Peppermint Patti’s FAQ V5 is copyright^© 1996-2005 by Dr. C.D. Mazoff, PhD, Patricia Johnson, and Joan King on behalf of HepCBC, the HepCAN list, and the HEPV-L Internet Mailing List. Permission is granted to redistribute or quote this document for non-commercial purposes provided that you include an attribution to HEPV-L and HepCBC, the contact address of CLOTHO@BELLATLANTIC.NET, INFO@HEPCBC.CA or HEPVL-REQUEST@MAELSTROM.STJOHNS.EDU, the FAQ’s version number and date, and at least two locations from which a current version of this FAQ may be retrieved (see Appendix A). For any other use, permission must be obtained in writing from Joan King (jking@hepcbc.ca), or Patricia Johnson (clotho@bellatlantic.net).

This is a document whose development is in progress. Please make comments to help improve it. Please send suggestions for additions, corrections, or changes privately to the authors (Patricia Johnson) at address clotho@bellatlantic.net, or to Joan King at jking@hepcbc.ca.

If you want your contribution to be anonymous, please state so.

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HEPV-L is a list devoted to people with chronic hepatitis, and related liver diseases. Its address is HEPV-L@MAELSTROM.STJOHNS.EDU ; HepCBC can be reached through www.hepcbc.ca.

Subscribe by addressing a message to: LISTSERV@MAELSTROM.STJOHNS.EDU and in the body of the message, on the first line, type: SUB HEPV-L FIRSTNAME LASTNAME (substituting your name for the first and last name). Any questions, or problems signing on—or off—the list, please contact one of the listowners at HEPVL-REQUEST@MAELSTROM.STJOHNS.EDU

HepCBC (www.hepcbc.ca) is an association of independent grassroots organizations in British Columbia, Canada, and beyond, dedicated to education and prevention of hepatitis C. It is the home of the hepc.bull, and the HepCAN list (http://groups.yahoo.com/group/hepcan/), a Canadian online information and support network, sister to HEPV-L.

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0.01 INTRODUCTION

This document answers frequently asked questions (FAQ) about the hepatitis C virus (HCV), its treatment, and related complications. We have made every effort to provide the most current and most accurate information.

This updated version (FAQ v5) reflects the international nature of the hepatitis C community. Although the home of the HEPV-L list is in the US, many of its members come from other parts of the globe. Patricia Johnson (Peppermint Patti), the original author of the FAQ had asked David Mazoff (squeeky), of HepCBC in Canada, if he could take over the arduous task of revising and updating the FAQ. David lives in Canada, and so this version has quite a bit of information for Canadians. To make the FAQ more accessible to those from countries other than Canada, information relating specifically to Canada has been put in appendices at the end of the document.

Thanks to a grant from the Legal Services Society of British Columbia, this edition now includes information on Disability Benefits for residents of BC. Hopefully, this section will expand to include all of Canada. The reader will also note that there is no list of physicians in the US comparable to the list of Canadian physicians given in Appendix D. Anyone wishing to compile this list is welcome to do so. Please contact the authors of the FAQ.

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0.02 DISCLAIMER

The information presented in this document was written and developed by patients and members of the HEPV-L mailing list.

It represents an informal catalogue of accumulated knowledge by people who for the most part are not medical professionals. As this file is developed further, we hope to include references and citations which will document more of the statements that are made here. Much of the information contained in this FAQ was compiled from the varied and personal experiences and opinions on the HEPV-L and HepCAN mailing lists, and from original research published in the hepc.bull. As useful as this information may be, it must not be considered medical advice, and must not be used as a substitute for medical advice. And as always, don’t forget to use your common sense. It is important that anyone who has, or thinks they may have, hepatitis should consult with a licensed health care practitioner who is familiar with liver disease and systemic disorders.

Thanks are due to the many contributors to this new official version of the FAQ. Below, in no particular order:

Alan Franciscus (HCV Advocate), Brad Kane (HepCBC), Andi Thomas (Hep-C-Alert), Anne Karim, Bruce Bennett, Bryce Brogan, Paul Harvey, Cindy Torchin, David Lang† (HEP Seattle), Frank Smith, Joe Shaw, Joan King (HepCBC), Kathryn Morse, Eileen Caldwell-Martin (FHCQ), Ken Benjamin, Kevin, Kunga Palmo (USHA), Sue White (Mid Island HepC), Capt. Kevin Donnelly†, Bruce Devenne (HepCNS), Leslie Gibbenhuck (Children’s Liver Alliance), Marjorie Harris (HepCure), Darlene Morrow (HepC VSG), Lucinda Porter, Pat Buchanan (LiverHope),**Peppermint Patti,** Sara Amber (HEP Seattle), Scott Warren (aka Reezer), C.D. Mazoff, aka squeeky (HepCBC), Rivaud (Hepv-l), Sheree Martin (Hep B List), Sybil, Smilin’ Sandi, Marie Stern, Brian D. Klein (HAAC), John & Matti Kirk, Rick Crane, and our mothers for making us possible.

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PART I - THE BASICS

I.0.1 WHAT IS HEPATITIS?

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The hepatitis A and E viruses first enter the gut and begin reproducing. They spread to the liver and multiply in liver cells. Hepatitis A and E thrive in unsanitary conditions. There is a vaccine for hepatitis A. Hepatitis A resolves itself, but can be fatal in children, the elderly, or the chronically ill. Hepatitis E poses a danger to pregnant women in the third world. If someone has hepatitis C and they get hepatitis A it can prove fatal.

Hepatitis B, C, D, and G enter the bloodstream; when they pass through the liver, they enter liver cells and begin to reproduce. The body attacks the infected cells, which causes the liver to become inflamed. In hepatitis B infection, the liver usually repairs itself, leaving antibodies to the surface antigen, which shows that the infection occurred, but that the body defeated it. However, recent studies show that hepatitis B may resurface many years later in individuals who have supposedly cleared the virus, much like the “post-polio syndrome.” Up to 90% of those infected with hepatitis B will clear the virus. There is a vaccine

When someone catches the hepatitis C virus, their body produces antibodies to try to destroy it. More often than not, the antibodies fail to identify the hepatitis C virus properly. The infection then remains long-term. Most infected people don’t know they have the virus. This is because for some people there will be no symptoms and for others, symptoms may take an average 13 years to develop. Some people may have hepatitis C for 20 years or more before finding out. There is no vaccine for hepatitis C.

The way that hepatitis affects people is different for different people. Some are not affected by the condition, but others are affected very badly.

It currently seems that if 100 people catch hepatitis C:

15-20 people will get rid of it within 2-6 months (much like we get rid of a flu virus)

60 people will have a long-term infection that may cause no problems or may cause levels of liver damage ranging from mild to serious.

20-25 people will have a long-term infection that leads to serious liver damage after 20 years. Of these people (i.e., those with serious damage after 20 years):

10-will remain stable and the other 15 will progress to liver failure or liver cancer after another 5 years According to an article in Gut 2000;47:131-136, the 5 year rate for progression to hepatocellular cancer is 13.4% and the 5 year rate for progression to death is 15.3%.

Hepatitis C infection doesn’t always make people sick. When someone does get sick, symptoms take a long time to develop (approximately 13 years).

Symptoms often stay at a certain level and don’t always get worse. They can come and go with no real pattern.

Some people with chronic infection don’t have any noticeable liver damage or symptoms. These people remain well, but THEY ARE INFECTIOUS AND SHOULD TAKE CARE TO REDUCE ANY RISK OF TRANSMITTING THE VIRUS TO OTHERS. ---

Data on the clinical course of HCV is limited because the onset of infection often goes unrecognized, and the early course of the disease is indolent and protracted in many individuals.

Prospective cohort studies are few, typically small, include relatively few subjects whose date of infection can be well documented, (e.g., blood transfusion recipients and victims of accidental needle sticks), and have relatively short follow-up. The natural history of the disease appears to differ according to geography, alcohol use, virus characteristics, (e.g., genotype, viral load), co-infection with other viruses, and other unexplained factors. - National Institutes of Health Statement on Hepatitis C 1997.

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I.0.3 WHAT IS THE INCUBATION PERIOD?

The incubation period (the amount of time that elapses between infection and the development of symptoms) varies for the different hepatitis viruses. Hepatitis A and E may develop as few as two weeks after exposure, but usually appear after four weeks. For hepatitis B and C it may take up to six months before symptoms develop. (The average incubation period is two to three months for hepatitis B and six to nine weeks for hepatitis C.) In experiments on chimpanzees, hepatitis D developed two to ten weeks after infection.

After initial exposure, HCV RNA can be detected in blood in 1-3 weeks. Within an average of 50 days (range 15-150 days), virtually all patients develop liver cell injury, as evidenced by elevation of serum alanine aminotransferase (ALT)—[an enzyme which leaks out of the damaged cells into the bloodstream]. The majority of patients are asymptomatic and anicteric [whites of the eyes are clear]. Only 25-35 percent develop malaise, weakness, or anorexia, and some become icteric [whites of the eyes are jaundiced]. Fulminant [rapid onset] liver failure following HCV infection has been reported but is a rare occurrence. Antibodies to HCV (anti-HCV) almost invariably become detectable during the course of illness. Anti-HCV can be detected in 50-70 percent of patients at the onset of symptoms and in approximately 90 percent of patients in 3 months after onset of infection. HCV infection is self-limited in only 15 percent of cases. Recovery is characterized by disappearance of HCV RNA from blood and return of liver enzymes to normal. - National Institutes of Health Statement on Hepatitis C 1997.

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I.0.4 HOW DOES HEPATITIS C USUALLY BEGIN?

For a slight majority of patients, the illness begins suddenly as though one had come down with the flu. Except that this “flu” doesn’t seem to completely go away. For many other patients, the onset appears gradually over a long period of time. Infants and young children often have no symptoms at all.

Many other symptoms may also be present, however they will typically be different among different patients. These include: fatigue, low-grade fever, headaches; slight sore throat, loss of appetite, nausea, vomiting, sensitivity to light, and stiff or aching joints.

Many people develop a pain in the right side, over the liver area.

The urine may become dark brown, and the feces may be pale. In severe acute infections, some people may develop jaundice in which the skin and whites of the eyes become yellowish.

The degree of severity can differ widely among patients, and will also vary over time for the same patient. Severity can vary between getting unusually fatigued following stressful events, to being totally bedridden and completely disabled. The symptoms have a tendency to wax and wane over time.

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I.0.5. WHAT ARE THE DIFFERENT TYPES OF HEPATITIS?

The different types of VIRAL hepatitis are:
A (formerly called infectious hepatitis, or yellow jaundice)
B (serum hepatitis)
C (formerly called non-A, non-B hepatitis)
D (delta hepatitis)
E (transmitted through the feces of an infected person)
G (a virus transmitted through infected blood products)
CRYPTOGENIC (or Non-A,B,C,D,E,G)
More hepatitis viruses are being discovered, but may be less common.

Other viruses, such as Yellow Fever, Epstein-Barre virus, Cytomegalovirus, as well as parasites and bacteria, can cause hepatitis as a secondary effect.

Other types of non-viral hepatitis are: Autoimmune, Wilson’s disease, hemochromatosis, drug or chemical induced, alcoholic hepatitis.

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I.0.6 WHAT IS THE FUNCTION OF THE LIVER?

The liver:

· Stores iron reserves, as well as vitamins and minerals

· Detoxifies poisonous chemicals, including alcohol, beer, wine, and drugs - prescribed and over-the-counter as well as illegal substances. Acts as a filter to convert them to substances that can be used or excreted from the body

· Converts food we eat into stored energy, and chemicals necessary for life and growth

· Makes your blood

· Manufactures new proteins

· Makes clotting factors to help blood clot

· Removes poisons from the air, exhaust, smoke and chemicals we breathe

· Manufactures and exports important body chemicals used by the body. One of these is bile, a greenish-yellow substance essential for the digestion of fats in the small intestine

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I.0.7 HEPATITIS C VIRUS (HCV)

Hepatitis C is a form of hepatitis caused by an RNA virus of the Flaviviridae family that targets the liver. HCV accounts for the majority of the hepatitis cases previously referred to as non-A, non-B hepatitis, and is responsible for 150,000 to 250,000 new cases of hepatitis each year.

The virus, which typically has a six to nine-month incubation period, presents symptoms such as: fatigue, nausea, loss of appetite, dark urine, and jaundice; and if left untreated can lead to liver failure, liver cancer and death. HCV is also a trigger for a host of autoimmune disorders and various other diseases, such as diabetes, non-Hodgkin’s lymphoma, retinal complications and thyroiditis. According to a recent report by a committee sponsored by the National Institutes of Health, nearly four million individuals in the U.S. are infected with HCV. The report also noted that treatment of the disease with current drugs is disappointing and estimated that the number of U.S. deaths caused by HCV will triple in the next 10-20 years.

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I.0.7a WHEN WAS THE HEPATITIS C VIRUS DISCOVERED?

In 1987, Michael Houghton and colleagues at Chiron Corporation in California discovered part of the genetic material of HCV using molecular recombinant technology. This discovery allowed the development of tests to detect specific antibodies. The first enzyme immunoassay (EIA) test made available in 1989 employed only a single recombinant protein to detect antibodies and produced a significant proportion of both false positive and false negative results. An antibody test that could be used to increase the safety of the blood supply and of transplantable organs and tissues was available by 1990.

In mid-1995 the hepatitis C virus was seen for the first time ever by scientists with the aid of an electron microscope. It is a linear single-strand RNA (ribonucleic acid) virus 40-50 nanometers in size.

It is covered with a lipid envelope and is encased with glycoprotein peplomers or “spikes”.

According to Bruce Devenne of Hepatitis Nova Scotia, governments and medical communities had knowledge of hepatitis C well before 1987, and could have done much to prevent the deaths of thousands. But they didn’t. Consider the poisoning of those in Ireland and France with HCV infected blood, and where court cases clearly found criminal liability on the part of blood merchants and governments. Consider also the history of blood safety in Canada, and the current Arkansas Blood Trail scandal (See Appendix E, below).

I.0.8 WHO GETS HEPATITIS?

People who have ever had blood transfusions or blood products before screening was introduced (1990), and people who have ever shared injecting equipment for drugs should be tested for the hepatitis C virus. Other people who should consider having the test done are those who have been tattooed, had body piercing or a needlestick injury. Healthcare workers who perform “exposure prone procedures” should also be tested.

People with abnormal liver function tests with no apparent cause would also benefit from having a hepatitis C antibody test. However, because of the historical inadequacy of sterilisation procedures in dentistry and in the health and beauty industry, we (HepCBC) recommend that anyone who has had extensive dental procedures where blood was present, or who has had manicures or pedicures be tested as well. Recent studies (2000) show that persons undergoing hemodialysis are still at risk, as are many cured cancer patients.

Hepatitis C currently causes between 150,000 and 250,000 new cases of chronic infection in the United States each year. Hemophiliacs and intravenous drug users are at the greatest risk, but anyone, of any status or age, and in any walk of life, is at risk for acquiring the hepatitis C virus. Researchers have found that many people infected with hepatitis C don’t even know it. From 20 to 40 percent of patients in inner-city hospitals are infected, as are 80 percent of intravenous drug users.

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I.1.0 HOW IS IT TRANSMITTED?

“Relax...you have cooties...but they aren’t as bad as you are imagining.” - Cindy Torchin: cindyt@cpcug.org Listowner HEPV-L ---

Most people with hepatitis C contracted it either through a blood transfusion or receiving a blood product (plasma, gammaglobulin, etc.) that was contaminated with hepatitis C, or by sharing needles with intravenous drug users that were infected with hepatitis C. Prior to 1990, the official line is that blood could not be screened for HCV (see, however, History of Blood Safety, below). Thanks to HCV testing with modern sensitive methods, the risk of acquiring hepatitis C from blood transfusion is now less than 1%. The other people who acquire hepatitis C include health care and laboratory workers that may get stuck with an infected needle or instrument, people receiving medical/dental procedures, people undergoing hemodialysis, body piercing, sharing razors, toothbrushes, nail clippers or people who have had tattoos or manicures that were performed with poorly sterilized equipment. Infected mothers can pass the virus to the fetus in utero; statistics for vertical transmission are between 5 and 10%. It may occur more readily if the mother is also infected with the human immunodeficiency virus (HIV) that causes AIDS--30% transmission rate.

Cases of hepatitis C with no evidence of exposure through blood transfusions, needle sticks or needle sharing are called “sporadic.”

How these individuals became infected is unknown. As early as 1956 the Merck Manual stated that NANB hepatitis could be spread through the use of glass syringes and other then current medical testing and mass vaccination devices.

Forty percent of all cases of hepatitis C were contracted through unknown means by people who are in no current risk category.

What this means is that we are all at risk for contracting hepatitis C.

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1.1.0a HOW HCV IS NOT TRANSMITTED

1. The hepatitis C virus is NOT airborne.

2. It is NOT spread by:

a. sneezing and coughing

b. holding hands

c. kissing (unless there is deep-kissing and open sores present)

d. using the same toilet

e. eating food prepared by someone with HCV

f. holding a child in your arms

g. swimming in the same pool

3. The virus IS in the blood of an infected person.

4. Hepatitis C can be spread by using something with infected blood on it such as:

a. razors, nail clippers or scissors

b. tooth brushes and water pics

c. tattoo or body piercing needles

d. illicit IV drug needles and paraphernalia (cottons, spoons, etc.)

e. tampons or sanitary napkins

5. The virus must enter the body through the skin or mucous membrane.

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I.1.1 HCV AND BLOOD TRANSFUSIONS

Anyone who received a blood transfusion or a blood product before 1992 is considered to be in a high risk group. Chance of infection by transfusion today is said to be 0.12%. Blood banks began screening donors for certain markers as early as 1986. In May 1990, screening tests for the hepatitis C virus came into use, and the risk is now thought to be one in 3,300 units of blood, or 0.12% for the typical recipient of a transfusion. - California at Berkeley Wellness Letter, May 1993 (see History of Blood Safety below).

HCV acquired through blood transfusion tends to be more severe than through other modes of transmission.

In a group of patients seen at a referral center, chronic post-transfusion hepatitis C infection was a progressive disease and, in some patients, led to death from either liver failure or hepatocellular carcinoma - N Engl J Med 1995;Vol 332, no 22:1463-1466

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I.1.2 HCV AND INTRAVENOUS DRUG USE

Investigators at Johns Hopkins report that injection drug users are at high risk for contracting hepatitis B and C, and that many contract hepatitis B or C within the first year of IV drug use.

Dr. David Vlahov and colleagues studied 716 volunteers who had been injecting for six years or less. Seventy-seven percent of them were infected with HCV and 65.7% were infected with HBV. Roughly 20% were HIV-positive. Hepatitis C was more prevalent among those who reported injection drug use for less than four months than among those who reported injecting drugs for 9 to 12 months. Am J Pub Health 1996;86:642-646 .

Recent studies in British Columbia (1999) show that 90% of the male prison population is infected with HCV.

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I.1.3 HCV AND IV IMMUNOGLOBULIN (GAMMAGARD/POLYGAM/FACTOR D)

Contaminated batches of Gammagard and Polygam, drugs used in intravenous immunoglobulin therapy, may have caused thousands across the U.S. to contract the hepatitis C virus. Many of those infected by Gammagard were children. Gammagard is primarily used to boost a patient’s immune system. Many women in Ireland were infected through the use of contaminated Factor D after childbirth.

Patients who received immunoglobulin therapy should contact their doctor immediately to have liver function tests performed.

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I.1.4 NEONATAL TRANSFER OF HCV

This following is from the HepCBC pamphlet, HCV & Pregnancy. The information was vetted by the BCCDC

Reducing the Risk of Transmission During and After Pregnancy

A woman living with Hep C who wishes to become pregnant may have particular anxieties about the health of her baby. The chance of the virus being transmitted to the baby is 5-10%, and higher in persons who have HIV as well. If a mother also has AIDS, the chances can increase up to 36 in 100. The risk may be even greater in mothers who are infected with both Hep B and Hep C.

Transmission to the baby can happen before or during birth. In parts of the world with lower standards of general health, transmission from a woman with Hep C to her baby is more likely. Most doctors and midwives will be helpful and supportive to a woman with Hep C who wants a child. Pregnancy with Hep C is not officially discouraged.

Viral Load and Mother-to-Baby Transmission

Viral load is the amount of Hep C in the blood. If a woman with Hep C has low viral load (less than 1 million copies/mL), it is less likely that the virus will be passed to her baby than if she has high viral load. However, even if viral load is very low, there is still a chance that Hep C will be transmitted.

Given the low risk of transmission from mother to infant there is not enough information at present regarding the use of Caesarean sections to reduce the risk of transmission. However, it is possible that if a woman has an acute case of Hep C, there is more of a risk of her baby being infected.

Breast Feeding

It is not yet known whether the breast milk of a woman with Hep C contains enough virus to infect a baby during breast feeding. Generally, women with Hep C are not advised to avoid breast feeding. No studies have documented transmission of Hep C infection to infants by breast-feeding.

Children with Hep C (See also II.8.0 How Does HCV Affect Children?)

In children, viral infection is usually silent, although children as young as 8 years old can become quite ill from HCV.

Children are less likely than adults to have symptoms of infection with Hepatitis C, and thus may be able to transmit the virus unknowingly.

Having hepatitis C does not seem to affect a child’s growth.

All children, with or without hepatitis C, should be taught proper hygiene.

Children and Advanced Liver Disease

Chronic hepatitis C eventually causes cirrhosis or cancer. However, it can take 10 to 20 years or more before cirrhosis may occur. Liver cancer rarely occurs in children.

Treatment in Children

Few studies exist examining interferon (IFN) use in children with chronic HCV. A recent study suggests that IFN therapy may benefit children with chronic HCV, and indeed, children may respond better than adults, possibly because they have been infected for less time and have a milder disease. Interferon is used in children only in clinical trials in Canada at this time. Another drug, called ribavirin, is being used in combination with IFN in adults and may be recommended for children in the future.

There are still many questions about Hepatitis C in children. More studies are necessary to learn more about how the disease progresses and about different treatments.

Talking to Health Care Workers

Doctors and midwives can be helpful and supportive to a woman with Hep C who wants a child. It can be very hard for a woman with Hep C to tell her health care workers she is pregnant or wants to be, if she suspects they will try to change her mind. Staff with experience of working with women who have Hep C are likely to be the best informed and most supportive.

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I.1.5 OTHER MEANS OF HCV TRANSMISSION

Like hepatitis B, hepatitis C is spread through exposure to blood from an infected person, such as through a blood transfusion or sharing needles. There is no evidence that the hepatitis C virus can be transmitted by casual contact, through foods or by coughing or sneezing.

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I.1.5a SEXUAL TRANSMISSION

The risk of sexual transmission of hepatitis C virus has not been thoroughly investigated but appears to be minimal. Some studies have shown no risk of passing hepatitis C on to a sexual partner, others have shown only a very low risk. The United States Centers for Disease Control and Prevention (CDC), as well as the British Columbia Centre for Disease Control do not recommend a change in sexual practices for those engaged in a long-term relationship with one sexual partner. However, people with acute illness and multiple sexual partners may be at greater risk and should use condoms to reduce the risk of acquiring or transmitting hepatitis C as well as other sexually transmitted infections. The risk is increased if the HCV positive partner is immunocompromised because the virus titer in the blood may be increased under those circumstances. Sex during the menstrual period should be avoided, due to the blood contact at that time. There is also some speculation about the possibility of transmission piggybacked on the genital herpes virus through genital lesions.

The reason that many studies say “multiple sexual partners” when referring to the risk of sexual transmission of HCV is that people who have multiple sexual partners have a greater risk of contracting other sexually transmitted diseases which can cause open sores and lesions. And with those open sores and lesions you are at greater risk for blood contact. Also, it is thought that the hepatitis C virus tends to “piggyback” on the herpes virus, and if you have herpes you are at much greater risk of contracting or transmitting the virus.

According to a report in the Archives of Internal Medicine, sexual transmission of HCV occurs at a rate of about 1% per year in at-risk partners, and shows that periodic serum immune globulin prophylaxis for sexual partners is protective.

Transmission of the virus “...occurred only in partners of HCV-infected patients with active liver disease,” the researchers report. They add an “intriguing” finding that patients who became infected during the study were older and had longer relationships with their partners compared with those who did not become infected. - Arch Intern Med 1997;157:1537-1544

A report from Health Canada, “Hepatitis C Prevention and Control: A Public Health Consensus,” June 1999, p.6, recommends that:

1. People with multiple partners should practice safer sex.

2. Longstanding sexual partners do not need to change sexual practices if one of them is found to be infected with hepatitis C

A recent study in The Lancet, 356:9223:42-43 (June 2000) detected the hepatitis C virus in the semen of infected men. The doctors concluded that “the presence of HCV-RNA in semen is a strong argument in favour of HCV sexual transmission from men to women.” However, HCV viral loads detected in semen were low, which suggests that the risk of HCV sexual transmission is probably also low.

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I.1.5b OCCUPATIONAL EXPOSURE (HEALTH CARE WORKERS)

The general consensus is that HCV is a greater threat to healthcare workers than HIV. The risk that healthcare workers will become infected with hepatitis C virus (HCV) following an accidental needlestick is 20 to 40 times greater than their risk of HIV infection, according to data presented at the International Conference on Emerging Infectious Disease. Sponsored by the US Centers for Disease Control and Prevention and the American Society for Microbiology (July 2000).

Occupational exposure to HCV is possible in any occupation in which there is exposure to possibly infected blood, (i.e., nurses and phlebotomists through needle sticks, emergency medical technicians, and firemen through blood at accident scenes, etc.). The risk of HCV infection following a needlestick injury with HCV-contaminated blood may be as high as 10%. Nonetheless, the risk of occupational transmission of HCV to Health Care Workers is far less than that of HBV.

Current recommendations are that "both private and public health providers be made aware of the risk, and above all that all source patient providers be tested for hepatitis C."

