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Hepatitis C

About Hepatitis C

Viral hepatitis is inflammation of the liver caused by a virus. There are five different hepatitis viruses, hepatitis A, B, C, D and E.

Transmission: Hepatitis C is mainly spread through blood-to-blood contact. In rare cases it can be transmitted through certain sexual practices and during childbirth

Prevention: There is no vaccination for hepatitis C. It is therefore necessary to reduce risk of exposure, by avoiding sharing needles and other items such as toothbrushes, razors or nail scissors with a person living with hepatitis C. It is also wise to avoid getting tattoos or body piercings from unlicensed facilities.

Treatment: Treatment for chronic hepatitis C aims to eradicate the virus. There is an increasing use of direct-acting antiviral drugs, which have a 95% cure rate. So there has never been a better time for people to access these treatments.

Reference: Originally published by Hepatitis Australia via worldhepatitisday.org and hepatitisaustralia.com

About Hepatitis C

The hepatitis C virus is a member of the flavivirus family of ribonucleic acid (RNA) viruses. The virus reproduces by making many copies of itself in liver cells.

The hepatitis C virus does not kill liver cells directly, but the immune response initiated by the presence of the virus in the liver can cause liver inflammation and cell death. (Farrell, G.C. 2002)

There are six main genotypes (strains) of hepatitis C. Each genotype contains numerous subtypes, labelled a, b, or c. Genotypes 1a and 1b (54% prevalence) and 3a (37% prevalence) are the most common genotypes in Australia. (McCaw, R., et al. 1997)

Hepatitis C was discovered by scientists in 1988 and found to be responsible for most of the cases of non-A, non-B hepatitis. Early studies confirmed that hepatitis C was transmitted through blood-to-blood contact. An accurate test to diagnose hepatitis C became available in Australia in 1990. The test detected antibodies produced in reaction to the hepatitis C virus.

It is estimated that 71 million people worldwide are chronically infected with hepatitis C. (WHO Hepatitis C Fact Sheet)

In Australia, it is estimated that 199,412 people are living with chronic hepatitis C. (Kirby Institute, Annual Surveillance Report (ASR) 2017 – p16)

In 2016, it was estimated that 11,949 new cases of hepatitis C infection were diagnosed of hepatitis C infection. 

Due to the introduction of the new directacting antiviral treatments through the Pharmaceutical Benefits Scheme it was also estimated that 30,434 people were cured from hepatitis C infection. (Kirby Institute, Annual Surveillance Report (ASR) 2017 – p16)


References

Farrell, G. C. (2002). Hepatitis C, other liver disorders, and liver health: A practical guide. Sydney, Australia: MacLennan and Petty Pty Limited.

McCaw, R., Moaven, L. D., Locarnini, S. A. & Bowden, D. S. (1997). Hepatitis C virus genotypes in Australia. Journal of Viral Hepatitis.

The World Health Organisation (WHO) (2014). Hepatitis C Fact Sheet. Available from: http://www.who.int/mediacentre/factsheets/fs164/en/index.html. Accessed 15 July 2014.

The Kirby Institute (2012). HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2017. The Kirby Institute, The University of New South Wales, Sydney, NSW. Available from: https://kirby.unsw.edu.au/sites/default/files/kirby/report/SERP_Annual-Surveillance-Report-2017_compressed.pdf

National Centre in HIV Epidemiology and Clinical Research (NCHECR) (2010). Estimates and projections of the hepatitis C virus epidemic in Australia. 

Poynard, T., Ratziu, V., Charlotte, F., Goodman, Z., McHutchison, J. G. & Albrecht, J. (2001). