Hepatitis C
Diagnosis and management

Diagnosis is indicated by the presence of anti-HCV antibody in serum. Current tests usually become positive 2-3 months after infection but occasionally remain negative for a much longer period. Current antibody tests do not distinguish chronic HCV carriers from individuals who are immune from past exposure to the virus. Liver function tests are used as one indicator of active disease.

Indeterminate results may indicate seroconversion in individuals with recent risk activity, but usually are not a reflection of hepatitis C infection. To clarify the situation, a careful history for potential risk factors needs to be elicited, as well as any history of hepatitic illness or jaundice. Liver function tests should be performed. If the liver function tests demonstrate no abnormality and there is no history suggestive of hepatitic illness or hepatitis C risk factors, the client may be reassured that hepatitis C infection is unlikely. Repeat hepatitis C serology may be offered in 6 months to exclude recent seroconversion. In most cases this result will again be indeterminate.

Further testing for hepatitis C RNA by polymerase chain reaction may be justified to clarify infection status. RNA can be detected within one to two weeks of exposure. Such testing should not be performed without prior discussion with a consultant, and care must be taken with the interpretation of results.

If the test is positive order LFTs including ALT and a -fetoprotein and monitor the ALT levels three monthly for six months. Patients with elevated ALT values over a period of six months or more should be referred to an appropriate specialist. Referral should also be considered if the client has symptoms or signs suggestive of chronic hepatitis or liver failure. Patients with elevated a -fetoprotein should be retested in one month to exclude hepatocellular carcinoma.

If LFTs are normal, regular 12 monthly testing and clinical assessment for symptoms or signs of liver disease is recommended.

The risk of chronic active hepatitis and cirrhosis is thought to be greater in individuals who are positive for both hepatitis B and C. There are case reports of fulminant hepatitis A infection in individuals with chronic hepatitis C. Hence, hepatitis A and hepatitis B vaccinations are recommended for individuals who are hepatitis C positive.

If there is a history of continuing injecting drug use a referral to drug and alcohol services for substance abuse management should be discussed with the patient.

The patient should be provided with written information and counselled in relation to

• potential sequelae of hepatitis C infection

• treatments and follow-up

• maintenance of health

• transmission issues

• support resources

The patient should be made aware of the potential for the development of chronic hepatitis, cirrhosis and hepatocellular carcinoma, but reassured that these sequelae usually take many years to develop and do not occur in all individuals.

Treatment (interferon) is available for individuals with evidence of liver damage and other eligibility criteria, and is provided on the basis of disordered liver function tests over a period of at least 6 months. The patient should therefore have regular liver function assessment to determine eligibility for treatment and allow the early detection of complications.

The patient should be advised to avoid further damage to the liver wherever possible. Alcohol consumption should be limited to a maximum of 50 g per week, but preferably discontinued altogether. Hepatotoxic drugs should be avoided and vaccination for hepatitis A and B should be considered if there is no evidence of pre-existing immunity.

To reduce the likelihood of transmission, the patient should not

• donate blood, semen or other body tissues or organs
• share toothbrushes, razor blades, drug injecting equipment or any other objects likely to be contaminated with their blood

The risk of sexual transmission cannot be dismissed but the efficiency of sexual transmission is considered to be very low. The transmission rate is probably greater during acute hepatitic illness and with anal rather than vaginal intercourse. Regular sex partners should be offered testing.

Health care workers involved with the management of the patient should be informed of their hepatitis C antibody status.

The risk of perinatal transmission is directly related to the level of maternal HCV RNA with a reported overall risk of transmission of about 6%.

The patient should be advised of the community support groups and resources available.

Patients who are Hepatitis C positive and who were not referred to a specialist after the initial assessment should be advised to have LFTs and clinical assessment for symptoms or signs of liver disease performed annually.