high prevalence of HCV or who are at risk for HCV / risky behavior.

2. Confirmation of the diagnosis of chronic HCV infection
It is suggested that, after receiving a positive result of the serological test for HCV, another testing (MANK on HCV RNA) be performed to diagnose chronic infection. Testing of IASC on HCV RNA should also be conducted to assess the need to initiate treatment for hepatitis C.

Recommendations for care for people infected with HCV
3. Screening for alcohol and counseling to reduce moderate and high alcohol consumption
It is recommended that alcohol use be assessed for all people infected with HCV, after which behavioral therapy should be offered to reduce alcohol consumption to persons consuming it in moderate to high amounts.

4. Evaluation of the degree of fibrosis and cirrhosis of the liver
In places with limited resources, the index of the ratio of aminotransferase to platelet count (APRI) or FIB4 tests, rather than other noninvasive tests requiring more resources, such as elastography or fibrotest, is recommended to assess liver fibrosis.

Recommendations for the treatment of hepatitis C
5. Assessment for treatment
All adults and children with chronic HCV infection should be evaluated for the possibility of antiviral treatment.

6. Treatment with direct-acting antivirals (PPD)
WHO recommends that all patients with hepatitis C undergo treatment according to the DTP-based regimen, with the exception of some specific groups of people, among whom interferon-based regimens can still be used (as an alternative regimen for treating patients with the 5th infection or the 6th genotype or patients with infection of the 3rd genotype and cirrhosis).

7. Treatment with telaprevir and bocetrevir should no longer be used
These two first-generation PAPs, prescribed together with pegylated interferon and ribavirin, were recommended in the 2014 guidelines. The data now available show that their use leads to more frequent adverse reactions and less frequent cure compared to newer schemes based on PPD. Therefore, WHO no longer recommends the use of these two drugs.

8. WHO recommends preferred and alternative regimens for treatment of BPH based on genotype and status of cirrhosis
The guidelines team reviewed all available data (more than 200 studies) to determine which schemes are most effective and safe for treating each of the six different genotypes.

WHO response

In May 2016, the World Health Assembly adopted the first "Global Health Sector Strategy for Viral Hepatitis for 2016-2021." This strategy underscores the important role of universal coverage of health services, and the objectives of this strategy are consistent with the objectives of the Sustainable Development Goals. The prospect of this strategy is the elimination of viral hepatitis as a public health problem, which is included in the global targets to reduce new infections of viral hepatitis by 90% and reduce deaths due to viral hepatitis by 65% by 2030. The strategy outlines the actions to be taken by countries and the WHO Secretariat to accomplish these tasks.

WHO works in the following areas to support countries in achieving global hepatitis targets in accordance with the Agenda for Sustainable Development for the period up to 2030:

  • raising awareness, fostering partnerships and mobilizing resources;
  • formulating evidence-based policies and compiling data for action;
  • transmission prevention; and expansion of screening, care and treatment services.
  • WHO published the "Global Report on Hepatitis 2017", which sets the benchmark for efforts to eliminate the disease. The report presents global statistics on viral hepatitis B and C, the incidence of new infections, the prevalence of chronic forms of infection and mortality as a result of these two high-burden hepatitis viruses, and the scope of key measures for fighting hepatitis - all of which are presented in at the end of 2015. The text of the report is available on the website at the link below.

The Global Report on Hepatitis

WHO also organizes the World Hepatitis Day every year on July 28 to raise awareness and understanding of viral hepatitis.

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