Hepatitis C

Organism

Hepatitis C is an infectious disease caused by the hepatitis C virus (HCV) that primarily affects the liver.

Clinical presentation

During the initial infection people often have mild or no symptoms. Occasionally a fever, dark urine, abdominal pain and jaundice occur.

Acute infection progresses to chronic disease in up to 75% of cases.

Chronic infection is usually asymptomatic. However, without treatment, around 20–30% of people with chronic HCV infection will develop cirrhosis, generally after 20–30 years of infection. In some cases, those with cirrhosis will develop complications such as portal hypertension, liver failure and liver cancer.

Investigations

Laboratory investigations of HCV infection include:

tests to diagnose HCV infection
tests for pre-treatment assessment of people with chronic hepatitis C infection
follow up tests to monitor liver function +/- response to treatment, see ‘Follow up’ section below.

Tests for diagnosing HCV infection

HCV diagnosis in Australia is based on detecting antibodies to HCV in a blood sample. A positive antibody test indicates past or current infection; these patients should have HCV RNA (NAAT)/HCV PCR testing to distinguish current/active infection (positive HCV RNA (NAAT)/HCV PCR) from past infection (negative HCV RNA (NAAT)/HCV PCR).

To ensure complete and timely diagnosis of chronic HCV, reflex testing is recommended.

Reflex testing:

Request on the pathology form that:

a) if the blood sample is positive to hepatitis C antibody, to then test for HCV ribonucleic acid (RNA); and

b) if the HCV RNA test is positive, that the pre-treatment virology assessment tests are also completed.

As a dedicated collection tube is required to undertake the HCV RNA, requesting the above will ensure the HCV RNA can be collected at the same time as the initial screening. This will reduce the number of appointments and blood tests required for your patients and reduce the likelihood of patient attrition.

See: ASHM Testing Portal | Hepatitis C (external site)

Window period

The screening test detects antibody to HCV. There is a period after infection, when the screening test will not detect antibody as they are yet to be produced or are present at a level that cannot be detected. This is called the window period. The time after infection at which antibody is identified can be up to 3 months, although it is usually 6 weeks.

A negative screening test for HCV excludes HCV infection provided that the last potential exposure was at least 12 weeks before the test. If not, the test must be repeated at an appropriate time.

Pre-treatment assessment of people with chronic hepatitis C virus (HCV) infection
History	Estimated duration of HCV infection Previous HCV treatment experience – date, regimen and response Cofactors for liver disease progression: alcohol intake, marijuana use, virological cofactors (HIV, HBV), diabetes, obesity For those planned to receive ribavirin, note history of ischaemic heart disease or cardiovascular risk factors Vaccinations against HBV and HAV Physical and psychiatric comorbidities Ongoing risk factors for viral transmission and reinfection Social issues – potential barriers to medication adherence
Medication	Concomitant medications (prescription, over-the-counter, illicit) NB: Current injecting of non-prescription drugs does not exclude the patient from treatment.
Physical examination	Features of cirrhosis: hard liver edge, spider naevi, leukonychia Features of decompensation or portal hypertension: jaundice, ascites, oedema, bruising, muscle wasting, encephalopathy Body weight and body mass index
Virology	HCV genotype and subtype HCV RNA level (quantitative) HBV (HBsAg, anti-HBc, anti-HBs), HIV, HAV serology
Investigations	Full blood examination, liver function tests, urea and electrolytes, eGFR, INR Pregnancy test for women of childbearing potential Liver fibrosis assessment, eg: Elastography (FibroScan, ARFI, SWE) OR Serum biomarker (APRI*, Hepascore, ELF test) Liver ultrasound should be performed in people with cirrhosis to exclude hepatocellular carcinoma Electrocardiogram should be performed if ribavirin therapy is planned and patient is > 50 years of age or has cardiac risk factors
HIV = human immunodeficiency virus. HBV = hepatitis B virus. HAV = hepatitis A virus. HBsAg = hepatitis B surface antigen. anti- HBc = hepatitis B core antibody. anti-HBs = hepatitis B surface antibody. eGFR = estimated glomerular filtration rate. INR = international normalised ratio. ARFI = acoustic radiation force impulse. SWE = shear wave elastography. *APRI = aspartate aminotransferase to platelet ratio index = (AST [IU/L] x 100) ÷ platelet count (x10^9/L) Online calculator available at Hepatitis C Online (external site). ELF = Enhanced Liver Fibrosis.

