Introduction

Hepatitis C is a virus that can infect and damage the liver. You can become infected with hepatitis C if you come into contact with the blood of an infected person.

 

In most cases, hepatitis C causes no noticeable symptoms until the liver has been significantly damaged.

When symptoms do occur, they are often vague and can be easily mistaken for another condition. Symptoms include:



flu-like symptoms, such as muscle aches and loss of appetite



feeling tired all the time



depression



Because of this, many people remain unaware that they are infected by hepatitis C.

 

How do you get hepatitis C?

The hepatitis C virus is particularly concentrated in the blood of an infected person, so it's usually transmitted through blood-to-blood contact. Some examples of ways blood can be transferred include:



sharing razors or toothbrushes



sharing unsterilised needles - for example, while injecting drugs



It's estimated that up to 49% of people who inject drugs in England are thought to have hepatitis C. It's not only regular drug users who are at risk. People who have only injected drugs once in their life have been known to develop hepatitis C.

Hepatitis C can be transmitted through sex, although this is very rare. The risk may be higher among men who have sex with men. Wearing a condom with a new partner is advised.

Hepatitis C is more common in certain parts of the world, including North Africa, the Middle East and Central and East Asia, and this is thought to result from the use of shared needles for vaccination or medical treatment.

 

Getting tested

Because hepatitis C often causes no obvious symptoms, testing is usually recommended if you are in a high-risk group, such as being a current or former injecting drug user.

Your GP, sexual health clinic, GUM (genitourinary medicine) clinic or drug treatment service all offer testing for hepatitis C. It can be done using a blood test.

The sooner treatment begins after exposure to the hepatitis C virus, the more likely it is to succeed.

 

Treating hepatitis C

Hepatitis C can be treated with antiviral medicines designed to stop the virus from multiplying inside the body and prevent liver damage.

Two widely used antiviral medications are interferon and ribavirin.

There are six different strains of hepatitis C, known as genotypes, and some genotypes respond better to treatment than others.

The most common genotypes of hepatitis C in England are genotypes 1 and 3.

With treatment, around half of people with genotype 1 will be cured, and around eight out of 10 people with genotype 3 will be cured.

Two new medications, released in 2011, called boceprevir and telaprevir, have been found to be effective in some people who do not respond to conventional antiviral treatments.

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Who is affected?

There were 10,873 reported new cases of hepatitis C in England during 2012, but the true figure is probably much higher.

It is estimated that around 215,000 people in the UK have chronic hepatitis C.

Hepatitis C is more common in men than women as men are more likely to inject drugs.

Prevention

Unlike other forms of hepatitis, there is no vaccine for hepatitis C.

Two ways to reduce your risk of catching hepatitis C are:



Never share any drug-injecting equipment with other people (not just needles, but also syringes, spoons and filters).



Don't share razors, toothbrushes or towels that might be contaminated with blood.



The risk of sexual transmission is low. However, the risk is increased if there is blood present, such as menstrual blood or during anal sex. For this reason, condoms are not usually recommended for long-term heterosexual couples.

However, the best way to avoid transmitting hepatitis C is to use a condom or female condom, especially with a new partner.

 

Stages of infection

The first six months of a hepatitis C infection are known as acute hepatitis C. Around one in four people will fight off the infection and will be free of the virus.

In the remaining three out of four people, the virus will stay in their body for many years. This is known as chronic hepatitis C.

Depending on other risk factors, such as alcohol use, between 10% and 40% of people with untreated chronic hepatitis C will go on to develop scarring of the liver (cirrhosis), often more than twenty years after first catching the virus.

Around one in five people with cirrhosis will then develop liver failure, and one in 20 will develop liver cancer, both of which can be fatal.

 

Symptoms of hepatitis C 

Only around one in four people will have symptoms during the first six months of a hepatitis C infection. This stage is known as acute hepatitis C.

The symptoms may include:



a high temperature of 38oC (100.4oF) or above



tiredness



loss of appetite



stomach pains



feeling sick



being sick



These symptoms occur a few weeks after infection.

In people who do have symptoms of acute hepatitis C, around one in five of them will also experience yellowing of the eyes and skin. This is known as jaundice.

In an estimated one in five cases of hepatitis C, the immune system will successfully eliminate the virus and the person will have no further symptoms (unless they become infected again).

In the remaining cases, the virus persists inside the body for many years. This is known as chronic hepatitis.

