– Hepatitis C | Facts & Cases

Hepatitis C is contracted through exposure to infected blood. Intravenous drug use is the most common mode of transmission.

There are a number of other modes of transmission, some of which include: blood transfusion prior to 1992, when routine testing of the blood supply for hepatitis C began;other exposures to hepatitis C in a health care setting, such as needle stick injury; sexual exposure, although the rate of transmission of hepatitis C sexually is relatively low; transmission from a hepatitis C infected pregnant mother to fetus; body piercing or tattooing by an unregulated establishment.

The majority of people in the United States infected with hepatitis C were born between 1945 and 1965. The Centers for Disease Control and Prevention (CDC) has recommended that all people born during that period be screened for hepatitis C.

No vaccine is available to help prevent hepatitis C infection, unlike the situation for hepatitis A and B, where effective vaccines are available. At least 75 percent of people who become infected with hepatitis C become chronically infected, meaning that the body’s immune system is not able to eliminate the virus. Acute hepatitis C infection often does not cause symptoms. Chronic hepatitis C infection may also be asymptomatic, although nonspecific complaints such as fatigue may be noted.

CHARACTERISTICS:

Liver enzyme levels may be normal or elevated with chronic hepatitis C. Liver enzymes may fluctuate over time, and do not reflect the degree of liver damage.
The combination of a positive antibody test for hepatitis C with undetectable hepatitis C virus by an RNA test for the virus suggests either a false positive antibody test or that the body’s immune system has successfully eliminated the virus. The presence of hepatitis C virus in the blood suggests active infection. The infection is considered to be chronic if present for at least six months. The  quantity of hepatitis C virus detected in the blood is not predictive of the extent of liver damage that is present, although higher levels of virus may predict a less favorable response to treatment.

CLASSIFICATIONS:

Classification of hepatitis C virus infection is based on the genetic variation in the hepatitis C virus. Seven major strains (genotypes) of hepatitis C virus have been identified, designated by the numbers one to seven. In addition, there are a number of subtypes, designated with letters. In all, there are 67 confirmed subtypes of the hepatitis C virus and another 40 or so provisional subtypes. The most common genotype found in the United States is type 1a. Knowledge of the particular hepatitis C genotype can help predict prognosis and guide treatment decisions.

Decades usually elapse between the acquisition of hepatitis C infection and the diagnosis of advanced liver disease. Inflammation of the liver can lead to fibrosis, and fibrosis can progress to cirrhosis (scarring of the liver).

The CDC noted in an August 2012 publication (MMWR, August 17, 2012) that about 20 percent of the population infected with hepatitis C will progress to cirrhosis twenty years after infection. The document stated that cirrhosis and hepatocellular carcinoma have been increasing and are projected to increase substantially in the coming decade.

The CDC publication also stated that it has been projected that there will be substantial increases in mortality as people enter their third, fourth, and fifth decades after contracting hepatitis C. Furthermore, it was noted that hepatocellular carcinoma is the fastest growing cause of cancer related mortality, with hepatitis C accounting for about half of newly diagnosed cases.

ASSESSMENT:

Liver biopsy is the most accurate method to assess liver damage due to hepatitis C. More advanced levels of fibrosis and inflammation are associated with worse outcomes. Noninvasive methods may also be used to assess the extent of liver damage, including blood tests and measurement of liver stiffness. However, they are not as accurate as liver biopsy.

Tests that may be used to screen for liver cancer in hepatitis C include a blood test called alpha-fetoprotein (AFP) and liver imaging, such as with sonography or CT scanning. Although it is difficult to predict which people with hepatitis C will develop advanced liver disease, some factors that have been associated with faster disease progression include obesity, alcohol use, male gender, age over forty at time of infection, longer time period since infection, coinfection with hepatitis B, and the presence of fatty liver on biopsy.

TREATMENT:

For many years the standard of care had been pegylated interferon, which is injected under the skin, in combination with an oral medication called ribavirin. The use of the pegylated interferon/ribavirin combination has been limited by potentially serious side effects and suboptimal success rates for certain genotypes, including 50 percent or less for genotype 1a, which as noted is the type most commonly encountered in the United States.

In 2011 the Food and Drug Administration approved the use of telaprevir and boceprevir, the first two oral medications that directly act on the hepatitis C virus. Subsequently additional medications have been approved and others are being studied.

It is now possible to successfully treat hepatitis C with oral medications and without the use of pegylated interferon.

The new medications hold the promise of higher success rates (perhaps over 90 percent), fewer side effects, and shorter treatment periods than pegylated interferon and ribavirin, although they tend to be more expensive and, being rather new medications, there is no long term track record.

T+reatment for hepatitis C is considered successful if it results in a sustained virologic response (SVR), which is usually defined as the absence of detectable virus in the blood 24 weeks after completion of therapy. If a sustained virologic response occurs, the hepatitis C virus has usually been eradicated, although the hepatitis C antibody may still be detected.

While chronic hepatitis C is associated with increased mortality, studies have shown that successful treatment does decrease the mortality, reduce the effects of the liver damage, and decreases the incidence of cirrhosis and hepatocellular carcinoma and the need for liver transplantation.

A number of factors are evaluated when underwriting hepatitis C, including age at infection, extent of liver damage, complications, alcohol use, laboratory results, and results of any treatment administered.

CASE STUDIES:

Applicant 1 is a 60 year old with a history of chronic hepatitis C who successfully completed treatment one year ago. Liver biopsy performed before treatment revealed minimal fibrosis. This case can be Standard Plus.

Applicant 2 is a 50 year old applicant with a history of untreated hepatitis C contracted at age 25 who had a recent biopsy that showed mild fibrosis. The applicant does not use alcohol and liver enzymes are elevated less than two times normal. This case can be three tables.

Applicant 3 is a 45 year old applicant who has a history of untreated chronic hepatitis C with cirrhosis and who drinks alcohol daily. This case is a decline.

 

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