See:

Treatment

GPs and other medical practitioners experienced in the treatment of chronic hepatitis C infection are eligible to independently prescribe hepatitis C treatment under the PBS without consulting an infectious diseases physician, hepatologist or gastroenterologist.

Medical practitioners NOT experienced in the treatment of chronic hepatitis C infection may initiate hepatitis C treatment in consultation with an infectious diseases physician, hepatologist or gastroenterologist by submitting, the remote consultation request for initiation of Hepatitis C treatment form (Word 49KB) or (PDF 248KB).

Please forward the Remote Consultation Request form to the Central Referral Service by:
Secure Messaging: HealthLink secure messaging – crefserv (email)
Fax: 1300 365 056
Post: Central Referral Service
PO Box 3462
Midland WA 6056

Patients who are medically suitable to be treated for hepatitis C in a general practice/primary health care setting and have a valid prescription but do not have a Medicare card can purchase generic hepatitis C medications through FixHepC (external site). All patients with evidence of cirrhosis should be referred via the Central Referral Service to an infectious diseases physician, hepatologist or gastroenterologist for hepatitis C treatment

Treatment protocols for people with hepatitis C virus (HCV) infection and compensated liver disease

As it is likely that new hepatitis C treatments will continue to be made available through the PBS, please check the following sources to determine the most appropriate treatment regimen for your patient:

'How to treat hepatitis C': This video resource provides important information regarding testing for, and treating hepatitis C, and can be used to assist patients as they progress through the testing process, and into treatment if required.

Education, counselling and prevention

'How to treat hepatitis C': This video resource provides important information regarding testing for, and treating hepatitis C, and can be used to assist patients as they progress through the testing process, and into treatment if required.

Alcohol and other drugs

Abstinence from alcohol and other drugs is best, tailor according to previous intake and stage of disease.

Early disease with no risk factors for progression, consistently normal ALT and normal clinical examination - alcohol advice as per general population, NHMRC Australian guidelines (external site) to reduce health risks from drinking alcohol.

Significant fibrosis - one standard drink/day and no bingeing.

Cirrhosis - aim for total abstinence.

Refer to alcohol and drug services (external site) as necessary for alcohol withdrawal, opiate substitution treatment, etc.

If your patient is a person who injects drugs, refer to the Peer Based Harm Reduction WA (external site) or a Needle and Syringe Program in their local area.

Note that patients who are using alcohol and other drugs, including patients who inject non-prescribed drugs, can be treated successfully. Implementing a patient-centred approach in collaboration with the patient and, if relevant, their family/ social supports is recommended.

Dental care

Optimise oral health. Visit Dental Health Services (external site) for more information.

Immunisation

People with hepatitis C should be offered HAV and HBV vaccination, if not immune. See Guidelines for the Provision of Hepatitis A and B Vaccine to Adults in Western Australia at Risk of Acquiring these Infections by Sexual Transmission (PDF 248KB).

Nutrition

General recommendations for a healthy diet see Australian Dietary Guidelines (external site) refer to a dietician as necessary.

Psychological support

For patient and their family/partners, telephone support, education and support groups are available through Hepatitis WA (external site).

Smoking

Quitting will lead to improved general health. Visit Quit Now (external site) for more information.

Weight management

Aim for an ideal body weight (BMI 18.5-25kg/m2) or in overweight patients a gradual but sustained loss of at least 5-10% body weight. For more information visit Live Lighter (external site).

Work

People with chronic HCV who are health care workers may perform exposure prone procedures (EPPs) if they comply with the Australian National Guidelines for the Management of Healthcare Workers Living with Blood Borne Viruses and Healthcare Workers who Perform Exposure Prone Procedures at Risk of Exposure to Blood Borne Viruses (external site).