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I.1.5c TOOTHBRUSHES/RAZORS/NAIL CLIPPERS

It is possible for toothbrushes, razors, nail clippers, tweezers and similar personal care items to come in contact with infected blood. Therefore, sharing of these items is not recommended. Recently concern was expressed over the sharing of electric razors in a VA hospital. A study in Hepatology showed that 19% of veterans tested in a VA hospital in San Francisco were infected with HCV.

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I.1.5d HEMODIALYSIS

Hepatitis C viral infection is a common infection in hemodialysis units, according to a report by Dr. Brian J.G. Pereira of Tufts University in the the January 25, 1996 edition of Family Practice News.

Dr. Pereira points to data from eight studies that indicate a 16% prevalence rate of infection in nearly 2,500 dialysis patients without a history of blood transfusion - a rate “considerably higher” than that seen in the general population.

Recent studies recommend regular testing for HBV and HCV among hemodialysis patients Though uncommon, new hepatitis virus infections were detected among patients with normal ALT tests (Harvey S. Bartnof, MD, (www.hivandhepatitis.com, July 9 2000). Reports at the Digestive Disease Week 2000 that was held in San Diego, California between May 21-24, 2000 reveal that in a study of 51 patients with CRF (chronic renal failure), 42 had a normal ALT and ten of them (24%) had detectable HCV RNA. Among the remaining nine patients with an elevated ALT, five of them (56%) had detectable HCV RNA.

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I.1.6 HIGHLY SPECULATIVE MODES OF TRANSMISSION OF HCV

The following are considered highly speculative because either no studies have been done, conflicting studies have been done, or there is scientific reason to believe this is not a mode of transmission, but there still is no conclusive study to rule it out.

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I.1.6a TEARS, SALIVA, URINE, AND OTHER BODY FLUIDS

Body fluids from 14 patients with chronic hepatitis C were analyzed for the presence of hepatitis C viral RNA using the polymerase chain reaction. The hepatitis C viral genome was not detected in any saliva or semen sample, although antibodies to the virus were (J Med Virol 1998 May;55(1):24-27). These findings suggest that body fluids of patients with chronic hepatitis C are rarely, if ever, contaminated with the hepatitis C virus. Another study (J Med Virol 1998 Apr;54(4):271-275), however, revealed the presence of the virus itself, and led the researchers to question whether or not the virus could reside in the salivary glands themselves (“Predominance of HCV type 2a in saliva from intravenous drug users.” University of Glasgow Dental School, Scotland).

A very recent study in France detected the presence of HCV RNA in the semen of HCV infected men. The researchers had to devise a special test to detect the virus. Ordinary PCR tests are not strong enough to detect the small amount of HCV viral particles in semen. The doctors caution that although the risk of transmission is low because the viral load in semen is low, nevertheless the risk of sexual transmission from men to women remains a possibility (The Lancet 356: 9223:42-43, July 2000).

Previous studies have provided conflicting results on the presence of hepatitis C virus-RNA in saliva. In this study, 23 (62%) of 37 patients tested positive for hepatitis C virus-RNA in saliva, using polymerase chain reaction analysis. A slightly greater proportion had a sporadic rather than a parenteral origin of chronic hepatitis C. These results provide a biological basis for saliva as a possible source of hepatitis C virus (HCV) infection, but do not necessarily imply transmission by this route. - “Detection of HCV-RNA in saliva of patients with chronic hepatitis C”, P. Couzigou, L. Richard, F. Dumas, L. Schouler; H. Fleury, Gut 34:S59-60 (1993)

We conclude that HCV RNA is present in the saliva of approximately half of patients with acute and chronic hepatitis C, and the presence of HCV RNA correlates with HCV viremia. The efficiency of HCV transmission is low among spouses. - “Hepatitis C virus RNA in saliva of patients with posttransfusion hepatitis and low efficiency of transmission among spouses”, J. T. Wang, T. H. Wang, J. C. Sheu, J. T. Lin; D. S. Chen, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Republic of China.

For up to 20 to 40% of patients chronically infected with hepatitis C virus (HCV), the mode of transmission is still unknown. We demonstrate that tear fluid contains HCV RNA-carrying material with the properties of infectious virus and conclude that smear infection with tear fluid may play a role in HCV transmission. - “Tear fluid of hepatitis C virus carriers could be infectious”, H. H. Feucht, B. Zollner, M. Schroter, H. Altrogge & R. Laufs, J Clin Microbiol 33: 2202-2203 (1995)

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I.1.6b CAT SCRATCHES

It is unknown if the hepatitis C virus can be transmitted via cat’s claws if the cat scratches one person and immediately scratches another.

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I.1.6c MOSQUITOS

Researchers have determined that the hepatitis C virus is not transmitted by mosquitos. There is a lack of epidemiological or physical evidence that it is mosquito-borne and experiments to see any HCV replication in mosquito cells have failed.

There are two ways that mosquitos can transmit illness to humans.

These are “mechanical transmission” in which a small amount of blood may be present on the mosquito’s feeding spike.

This type of transmission does not occur with serious human diseases such as HCV, HBV, or HIV. The second way mosquitoes transmit disease is called “biological” transmission. Studies show that mosquitoes can swallow viruses into their middle gut, but once there the virus dies and is digested in the same way we digest food - by breaking it down using acid.

