Hepatitis C

This is one of the more commonly missed chronic diseases in conventional medicine. Hepatitis C is an infection of the liver and it can manifest symptoms throughout the body. Between the years of 2010 and 2018, the incidence of acute #hepatitis C infection among people 18 to 39 years of age quadrupled because of the opioid epidemic and the associated increased in people who inject drugs. Globally, fewer than 5 percent of those infected have been diagnosed, and less than one percent have received treatment (Manness, Riley, & Studebacker, 2021).

However, don't assume this virus is specific to one particular population. It is expected that the burden of hepatitis C virus will increase because of the high proportion of persons who were infected in the 1960s and 1970s, who went undiagnosed and untreated. This virus is passed in anyway that blood-to-blood transmission may occur, such as sex with partners with open lesions, sex during your menses, sharing of sexual paraphernalia, anal sex, or of course, through exposure in healthcare (Wilkins, Akhtar, & Gititu, 2015).

In the United States, only about half of those infected with hepatitis C are even aware of it, and only 37 percent of those are receiving treatment. It is so prominent and so missed, that the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention recommends testing all individuals for hepatitis C at least once between the ages of 18 and 79 years of age, and periodic screening in adults with ongoing risk factors. The American College of Obstetricians and Gynecologists recommends screening all pregnant people for hepatitis C infection (Maness, Riley, & Studebacker, 2021; Wilkins, Akhtar, & Gititu, 2015).

Although the World Health Organization has the aim of completely eradicating hepatitis C by 2030, the United States is certainly not on track for achieving this goal. In fact, only half, as mentioned previously are even aware they are infected. Hepatitis C can endure without individuals experiencing any symptoms whatsoever. Even when there are though, many people in the United States lack access to care, especially specialty care. The cost of treatment also limits access to care, although even those with insurance are often denied treatment because insurance mandates advanced disease before they will provide coverage or they require the completely cessation of substance abuse and total sobriety (Maness, Riley, & Studebacker, 2021).

Injection drug use accounts for approximately 60 percent of acute hepatitis C infections in the United States. Men who have sex with men, particularly unprotected, are at increased risk, as are those who received blood products before 1992, and babies born to mothers who are infected. Transmission can even occur from various healthcare procedures, such as during hemodialysis, through needlesticks, even cosmetic procedures such as tattooing or piercings when not done following standard infection-control practices (Maness, Riley & Studebacker, 2021).

Acute Hepatitis C Virus

Most everyone within the acute phase of Hepatitis C are unaware as they do not have any symptoms. About ten to twenty percent though, start to demonstrate some anorexia, malaise, jaundice, and even abdominal pain about two-to-twelves weeks after exposure. We can start to identify in through laboratory finding at about four-to-ten weeks, so as you can imagine, sometimes we are testing and ruling out hepatitis C before it is even detectable in the blood. By six months however, 97 percent demonstrate positive with laboratory evaluation.

Once infected, about 15-to-45 percent of individuals completely clear the virus spontaneously, without any effort otherwise. Of course, this more often occurs in those who are younger and in the female sex. Polymorphisms impact clearance as well, such as IL28B, as does elevated alanine transaminase levels. The HCV genotype 1 and hepatitis also impact clearance, but either way, once diagnosed with acute infection, treatment begins (Maness, Riley, & Studebaker, 2021).

Chronic HCV Infection

The persistence of HCV after six months indicate chronic infection, even if symptoms are minimal. This infection can then progress towards liver fibrosis, cirrhosis, hepatocellular decompensation, and hepatocellular carcinoma. About 20-to-30 percent of individuals with chronic hepatitis C do progress towards cirrhosis in the next two-to-three decades. These are more often older men, generally 50 years or older, who are obese, drink a bit of alcohol, maybe have HIV and are on immunosuppressive therapy, or those who have nonalcoholic steatohepatitis (Maness, Riley, & Studebaker, 2021).

An elevated bilirubin level, hypoalbuminemia, prolonged prothrombin time, or decreased platelet count suggests cirrhosis. These individuals are at increased risk for liver cancer, ascites, encephalopathy, jaundice, spontaneous bacterial peritonitis, or variceal hemorrhage. Three of every four individuals in this situation have other health concerns beyond their liver disease, such as diabetes, hypertension, and cardiovascular disease, which further exacerbates their liver condition. Antiviral therapy may be helpful for these individuals, which has been shown to be more effective, better tolerated, and offer a shorter course than previous therapies such as interferon and ribavirin-based regimens (Maness, Riley, & Studebaker, 2021).

Family Practitioners verses Specialty Care

The ASCEND study demonstrated that primary care practitioners offer safe and comprehensive care for those with Hepatitis C and offer greater access to care. Certainly specialty consults may be in order, depending on the experience of the PCP, however, nonspecialists - either physician or nurse practitioner, have demonstrated excellent management of these clients (Maness, Riley, & Studebacker, 2021).

Referral is increasingly necessary when there is clinical deterioration or laboratory changes during treatment. If there is relapse, then a specialist can be helpful for genotyping and testing. Of course referrals to the appropriate addiction specialists, medical and psychiatric resources are also necessary.

No specific liver follow-up is recommended for those who never reached cirrhosis, but for those who do, surveillance is recommended indefinitely to rule out subsequent liver cancer and esophageal varices. This would include a liver ultrasound every six months and an upper endoscopy every two to three years, depending on initial results (Maness, Riley, & Studebacker, 2021).

References

Maness, D. L., Riley, E., & Studebacker, G. (2021). Hepatitis C: Diagnosis and management. Am Family Physicians, 104(6), 626-635.

Wilkins, T., Akhtar, M., & Gititu, E. (2015). Diagnosis and management of hepatitis C. American Family Physicians, 91(12), 835-842.