Hepatitis C

Notification requirement for hepatitis C

Hepatitis C infection is a ‘routine’ notifiable condition and must be notified by medical practitioners and pathology services in writing within 5 days of diagnosis.

The treating doctor and patient may be asked to complete a confidential questionnaire by the department to collect additional information. This is used for the detection of disease trends and policy development.

This is a Victorian statutory requirement.

Primary school and children’s services centre exclusion for hepatitis C

Exclusion is not required.

Infectious agent of hepatitis C

Hepatitis C virus (HCV) is a small RNA virus that is closely related to the flaviviruses and animal pestiviruses. At least six HCV genotypes and a large number of subtypes have been described.

Identification of hepatitis C

Clinical features

The majority of people with acute HCV infection are asymptomatic. For this reason, many people are diagnosed with hepatitis C following routine antibody screening, rather than during the acute phase of infection.

When symptoms and signs of acute hepatitis C occur, they are similar to other forms of viral hepatitis, but usually milder. Symptoms include anorexia, abdominal discomfort, nausea, vomiting, lethargy, and occasionally rashes and arthralgia. Jaundice and dark urine may follow. Fulminant acute hepatitis C is rare.

Without hepatitis C treatment, approximately one third of people with HCV infection will spontaneously clear the virus, usually within 6 to 12 months of infection. The remaining two thirds of people with HCV infection will develop chronic hepatitis C.

Chronic hepatitis C is often asymptomatic, but may cause non-specific symptoms such as fatigue, anorexia, nausea and vomiting. Approximately 15–20 per cent of people with chronic hepatitis C develop liver cirrhosis over a period of 20–40 years. Among those with cirrhosis, approximately 1–5 per cent per year will develop hepatocellular carcinoma. This risk can be further exacerbated by liver injury, especially concurrent alcohol use.

People can be reinfected with hepatitis C after clearing the virus spontaneously, and after being successfully treated for hepatitis C.

Diagnosis

People who have current or historical risk factors for hepatitis C infection should be tested for hepatitis C.

HCV infection is diagnosed using the combination of an HCV antibody test and a polymerase chain reaction (PCR) test that detects HCV RNA in blood.

A positive HCV antibody test indicates previous exposure to HCV but does not indicate whether a person has a current HCV infection.

A positive HCV PCR test indicates current HCV infection. However, a single negative PCR does not necessarily exclude current infection, as viraemia may be intermittent, particularly during acute infection.

In practice, it is useful to order HCV antibody and HCV PCR tests simultaneously, to avoid the need for an additional blood test. To do this, order both HCV antibody and HCV PCR on the same pathology request form, and note that the HCV PCR should only be done if HCV antibody is positive. The Medicare Benefits Schedule (MBS) covers the cost of a HCV PCR test only if the HCV antibody test is positive.

Any person with HCV should also be tested for hepatitis B virus and human immunodeficiency virus (HIV).

Incubation period of hepatitis C virus

The incubation period of HCV ranges from 2 weeks to 6 months. It is most commonly 6–9 weeks.

Tests can detect viral RNA as early as 1–2 weeks after exposure to the virus. HCV antibody tests usually become positive 2–3 months after exposure.

Public health significance and occurrence of hepatitis C

Hepatitis C occurs worldwide. In Australia, the overall number and rate of new HCV notifications is declining over time. However, chronic HCV infection causes a significant burden of disease in Australia and represents an important public health concern. Hepatitis C is a leading cause of liver cancer, and liver cancer is the fastest increasing cause of cancer death in Australia.

Hepatitis C prevalence and incidence are considerably higher in selected populations compared with the general population in Australia. People who inject drugs are a key population at risk of HCV infection. It has been estimated that up to 80% of HCV notifications in Australia occur in people with a current or past history of injecting drug use. While there is evidence that needle and syringe programs (NSPs) and other harm reduction strategies have decreased HCV incidence among people who inject drugs, this group remains at highest risk of HCV in Australia.

Other people at increased risk of HCV infection in Australia include:

• People in custodial settings (currently or in the past)
• People from regions with high HCV prevalence (in particular Egypt, Pakistan, Central Asia and Eastern Europe)
• People who have been treated with blood or blood products in Australia or other high-income countries prior to 1990, or in low- and middle-income countries at any time
• Children born to mothers with HCV infection
• Aboriginal and Torres Strait Islander people
• People with hepatitis B virus infection or HIV infection, which share HCV risk factors

The Victorian hepatitis C plan 2022-30 sets out a vision to eliminate HCV as a public health concern by 2030.

Reservoir of hepatitis C virus

Humans are the only known reservoir.

Mode of transmission of hepatitis C virus

Hepatitis C is primarily transmitted by blood-to-blood contact. Most common transmission routes include:

• Shared injecting drug equipment, particularly re-using needles/syringes. Sharing other injecting equipment (swabs, filters, water, spoons, and tourniquets) can also lead to transmission.
• Needlestick injuries or other iatrogenic exposure in health care settings, usually due to inadequate infection control practices.
• Receipt of blood, blood products and organs where donor screening was not performed. Donor screening was introduced in early 1990 in Australia.
• Other skin-penetrating procedures (e.g. tattooing or body piercing) where there are inadequate infection control practices

Hepatitis C can be transmitted vertically (from mother to infant) around the time of birth. Approximately five per cent of infants born to women infected with HCV will develop HCV infection. Breastfeeding is not an additional risk factor for transmission unless the nipples are cracked, or the baby has cuts on or inside the mouth.

Risk of sexual transmission of HCV infection is extremely low. The risk of HCV transmission is increased in people with HIV infection, particularly in men who have sex with men.

Sharing of household equipment including razors and toothbrushes is an extremely uncommon mode of HCV transmission.

Period of communicability of hepatitis C

People with hepatitis C are infectious from very early in the course of infection, from the time RNA is detectable in blood. People who clear the infection spontaneously are no longer infectious. People with chronic HCV should be considered infectious until they have cleared the infection through treatment.

Susceptibility and resistance to hepatitis C

No one is considered immune to hepatitis C. Despite the presence of antibodies in the blood, people who have spontaneously cleared HCV infection and people who have been successfully treated for HCV remain susceptible to HCV and can be reinfected if they have ongoing risk factors.

Control measures for hepatitis C

Preventive measures

There is no vaccine to prevent hepatitis C. The best way to prevent hepatitis C is by avoiding behaviours that can lead to disease transmission. Key prevention activities include:

• Promoting safe injecting drug practices, including access to needle and syringe programs
• Using single-use equipment for all skin-penetration procedures, or using appropriate cleaning, disinfection or sterilisation methods when reusable instruments are used for any procedure
• Ensuring appropriate infection prevention and control guidelines (standard precautions) in all healthcare settings
• Screening of donated blood and tissues
• Offering HCV testing for people with risk factors for HCV infection
• Providing curative treatment to people with chronic HCV infection

Control of case

Hepatitis C is curable. Direct-acting antiviral drugs for hepatitis C are administered orally and are highly effective and well tolerated. All people diagnosed with HCV infection should be considered for direct-acting antiviral therapy.

Direct-acting antiviral drugs for hepatitis C are available on the Pharmaceutical Benefits Scheme (PBS). They can be prescribed by any medical practitioner or authorised nurse practitioner experienced in the treatment of chronic HCV infection, or in consultation with a gastroenterologist, liver specialist or infectious diseases physician experienced in treating chronic HCV infection.

After treatment has been completed, it is important to confirm that cure of hepatitis C has been achieved.

People with ongoing risk factors for hepatitis C infection (e.g., ongoing injecting drug use) should continue to be offered regular HCV RNA tests following successful treatment, and should be offered retreatment if they become reinfected.

Counselling of the patient is a very important part of management. This counselling should include:

• Exploring the likely source of the infection
• Explaining the natural history of HCV infection and the availability of safe and effective treatment
• Providing advice on prevention of further transmission of infection
• Providing advice on reducing further liver damage, such as being vaccinated against hepatitis A and B, limiting or avoiding alcohol intake, smoking cessation, and maintaining a healthy diet.

Patients should be advised not to:

• Donate blood or body organs
• Use nonsterile injecting equipment
• Share personal items such as toothbrushes or razors.

They should also be advised to:

• Cover any cuts or wounds with an occlusive waterproof dressing
• Wipe up any blood spills with single-use disposable paper towels, and clean the area with detergent and warm water
• Place bloodstained paper tissues, sanitary towels or dressings in a plastic bag before disposal
• Use safer sex practices, particularly if blood is going to be present or if a sexual partner has HIV infection.

Control of contacts

Contacts include all people who have had exposure to blood from a person with current HCV infection, such as people who have shared injecting equipment. Children born to women with current HCV infection are also considered contacts. Sexual partners may be considered contacts in some circumstances (for example, if they have HIV infection or are long-term sexual partners).

Contacts should be notified of their potential exposure to hepatitis C, tested for hepatitis C, provided with information about HCV infection, and given advice on risk reduction where applicable. There is no post-exposure prophylaxis available.

Control of environment

Healthcare settings should have policies and procedures in place regarding action to be taken in the event of a blood spill or sharps injury. Further information can be found in Australian guidelines for the prevention and control of infection in healthcare at the National Health and Medical Research Council website.

Outbreak measures for hepatitis C

Not applicable.

Special settings

Healthcare workers

Registration boards should be consulted in relation to their policies regarding healthcare workers with bloodborne viruses. Recommendations are also included in Australian guidelines for the prevention and control of infection in healthcare at the National Health and Medical Research Council website.

Antenatal care

Antenatal care should include a comprehensive assessment of hepatitis C risk factors. Women found to be at higher risk of HCV infection or exposure should undergo HCV antibody screening, and PCR testing if HCV antibody positive. Infants born to women with hepatitis C should undergo appropriate testing and referred for specialist case.