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I.1.6d ALTERNATIVE MEDICAL PROCEDURES

Some cases may be related to the use of poorly sterilized needles by medical practitioners in some countries as well as folk medicine and cultural practices that involve skin piercing.

Alternative medical procedures involving invasive medical procedures, particularly those performed in non-medical settings (i.e., acupuncture), or involving autologous blood (such as the ozone-enrichment of blood) may transmit the hepatitis C virus. ref: “Transmission of Hepatitis C by Ozone Enrichment of Autologous Blood,” Lancet, 1996;347:541).

A cross sectional survey of seropositivity for hepatitis C in Japan found an increased risk of hepatitis C associated with acupuncture (BMJ 2000;320:513, 19 February).

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I.1.6e HOUSEHOLD TRANSMISSION

Household transmission of hepatitis C is rare. It can occur where blood-to-blood contact happens. This could involve your blood spills coming into contact with someone’s open cut, or to a lesser extent, the sharing of razor blades, toothbrushes and sharp personal grooming aids. It is advisable to wipe up blood spills with paper towels and bleach, and to keep razors and toothbrushes separate from those belonging to other family members. Wiping a surface with isopropyl alcohol and leaving it to air dry will also kill the virus.

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I.1.6f OTHER

A proportion of HCV infected individuals do not fall into any currently recognized risk group. It is thought that some of these cases may have had exposure to injected drugs many years ago which they have forgotten or are unwilling to discuss. It is also possible that many persons were infected in the early 50s during mass vaccination programs in schools and camps. As well, programs for the poor often used cost cutting measures which included the recycling of medical devices (syringes, needles) which should have been thrown away. Furthermore, blood products have been used in the making of many vaccines and in the 50s and 60s these products were not screened for HCV.

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I.1.6g IS HCV ANYTHING LIKE HIV?

Yes and No. HIV and HCV are both RNA viruses. That is both use RNA to carry their genetic code until they find a yummy host! However, these viruses belong to two entirely different families. Sort of like whales and humans are both mammals, but boy what a difference. They have completely different strategies for replication and for survival.

HIV is a retrovirus, and once the virus is in a human cell it copies itself to DNA and migrates into the cell nucleus and integrates into the host genome and is then copied every time the cell copies its own DNA. Retro means that the virus reverts to a DNA virus once it is in the cell. Other retro viruses are HTLV viruses like some types of leukemia.

HCV is a flavivirus. It is related to yellow fever and dengue fever viruses. It replicates by making positive and negative RNA strands and does not make DNA or integrate into the host genome.

There are lots of other structural and envelope differences between these two, but the main point is that HIV and HCV are NOT very similar at all—except they both completely screw up the immune system and there is no known cure. (See Double Jeopardy: The HIV/HCV Co-Infection Handbook, which we have appended to the printed version of this FAQ). See also Appendix F: “The Double Challenge of HIV/HCV Co-infection.”

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I.1.7 PREVENTION

Prevention: avoid risk behaviors. Shots of gamma globulin (now supposedly safe) after a person has been stuck with a needle do not seem to work. There are no current HCV vaccines. With screening of the blood supply, the risk of HCV infection from a transfusion has dropped from 10% (1970’s) to less than 1%. “Prevention, Diagnosis, and Management of Viral Hepatitis,” AMA.

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I.1.7a WHEN, AND FOR HOW LONG, IS A PERSON ABLE TO SPREAD THE HEPATITIS C VIRUS?

Eighty-five to ninety percent of all HCV carriers will have it for life, or until a cure is found. All carriers of HCV can transmit the disease to others via his or her blood. The disease may occur in the acute form and be followed by recovery, but the majority of the cases become chronic and cause symptoms for years.

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I.1.7b HOW CAN THE SPREAD OF HEPATITIS C BE PREVENTED?

People who have hepatitis C should remain aware that their blood and possibly other body fluids are potentially infective, even when the person carrying the virus is asymptomatic. Care should be taken to avoid blood exposure to others by sharing toothbrushes, razors, needles, etc. Infected people must not donate blood, plasma or semen, and should inform their dental or medical health providers so that proper precautions can be followed.

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I.1.7c CLEANING UP BLOOD SPILLS

A 10% bleach (soak for 30 minutes) should be used on all contaminated surfaces. There is no proof that this KILLS everything, but you can’t autoclave the world. There are also chemical disinfectants containing phenols and other very expensive ingredients, but for home use bleach is the best we have. Bleach can be VERY VERY corrosive on some surfaces...so be careful what you slop it on.

Pure H2O Bio-Technologies Inc. is currently working on a new germ killing liquid that kills bacteria and some viruses, including hepatitis C.

From the hepc.bull Dec 1999, Issue 18.

“BLOOD SPILLS: DO YOU KNOW HOW TO SAFELY CLEAN UP A SPILL OF BLOOD OR BODY FLUID? THIS ARTICLE WILL TELL YOU HOW. by Mark Bigham, MD, FRCPC, British Columbia Centre for Disease Control

Hepatitis C virus (HCV) is transmitted mainly by exposure to HCV-contaminated blood. HCV infection is not generally associated with exposure to other body fluids, such as saliva, urine, feces or vomit, but if HCV-contaminated blood is present in these or other body fluids, then the risk of infection will be greater. Therefore, it’s important to treat any environmental contamination of blood or body fluid as potentially infectious. The simple principles of cleaning and disinfecting, which are effective against HCV, are also very effective against other micro-organisms.