Management of partners

Patients should be advised to avoid behaviours that risk re-infection/super-infection and transmission to others, such as sharing injecting equipment. A superinfection is generally defined as a second infection superimposed on an earlier one, especially by a different microbial agent of exogenous or endogenous origin that is resistant to the treatment being used against the first infection.

Avoid sharing equipment that could be contaminated with visible or microscopic amounts of blood, e.g. injecting equipment, razor, toothbrush, dental floss, nail clippers, tweezers.

A new, sterile needle should be used for each episode of injecting drugs.

If patients are re-infected, they should be offered retreatment.

Counsel patients with chronic HIV or HBV co-infection about safe sex practices.

Follow up

Recommended follow-up for people not on treatment.

Ongoing

Review every 6 to 12 months and monitor for signs and symptoms of liver disease e.g. palmar erythema, spider naevi, jaundice, ascites, encephalopathy, hepato-splenomegaly, pruritis, weight loss and/or lethargy.

Monitor FBC, ALT, INR, albumin and bilirubin every 6 to 12 months.

Screening for hepatocellular carcinoma: Ultrasound and AFP every 6 months for those with cirrhosis.

Symptom management

Fatigue: advise planning rest periods during the day and the addition of light to moderate exercise into their routine to reduce fatigue.

Important: Provide immunisation and advice on how to reduce transmission.

Recommended follow-up for people on treatment or post-treatment

Monitoring of patients receiving antiviral therapy for hepatitis C virus (HCV) infection should be as per the recommendations in the Australian recommendations for the management of hepatitis C virus infection: a consensus statement (2022) (external site).

Referral

Refer to a PBS approved specialist for the following (see metro and regional list of approved specialists):

1. If the patient is suspected of having cirrhosis or the hepascore is >0.8
2. If the ALT following treatment remains elevated
3. All people with decompensated cirrhosis should urgently be referred.

Hepatitis C and HIV infection

Refer to specialist for treatment.

Hepatitis C in pregnancy and breastfeeding

There is a small risk (about 5%) of mothers transmitting hepatitis C to their babies at birth. It is unknown why the spread occurs or how to reduce this small risk.

All children born to a mother with hepatitis C should have a blood test after 8 weeks of age. However, it may not be possible to know if the child has hepatitis C until they are 12 to 18 months old.

Breast milk has not been shown to transmit hepatitis C. Breastfeeding is safe unless

your patient's nipples are grazed, cracked or bleeding
there is an infection in your patient's breast, such as mastitis
you patient's breast is bruised, such as through injury
there are cuts in your patient's baby's mouth.

Hepatitis C treatment in pregnancy and breastfeeding

There are no safety data for the use of any DAA regimen during pregnancy, with all PBS-listed DAA regimens classed as Category B. Treatment of pregnant women with DAA therapy is therefore not recommended.

Hepatitis C treatment for children

HCV treatments listed on the PBS can now be prescribed to children under the age of 18 years. People under the age of 18 years should be referred to a paediatrician who is experienced in the treatment of HCV.

HCV in Children: Australian Commentary on AASLD-IDSA Guidance (2021) provides recommendations for testing, managing, and treating hepatitis C.

Decision making – Hepatitis C in Children (2021) is a two-page summary was developed from the HCV in Children: Australian Commentary on AASLD-IDSA Guidance. The resource supports clinicians to provide advice and manage hepatitis C in children.

Public health issues

No specific prophylaxis or vaccine is available for HCV.
Notify WA Health of any cases.
Contact tracing is generally not carried out for all HCV cases.
Consider testing for other STIs and blood-borne viruses (HIV and HBV).
Provide information about other sources of information and support, such as HepatitisWA (see contacts for specialist advice on STIs and HIV for contact details).
Hepatitis A and B vaccination is recommended.

Notification

This is a notifiable infection. Medical practitioners must complete the appropriate notification forms for all patients diagnosed with a notifiable STI/HIV, as soon as possible after confirmed diagnosis.