Chronic hepatitis C

The symptoms of hepatitis C can vary widely from case to case. In some people, symptoms may be barely noticeable. In others, they can have a significant impact on quality of life.

The symptoms can also go away for long periods of time (remission) and then return.

Some of the most commonly reported symptoms of hepatitis C include:



feeling tired all the time – sleeping does not seem to help improve energy levels



headaches



depression



problems with short-term memory, concentration and completing relatively complex mental tasks such as mental arithmetic – many people describe this combination of symptoms as "having a brain fog"



mood swings



indigestion or bloating



joint and muscle aches and pain



itchy skin



flu-like symptoms, like those that occur in the acute phase of the infection



abdominal pain



pain in the liver area (which is located in the right upper side of your abdomen)



When to seek medical advice

See your GP if you persistently have any of the chronic symptoms above, or if they keep returning, especially if you inject drugs or have injected drugs in the past.

None of the symptoms above automatically means you have hepatitis C, but they do require further investigation.

Causes of hepatitis C 

You can become infected with hepatitis C if you come into contact with the blood of an infected person.

The blood has the highest concentration of the virus, so exposure to infected blood is the easiest way to get the virus. Just a small trace of blood can cause an infection.

The virus can survive outside the body in patches of dried blood on surfaces for at least 16 hours, but no longer than four days (at room temperature conditions).

Injecting drugs

Injecting drugs is the most important risk factor for hepatitis C in the UK. Up to 49% of people who inject drugs in England are thought to have hepatitis C.

The infection can be spread by sharing needles and associated equipment. Injecting yourself with just one contaminated needle may be enough to become infected.

Cocaine

There have also been reports of people catching hepatitis C when sharing bank notes or straws to snort cocaine.

Cocaine can damage the inside of the nose, leading to bleeding. It's possible to then inhale contaminated blood and become infected.

Less common causes

Unprotected sex

Hepatitis C may be transmitted during unprotected sex (sex without using a condom), although this risk is considered very low.

The risk of transmission through sex may be higher among men who have sex with men. The risk is also increased if there are genital sores or ulcers from a sexually transmitted infection, or if either person also has HIV.

The best way to prevent transmission of hepatitis C through sex is to use a male condom or female condom.

However, as the risk is very low for couples in a long-term, stable relationship, many choose not to use a condom. If your partner has hepatitis C, you should be tested for the condition.

Blood donations before September 1991

Since September 1991, all blood donated in the UK is checked for the hepatitis C virus. If you received blood transfusions or blood products before this date, there is a possibility you were infected with hepatitis C.

Blood transfusions and treatment abroad 

If you have a blood transfusion or medical or dental treatment overseas where medical equipment is not sterilised properly, you may become infected with hepatitis C. The virus can survive in traces of blood left on equipment.

Sharing toothbrushes, scissors and razors

There is a potential risk that hepatitis C may be passed on through sharing items such as toothbrushes, razors and scissors.

Equipment used by hairdressers can pose a risk if it has been contaminated with infected blood and not been sterilised or cleaned between customers. However, most salons operate to high standards, so this risk is low.

Tattooing and body piercing

There is a potential risk that hepatitis C may be passed on through using tattooing or body piercing equipment that has not been properly sterilised.

However, most tattoo and body piercing parlours in the UK operate to high standards and are regulated by law, so this risk is low.

Mother to child

There is a small chance that a mother who is infected with the hepatitis C virus will pass the infection on to her baby. This can happen in around 2% of cases.

However, the risk is thought to increase if the mother also has HIV or particularly high levels of the virus.

Needlestick injury

There is a small (approximately one in 30) risk of getting hepatitis C if your skin is accidentally punctured by a needle used by someone with hepatitis C.

Healthcare workers, nurses and laboratory technicians are at increased risk because they are in regular close contact with blood and bodily fluids that may contain blood.

Diagnosing hepatitis C 

If you think you may have been exposed to hepatitis C, taking a test will put your mind at rest or, if the test is positive, allow you to start treatment early.

Your GP, sexual health clinic, GUM (genitourinary medicine) clinic or drug treatment service all offer testing for hepatitis C.

Find your nearest sexual health service.

Testing for hepatitis C

Hepatitis C is diagnosed with two blood tests:



the antibody test



the PCR test



The antibody test

This blood test determines whether you have ever been exposed to the hepatitis C virus by testing for the presence of antibodies to the virus.

Antibodies are proteins produced by your immune system to fight invading particles, such as viruses, when they enter your bloodstream.

The test will not show a positive reaction for some months after infection. This is because your body takes time to make these antibodies.

If the antibody test is negative but you have had symptoms, or you have been exposed to hepatitis C, you may be advised to have the test again.

A positive test (showing antibodies) indicates that you have been infected at some stage. It does not necessarily mean you are currently infected, as you may have since cleared the virus from your body.

The only way to tell if you are currently infected is to have a second blood test, called a PCR test.

The PCR test

This blood test checks if the virus is still present by detecting whether it is reproducing inside your body.

A positive test – often reported as "detectable" or "detected" – means that your body has not fought off the virus, and the infection has progressed to a chronic (long-term) stage.

Test results usually come back within two weeks.

It is recommended that the following groups of people should be tested for hepatitis C:



ex-drug users



current drug users



people who received blood transfusions before September 1991



recipients of organ or tissue transplants before 1992, or in countries where hepatitis C is common



babies and children whose mothers have hepatitis C



anyone accidentally exposed to the virus (needlestick or splash injury), such as health workers



people who have received a tattoo or piercing where equipment may not have been properly sterilised



sexual partners of people with hepatitis C



people who have lived or had medical treatment in parts of the world where hepatitis C is more common – high risk areas include North Africa, the Middle East and Central and East Asia



If you continue to engage in high-risk activities, such as injecting drugs frequently, then regular testing may be recommended. Your GP will be able to advise you.

Other tests and referral

If you have the virus, your GP may recommend other tests to check for damage to your liver. These include liver function tests, which measure certain enzymes and proteins in your bloodstream that indicate whether your liver is damaged or severely inflamed.

Your GP will also refer you to a specialist centre for an assessment and to discuss treatment. The specialist will ask for more checks to assess the extent of liver damage, including blood tests and ultrasound scans of the liver and abdomen. Many centres are now using a fibroscan (a type of ultrasound) to check for liver damage and scarring.

The amount of liver damage can also be assessed by taking a sample of your liver tissue for examination. This is called a liver biopsy and involves passing a hollow fine needle through the skin into your liver. The cells are then examined under a microscope to assess the amount of liver damage and cirrhosis (scarring). The specialist will advise you about the need for a liver biopsy. However, a biopsy is not always necessary before treatment.

Treating hepatitis C 

Most cases of acute hepatitis C are not treated as the person either does not have any symptoms or mistakes the symptoms for the flu.

If hepatitis C is detected during this acute phase, it is normally recommended that you are monitored for three months to see if your body fights off the virus.

If it doesn’t, a six-month course of pegylated interferon (see below) may be recommended. This is successful at curing the infection in around 85% of cases.

Chronic hepatitis C

Treatment for chronic hepatitis C usually involves using a combination of two medicines:



pegylated interferon (given as an injection) – a synthetic version of a naturally occurring protein in the body that stimulates the immune system to attack virus cells



ribavirin (given as a capsule or tablet) – an antiviral drug that stops hepatitis C from spreading inside the body



This is known as combination therapy.

Course and dosage

The length of your recommended course will depend on which genotype of the hepatitis C virus you have.

If you have genotype 1, a 48-week course is recommended. For all other genotypes, a course of 24 weeks will be recommended.

You may have a blood test four weeks into your course, and again at 12 weeks. If the test shows that the medications are having little effect in removing the virus, it may be recommended that treatment is stopped as further treatment may be of little use.

You are normally given weekly injections of pegylated interferon. Ribavirin is normally taken twice a day with food.

How effective is treatment?

The effectiveness of combination therapy depends on the genotype of the hepatitis C virus.

Genotype 1 is more challenging to treat. Only half of people treated with combination therapy will be cured.

Other genotypes respond better to treatment, with a cure rate of around 75–80%.

Side effects

Side effects of combination therapy are common and can be severe. Three out of four people being treated will experience one or more side effect.

Side effects of combination therapy include:



a drop in the number of red blood cells (anaemia), which can make you feel tired and out of breath



loss of appetite



depression



anxiety



irritability



problems sleeping (insomnia)



difficulties concentrating and remembering things



hair loss



itchiness



feeling sick



dizziness



flu-like symptoms, such as a high temperature, that occur in the 48 hours after an interferon injection



Side effects may improve with time as your body gets used to the medications.

Tell your care team if any side effect is becoming particularly troublesome as your dosage may need to be adjusted.

Coping with side effects may be challenging, but it is recommended that you continue to take medication as instructed.

Missing doses to try to minimise side effects will reduce the chances of you being cured.

Ribavirin and pregnancy

Ribavirin will harm an unborn child if it is taken by a pregnant woman. If you are a woman of childbearing age, you will need to have a pregnancy test to confirm you are not pregnant before treatment can begin. If you find out you are pregnant, treatment will need to be delayed until you have your baby.

If you are not pregnant, you will still need to use a reliable method of contraception (preferably two methods) if you are sexually active.

Men who are taking ribavirin should not have sex with a pregnant woman unless they use a condom. If their partner is not pregnant but is of childbearing age, she will need to be tested for pregnancy each month during treatment and for seven months after treatment has stopped.

Boceprevir and telaprevir

In April 2012, the National Institute for Health and Care Excellent (NICE) released guidance for two newer medications, boceprevir and telaprevir.

Both medications are known as protease inhibitors. Protease inhibitors block the effects of enzymes that viral cells need to reproduce.

The NICE guidance recommends that boceprevir or telaprevir should be made available free of charge for people who:



have genotype 1 hepatitis C that has not previously been treated (a genotype is a particular viral strain)



have been treated for genotype 1 hepatitis C but treatment was unsuccessful



The medications are designed to be used in combination with pegylated interferon and ribavirin and not as a sole treatment. The tablet is taken three times a day for 48 weeks.

It is still unclear whether boceprevir or telaprevir is more effective.

Side effects of boceprevir include:



flu-like symptoms such as a high temperature and chills



loss of appetite



feeling sick



insomnia



weight loss



shortness of breath



Side effects of telaprevir include:



anaemia



feeling sick



being sick



diarrhoea



haemorrhoids



itchy skin rash



Deciding against treatment

Some people with chronic hepatitis C decide against treatment. There can be several reasons for this, for example if they:



do not have any symptoms



are willing to live with the risk of cirrhosis at a later date



do not feel the potential benefits of treatment outweigh the side effects treatment can cause



Your care team can give you advice about this, but the final decision about treatment will be yours.

If you decide not to have treatment but then change your mind, you can still request to be treated.

Re-infection

If the virus is cleared with treatment, you are not immune to future infections of hepatitis C.

This means, for example, that if you continue to inject drugs after taking the medicines, you risk becoming re-infected with hepatitis C.

Vaccination

It is possible to be infected with more than one type of hepatitis, which can complicate treatment.

Therefore, if you have chronic hepatitis C, your GP or practice nurse may recommend that you are vaccinated against hepatitis A andhepatitis B.

They may also recommend that you consider vaccination againstseasonal flu and pneumococcal infections.

Complications of hepatitis C 

If it is not treated, chronic hepatitis C can sometimes cause scarring of the liver (cirrhosis). This can develop up to 20 years after you first become infected.

A number of factors can increase your risk of getting cirrhosis, such as:



drinking alcohol



having type 2 diabetes



contracting hepatitis C at an older age



having HIV or other types of hepatitis, such as hepatitis B



Depending on these factors, the risk of cirrhosis can range from 10% to 40%.

Symptoms of cirrhosis include:



tiredness and weakness



loss of appetite



weight loss



feeling sick



very itchy skin



tenderness or pain around the liver



tiny red lines (blood capillaries) on the skin above waist level



jaundice



Other than a liver transplant, there is no cure for cirrhosis. However, treatments can help relieve some of the symptoms of cirrhosis and prevent the condition from worsening.

 

Liver failure

In severe cases of cirrhosis, the liver loses most or all of its functions. The liver has a wide range of functions, such as filtering toxins from the blood and producing a number of important hormones.

This is known as liver failure or end stage liver disease. Liver failure occurs in around one in five people with hepatitis-associated cirrhosis.

Symptoms of liver failure include:



hair loss



build-up of fluid in the legs, ankles and feet (oedema)



build-up of fluid in your abdomen that can make you look heavily pregnant (ascites)



dark urine



black, tarry stools or very pale stools



frequent nosebleeds and bleeding gums



a tendency to bruise easily



vomiting blood



Once liver failure has occurred, it is usually possible to sustain life for several years using medication. However, a liver transplant is currently the only way to cure liver failure.

Liver cancer

It is estimated that around one in 20 people with hepatitis-associated cirrhosis will develop liver cancer.

Symptoms of liver cancer include:



unexplained weight loss



feeling sick



vomiting



tiredness



jaundice



It is usually not possible to cure liver cancer, especially in people with cirrhosis, though chemotherapy can be used to slow the spread of the cancer.

 

Other complications

Other rarer complications of chronic hepatitis C include:



dryness of the mouth and eyes (caused by the destruction of sweat, saliva and tear glands)



patches of itchy skin (lichen planus)



swelling inside the kidneys (glomerulonephritis)



sensitivity to light, leading to blisters and ulcers on the skin



underactive thyroid gland



overactive thyroid gland



cryoglobulinemia (a disorder in which abnormal proteins may damage the skin, nervous system and kidneys)



non-Hodgkin's lymphoma (a type of cancer that affects the body's lymphatic system)



insulin resistance and diabetes



gallbladder disease



Preventing hepatitis C 

There is no vaccination to protect against hepatitis C, but there are ways to reduce your risk of becoming infected.

Injecting drug users are most at risk of contracting the infection. Never share any injecting equipment, such as needles, syringes, spoons and filters.

Also, do not share razors, toothbrushes or towels that might be contaminated with blood.

If you have hepatitis C

You can reduce the risk of passing hepatitis C on to other people by:



keeping personal items, such as toothbrushes or razors, for your own use



cleaning and covering any cuts or grazes with a waterproof dressing



cleaning any blood from surfaces with household bleach



not sharing needles or syringes with others



not donating blood 



Sexual transmission

The risk of sexual transmission is low. However, the risk is increased if there is blood present, such as menstrual blood or during anal sex. For this reason, condoms are not usually recommended for long-term heterosexual couples.

However, the best way to avoid transmitting hepatitis C is to use a condom or female condom, especially with a new partner.

Living with hepatitis C 

Below are answers to some questions about living with hepatitis C, including questions about diet, the workplace, travelling and having a baby.

If you have hepatitis C, the following questions are answered below:



Do I need to eat a special diet?



Could anything I do make hepatitis C worse?



Is there anything else I can do to help myself?



Do I have to tell my boss?



Can I travel abroad?



Can I have a baby if I or my partner has hepatitis C?



 Do I need to eat a special diet? 

You will not usually need to change what you eat, as long as you eat ahealthy, varied diet.

If your liver is badly damaged, however, your doctor may suggest limiting your intake of salt and protein to avoid putting too much strain on your liver. The hospital dietitian can advise you on what you can and cannot eat.  

Could anything I do make hepatitis C worse?

Drinking alcohol can increase the damage to your liver. If you have hepatitis C, cut out or limit your intake of alcohol. If you need advice about this, ask your doctor or contact an alcohol self-help organisation.

If you are concerned that you are addicted to alcohol and are unable to stop drinking, contact your GP. Medications are available to help people quit alcohol.

Is there anything else I can do to help myself?

Control your weight by eating a healthy diet and exercising regularly (aim for 150 minutes a week).

Some studies suggest that being overweight raises the risk of fatty deposits in the liver, which could make your condition worse. Being a healthy weight can also help you respond better to treatment.

 

Do I have to tell my boss?

You do not have to tell your boss that you have hepatitis C, unless you are a healthcare worker.

However, if hepatitis C is affecting your performance at work and your employer knows about your condition, they may be obliged to make allowances for you, such as giving you leave of absence for going to the clinic, under the Equality Act 2010. Therefore, you may want to consider telling your boss about your condition. You may also be entitled to statutory sick pay to cover doctor appointments or time off work.

Can I travel abroad?

If you are planning to travel abroad, seek advice from your doctor or a travel clinic about vaccination.

It is also a good idea to take any documentation, such as details of blood tests or medical records, in case you need medical treatment abroad.

Can I have a baby if I or my partner has hepatitis C?

Yes, but there is a small risk (around 2%) of hepatitis C passing from mother to baby. The risk is higher if the mother also has HIV. If the male partner has hepatitis C, there is a very small risk the virus could spread to the female during sex. If you are female with a male partner who has hepatitis C, you may want to have a hepatitis C test.



Hepatitis C