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Wednesday, December 10, 2008

Hepatitis C Infection

The eighth Round Table Conference on Hepatitis C Infection, under the aegis of the Ranbaxy Science Foundation held at the India Habitat Centre on October 15, 2001, was attended by some of the most prominent gastroenterologists, pathologists and other related medical specialists from across the country. The conference sought to elucidate the various aspects of the infection and recent medical advances in the field of management and treatment. The highlights of the conference are discussed below.

Hepatitis C is an infectious viral disease of the liver that affects more than 150 million people worldwide. Of these almost 15-20% people develop chronic liver disease, liver cirrhosis and liver cancer. However, this condition has not received as much attention as other infectious conditions, notably AIDS, because of ignorance about the disease and the absence of effective treatment options. In India, approximately 18 million people are estimated to be infected.

Causes and transmission of the disease:

The infection is caused by the Hepatitis C Virus (HCV) that enters the body through two main routes – parenteral (through blood) and non-parenteral (sexual or vectors). The incubation period of the infection is 2-26 weeks i.e., the symptoms may take this much time to appear after a person has been infected. It may take as long as 5-10 years for an infected person to develop chronic liver disease after exposure to the virus.

The transmission of the virus by the parenteral route can occur through a variety of ways, the most common being through blood transfusion when the donor blood is infected. Other ways through which the virus may be transmitted are:

  • Intra-venous drug use - through infected syringes used during drug usage.
  • Body fluids like saliva/vaginal secretions etc. However, this form of transmission is very rare and occurs only in rare cases.
  • Siblings and children of infected persons may contract the disease through sharing contaminated instruments like razors, tooth brushes, etc.
  • Piercing of the skin as in the case of ear piercing, tattooing etc., with non-sterilised instruments increases the risk of exposure to the virus.
  • Though breast-feeding does not cause transmission of the infection, mothers who show symptoms of Hepatitis C infection should refrain from breast-feeding their children. The transmission of the infection is not dependant upon the type of delivery.

In most non-parenteral cases, a continuous exposure to the virus over a considerable period of time is needed before the individual becomes infected. Other alternate modes of transmission are through insect vectors and human bites.

Risk factors for Hepatitis C Infection:

Anyone who has had an exchange of blood due to any reason is at a risk for the infection. Since the primary mode of transmission of the HCV is through blood transfusion, any person who has had a surgery is susceptible to the infection. Of these, the maximum risk is to those patients who have had an obstetric/gynaecological surgery, an abdominal surgery or operation of the eyes or the heart. Dental procedures also expose an individual to the risk of infection. Patients on haemodialysis or those who have had organ transplants are also at an increased risk.

Other risk factors, apart from blood transfusion are:
  • Health workers who work with trauma patients are at an increased risk. Studies have shown that wearing gloves by health workers while handling such patients decreases the risk by 10 times.
  • Risk of intrafamilial transmission increases with increased severity of symptoms of the infected person, increased duration of contact, sexual contact between family members and the number of infected persons present in the family.
  • Age of a person is also a dependent variable, with the risk of infection increasing for people more than 45 years of age.
  • The type of viral infection (genotype 1, 2 or 3) is also important in determining the chronicity of the condition.

The rapidity of spread of the infection also depends on conditions like malignancy, alcohol use, other infections like HIV, lichen planus, vitiligo, urticaria, arthritis etc. the presence of any other infectious disease increases the risk of the infection with the HCV. Apart from the liver, the pancreas is another organ that is affected by the virus.

Symptoms and Diagnosis:

The Hepatitis C Virus (HCV) is also reportedly asymptomatic in almost 70-90% of the cases making diagnosis very difficult. Experts believe that if a patient who has had a recent surgery comes with symptoms of liver malfunction or jaundice, Hepatitis C infection must be suspected and checked for. Some of the laboratory tests that detect HCV are –
  • RIBA (Recombinant Immunoblot Assay)
  • HCV-RNA testing
  • Matrix
  • Liatek III
  • DB-2 blot test
  • Murex blot test

  • Treatment modalities:

    The main form of treatment of HCV infection is through drugs like Interferon, Amantadine and Ribavarin. A combination therapy of Interferon and Ribavarin for 6 months is most commonly used for HCV treatment. However, there are certain conditions in which therapy should be used with utmost caution. Some of these conditions are:
  • Kidney failure/transplant
  • HIV infection
  • Children
  • Blood disorders
  • When the patient is already on chemotherapy or any other immunosuppressive treatment.

  • Ribavarin is the drug of choice along with Interferon for HCV treatment, but it is not used in conditions like pregnancy, heart and kidney problems and psychological illnesses. Some categories of people do not respond to treatment at all and in such patients alternatives need to be sought. Elderly and overweight (>95 kg) patients and those with advanced fibrosis do not respond to this drug therapy. Patients who respond well to medication during the first week are also more likely to respond later and thus have a better prognosis.

    The current status of HCV vaccine is not too optimistic due to certain obstacles in the path of development of potent vaccines. There are too many diverse strains of the Hepatitis C virus to have be responsive to one vaccine. Even within an individual, the virus changes and evolves thus making its isolation and treatment difficult. No small animal models are currently available for vaccine testing.

    In light of the above information, control of hepatitis C infection is an ambiguous proposition. By the middle of this century, HCV will be a major chronic disease. Treatment of Hepatitis B is already available, so the epidemiology of Hepatitis C must be understood and given enough importance to prevent it from taking on epidemic proportions.

    Via: http://doctor.ndtv.com

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