Hepatitis C is a liver disease caused by the hepatitis C virus: the virus can cause both acute and chronic hepatitis, ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness.
The hepatitis C virus is a bloodborne virus and the most common modes of infection are through exposure to small quantities of blood. This may happen through injection drug use, unsafe injection practices, unsafe health care, and the transfusion of unscreened blood and blood products.
Globally, an estimated 71 million people have chronic hepatitis C infection.
A significant number of those who are chronically infected will develop cirrhosis or liver cancer.
Approximately 399 000 people die each year from hepatitis C, mostly from cirrhosis and hepatocellular carcinoma.
In Georgia Approximately 150 000 people have hepatitis C and most of them do not know about their disease.
Antiviral medicines can cure more than 95% of persons with hepatitis C infection, thereby reducing the risk of death from liver cancer and cirrhosis, but access to diagnosis and treatment is low.
There is currently no vaccine for hepatitis C; however research in this area is ongoing.
Since 2015, Georgia has launched unique hepatitis C elimination program, in which all citizens of Georgia have the possibility to cure this disease. Within the program, screening and medicines for hepatitis C are provided for free.
Hepatitis C virus (HCV) causes both acute and chronic infection. Acute HCV infection is usually asymptomatic, and is only very rarely (if ever) associated with life-threatening disease. About 15–45% of infected persons spontaneously clear the virus within 6 months of infection without any treatment. The remaining 55-85 % of persons will develop chronic HCV infection. Of those with chronic HCV infection, the risk of cirrhosis of the liver is between 15–30% within 20 years.
The hepatitis C virus is a bloodborne virus. It is most commonly transmitted through:
Injecting drug use through the sharing of injection equipment;
The reuse or inadequate sterilization of medical equipment, especially syringes and needles in healthcare settings;
Transfusion of unscreened blood and blood products.
HCV can also be transmitted sexually and can be passed from an infected mother to her baby; however these modes of transmission are much less common.
Hepatitis C is not spread through breast milk, food, water or by casual contact such as hugging, kissing and sharing food or drinks with an infected person. Estimates obtained from modelling suggest that worldwide, in 2015, there were 1.75 million new HCV infections (globally, 23.7 new HCV infections per 100 000 people).
Populations at increased risk of HCV infection include:
People who inject drugs;
People who use intranasal drugs;
Recipients of infected blood products or invasive procedures in health-care facilities with inadequate infection control practices ;
Children born to mothers infected with HCV ;
People with multiple sexual partners;
People with sexual partners who are HCV-infected
People with HIV infection;
Prisoners or previously incarcerated persons; and
People who have had tattoos or piercings.
About 2.3 million people of the estimated 36.7 million living with HIV globally have serological evidence of past or present HCV infection. Conversely, among all HIV-infected persons, the prevalence of anti-HCV was 6.2%. Liver diseases represent a major cause of morbidity and mortality among persons living with HIV.
The incubation period for hepatitis C is 2 weeks to 6 months. Following initial infection, approximately 80% of people do not exhibit any symptoms. Those who are acutely symptomatic may exhibit fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, dark urine, grey-coloured feaces, joint pain and jaundice (yellowing of skin and the whites of the eyes).
Hepatitis C infected person can transmit the disease till the end of treatment process. Patient is considered free of disease after conducting HCV RNA Test (SVR). However, rapid screening test for HCV antibodies will always stay positive.
Screening and diagnosis
Due to the fact that acute HCV infection is usually asymptomatic, few people are diagnosed during the acute phase. In those people who go on to develop chronic HCV infection, the infection is also often undiagnosed because the infection remains asymptomatic until decades after infection when symptoms develop secondary to serious liver damage.
HCV infection is diagnosed in 2 steps:
Screening for anti-HCV antibodies with a serological test identifies people who have been infected with the virus.
• If the test is positive for anti-HCV antibodies, a nucleic acid test for HCV ribonucleic acid (RNA) is needed to confirm chronic infection because about 30% of people infected with HCV spontaneously clear the infection by a strong immune response without the need for treatment. Although no longer infected, they will still test positive for anti-HCV antibodies.
After a person has been diagnosed with chronic hepatitis C infection, they should have an assessment of the degree of liver damage (fibrosis and cirrhosis). This can be done by liver biopsy or through a variety of non-invasive tests.
