Maintaining Your Health on Mackinac
Hepatitis C Virus Has Been Called the Shadow Epidemic
By Yvan Silva, M.D.

The hepatitis-C virus (HCV) is believed to have been present in humans for many decades. It was first recognized clinically in 1975 as distinct from the other viral forms of hepatitis types A and B, but not actually identified until 1989. A blood test for hepatitis C was developed in 1990 and then refined in 1992.

The magnitude of this widespread viral infection in humans has long been termed a shadow epidemic. HCV infects about 170 million people worldwide, five times as widespread an infection as HIV. The hepatitis-C epidemic has been overshadowed by the focus on AIDS and as a shadow epidemic it has continued to silently spread. In Europe, nine million individuals are infected. In the United States it affects four million. In contrast, one million Americans are believed to be HIV positive. Four percent of people between the ages of 30 and 50 may be carrying the virus; the incidence in African American men is thought to be 10 percent. Each year, an estimated 30,000 new infections are diagnosed and there are about 10,000 deaths. The death rate could rise to 30,000 over the next decade because there is yet no broadly effective and curative treatment. Unlike the biological response to the other forms of hepatitis A and B, where immunity to the virus will develop, we are unable to develop intrinsic immunity to attack the virus efficiently, and so it will continue to reside in the liver and bloodstream.

The HCV is an insidious virus. Few individuals who are infected become aware of the infection until there is severe liver damage. Infrequently, clinical symptoms ensue in the acute phase; malaise, nausea, fever, and jaundice. About 85 percent of people who acquire HCV become chronically infected. They continue to carry the virus and transmit it to others. For reasons not clearly understood, 15 percent of infected individuals lose the virus. The majority of carriers can remain fairly healthy and have no symptoms for several years, although insidious liver

damage continues. About 15 to 20 percent of infected individuals eventually develop cirrhosis of the liver, a result of scarring from the inflammation. Liver cancer occurs in one to five percent of those who have had the disease for more than 20 years.

HCV is transmitted primarily by infected blood. Initially, blood transfusion posed a serious risk for HCV infection. The introduction in 1990 and 1992 of improved blood screening measures has dramatically reduced the risk of transfusion-associated infection. The available information in 2001 indicated that blood that was negative for HCV antibodies was fewer than one in 103,000 transfused units. Today the risk is believed to be even lower as newer screening methods have become available.

Injection drug use is strongly associated with risk of infection. Like HIV, the spread is most efficient through direct contact with the blood of infected individuals. However, it is much more difficult to pass from mother to child or between monogamous sexual partners. The virus is not passed through everyday contact between people. Theoretically, using a razor, toothbrush, or scissors that might contain traces of blood might possibly cause an infection. Tattooing, acupuncture, and body piercing also theoretically carry this risk. The prevalence in health care workers has not been shown to be higher than the general population, yet needle stick injuries involving blood of infected patients increase the risk depending on the amount, the size, and depth of the inoculum. In a large number of cases, the cause of HCV infection is never identified.

These are the guidelines offered for those who should be tested for HCV: anyone who has ever injected illegal drugs, even once; those who received blood products for blood clotting disorders before 1987 or a blood transfusion or organ transplant before 1992; longterm hemodialysis patients; health care workers exposed to HCV contaminated blood; children born to mothers who are HCV positive, and people with any signs of liver disease, especially with blood tests that reveal abnormal liver functions. Those who might consider testing include people who have sniffed illegal drugs, undergone tattooing or body piercing, have a positive sexual partner or multiple partners, or have shared a toothbrush, razor, or other personal items.

There are several blood tests to determine the diagnosis and extent of the problem. Usually HCV testing follows the discovery of elevations in liver enzymes during routine tests; this increase occurs when liver cells are injured or die. The goal of the HCV test is to determine the presence of antiHCV antibodies, proteins that are made by the immune system in an attempt to fight the infecting virus. There are molecular tests for viral particles that are relevant to the outcome of anti-viral treatment if this is undertaken. In the broad scope of assessment and treatment, a liver biopsy with a fine needle is recommended for efficacy of treatment as well as to rule out other causes of liver disease if suspected.

In principle, all individuals with HCV should receive treatment. There is no way to predict who will develop serious complications when the diagnosis is made early. The treatment is difficult with debilitating side effects, in addition to being expensive. Treatment consists of oral antiviral agents and injections of interferon. Treatment takes six to 12 months, and only 40 percent achieve long-term remission. Therefore, each case needs to be individualized, ranging from watchful waiting, periodic testing for progression, weighing the pros and cons in each case.

In a review of persisting trends of this shadow epidemic the global impact continues to be serious. In spite of recent progress in diagnosis and treatment, the development of improved treatment methods remains a high priority. There is serious research into the development of a vaccine, but this remains elusive as of now.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.