Viruses can only reproduce inside cells and HCV will not survive very long outside the human body—usually no more than a few hours. Survival of HCV in the environment is limited by such factors as lower temperature and dryness. HCV is also readily killed by standard household products, such as 5% household bleach or 70% isopropyl alcohol.

If you encounter a spill of blood or body fluid, the most important infection control principle is to avoid direct contact. This is easily and effectively achieved by wearing rubber gloves—preferably single use, disposable vinyl gloves, or even household rubber gloves. Litter, such as broken glass should be picked up first. Try not to handle broken glass that could tear the gloves. Pieces of stiff cardboard or newspaper folded over can be used to pick up glass. When disposing of glass, wrap it in a newspaper before throwing it in the garbage bag, to protect municipal waste disposal workers from being cut when handling the bag.

Next, clean up the visible blood or body fluid with plain water and disposable paper towel. Using water will dilute the spill, reduce its infectivity, and facilitate wiping up the spill. Cleaning the visible spill will also remove organic matter that can reduce the effectiveness of disinfectants. The used paper towel can be put in a plastic bag (double bag if very wet and dripping) and disposed of in the regular household garbage.

A disinfectant should then be used. Regular 5.25% household bleach is an excellent disinfectant choice—it is inexpensive; has low toxicity and is not usually irritating to the skin; is fast acting; and is very effective not only against HCV, but also other blood-borne viruses (e.g., HIV, Hepatitis B virus), bacteria and fungi. It can be diluted with water to make a 1:10 to 1:100 bleach solution. The diluted solution should be prepared fresh, since bleach degrades over time when exposed to air or light. It can be wiped onto the surface with a towel and left to air dry, or poured onto the affected area and then wiped up with disposable paper towels after 10 minutes. An effective, alternative disinfectant for use on colour-sensitive fabrics or materials is 70% isopropyl alcohol, full strength, and applied in the same manner as described for bleach.

Gloves can then be carefully removed and disposed of in the regular household garbage along with the used paper towels. Reusable gloves can be rinsed in water and dipped or wiped in disinfectant and allowed to air dry. Finally, don’t forget to wash your hands.

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I.1.7d WHAT TO DO IN CASE OF AN ACCIDENTAL NEEDLESTICK

Because there is no effective neutralizing antibody or vaccine for preventing hepatitis C virus (HCV) transmission, HCV can be transmitted to health care workers through accidental needlesticks. In a study reported in the journal Clinical Infectious Diseases, after the clinical onset of acute hepatitis, two health care workers who had sustained accidental needlesticks were treated with interferon (total dose, similar to 300 megaunits). Neither individual developed chronic hepatitis. This finding raises the possibility that treatment with low-dose interferon following an accidental needlestick may be beneficial, even when it is started after the clinical onset of hepatitis. - “Early Therapy with Interferon for Acute Hepatitis C Acquired Through a Needlestick.” Clinical Infectious Diseases, May 1997;24(5):992-994.

A more recent study showed 100% 2-year sustained virologic response with alfa interferon monotherapy for acute hepatitis C. In a small study with seven patients, high-dose treatment for one year (5 mil daily for was 12 weeks, followed by 3 MIU 3-times weekly for 40 weeks. This represents a total alfa interferon dose of 780 MIU. The results were that all seven of the seven treated patients (100%) with acute HCV infection had a sustained virologic response two years after completing therapy. By contrast, only two of ten (20%) of those with chronic hepatitis C in the comparative arm achieved a sustained virologic response. The difference was statistically significant (Digestive Disease Week 2000).

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I.1.8 WHOM SHOULD I TELL?

If you have hepatitis C, you are under no legal obligation to tell others. However, the law may change. Right now, it is up to you to decide whether to tell anyone of your hepatitis C status. Some people, (and unfortunately some health care providers also) may have judgmental attitudes or unnecessarily exaggerated fears of infection. People should carefully consider whom they inform, in the light of possible discrimination. How people might have caught the virus is not important. Those who have the hepatitis C virus are covered by anti-discrimination laws.

Recent cases where patients have been infected by physicians has raised the ethical issue of whether or not infected physicians should be banned form performing invasive procedures. So far nothing has been done in this respect (Milbank Q 1999;77(4):511-29) Infected physicians and invasive procedures: national policy and legal reality; Rev Med Virol 2000 Mar;10(2):75-78 Surgeons who test positive for hepatitis C should be transferred to low risk duties).

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I.1.9 CAN YOU GET HEPATITIS MORE THAN ONCE?

Once you completely recover from hepatitis A or B you can’t get it again, although in some people the condition becomes chronic and can last their whole lives. But since there are at least five different viruses that cause hepatitis, you can get one of the others (though not D if you are immune to B). Becoming infected with B and C at the same time may actually cause a much more severe, dangerous case of hepatitis. A person who has recovered from a case of viral hepatitis could also develop hepatitis again due to other causes, such as alcohol or drugs.

If you have had hepatitis C and clear the virus, you can become infected with it again. Because there are so many different genotypes of hepatitis C, and because the virus mutates so rapidly, natural immunity is not developed. Studies with chimpanzees have shown that after resolution of an acute hepatitis C infection, rechallenge with the same strain of HCV causes reinfection.

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