In addition, these people should have a laboratory test to identify the genotype of the hepatitis C strain. There are 6 genotypes of the HCV and they respond differently to treatment. Furthermore, it is possible for a person to be infected with more than 1 genotype. The degree of liver damage and virus genotype are used to guide treatment decisions and management of the disease.
Hepatitis C does not always require treatment as the immune response in some people will clear the infection, and some people with chronic infection do not develop liver damage. When treatment is necessary, the goal of hepatitis C treatment is cure. The cure rate depends on several factors including the strain of the virus and the type of treatment given.
The standard of care for hepatitis C is changing rapidly. Sofosbuvir, daclatasvir and the sofosbuvir/ledipasvir combination are part of the preferred regimens in the WHO guidelines, and can achieve cure rates above 95%. These medicines are much more effective, safer and better-tolerated than the older therapies. Therapy with DAAs can cure most persons with HCV infection and treatment is shorter (usually 12 weeks). WHO is currently updating its treatment guidelines to include pangenotypic DAA regimens and simplified laboratory monitoring. Meanwhile, there remains a very limited role for pegylated interferon and ribavirin in certain scenarios. Although the production cost of DAAs is low, these medicines remain very expensive in many high- and upper middle-income countries. Prices have dropped dramatically in some countries (primarily low-income) due to the introduction of generic versions of these medicines.
Access to HCV treatment is improving, but remains limited. In 2015, of the 71 million persons living with HCV infection globally, 20% (14 million) knew their diagnosis. 7.4% of those diagnosed (1.1 million) were started on treatment in 2015. Much needs to be done in order to achieve more progress worldwide.
Nowadays, in Georgia interationaly recognized guidelines and modern approaches are applied within the Hepatitis C Elimination program and whole treatment process if covered by the state. According to data from June, 2017, 40 000 people are involved in Hepatitis C treatment process.
There is no vaccine for hepatitis C, therefore prevention of HCV infection depends upon reducing the risk of exposure to the virus in health-care settings and in higher risk populations, for example, people who inject drugs, and through sexual contact.
WHO recommendations for primary prevention interventions :
- Hand hygiene: including surgical hand preparation, hand washing and use of gloves;
- Safe and appropriate use of health care injections;
- Safe handling and disposal of sharps and waste;
- Provision of comprehensive harm-reduction services to people who inject drugs including sterile injecting equipment;
- Testing of donated blood for hepatitis B and C (as well as HIV and syphilis);
- Training of health personnel;
- Promotion of correct and consistent use of condoms.
Secondary and tertiary prevention
- • For people infected with the hepatitis C virus, WHO recommends education and counselling on options for care and treatment;
- • Immunization with the hepatitis B vaccines to prevent coinfection from these hepatitis viruses and to protect their liver;
- • Early and appropriate medical management including antiviral therapy if appropriate;
- • Regular monitoring for early diagnosis of chronic liver disease.
In confirmed cases all risky contacts should be revealed (shared needle in injection drug use, recipients of risky blood transfussion, personnel, patients in unsafe medical or non medical procedures, also sexusal contacts) and encouraged for further screening.
Hepatitis C is found worldwide. The most affected regions are WHO Eastern Mediterranean and European Regions, with the prevalence of 2.3% and 1.5% respectively. Prevalence of HCV infection in other WHO regions varies from 0.5% to 1.0%. Depending on the country, hepatitis C virus infection can be concentrated in certain populations (for example, among people who inject drugs) and/or in general populations. There are multiple strains (or genotypes) of the HCV virus and their distribution varies by region.
In May 2016, The World Health Assembly adopted the first “Global Health Sector Strategy on Viral Hepatitis, 2016-2021”. The strategy highlights the critical role of Universal Health Coverage and the targets of the strategy are aligned with those of the Sustainable Development Goals. The strategy has a vision of eliminating viral hepatitis as a public health problem and this is encapsulated in the global targets of reducing new viral hepatitis infections by 90% and reducing deaths due to viral hepatitis by 65% by 2030. Actions to be taken by countries and WHO Secretariat to reach these targets are outlined in the strategy.
WHO is working in the following areas to support countries in moving towards achieving the global hepatitis goals under the Sustainable Development Agenda 2030:
Raising awareness, promoting partnerships and mobilizing resources;
- Formulating evidence-based policy and data for action;
- Preventing transmission; and scaling up screening, care and treatment services.
WHO also organizes World Hepatitis Day on 28 July every year to increase awareness and understanding of viral hepatitis.
Annually World Hepatitis Day is organized in Georgia as well, where national and international experts take part in the event.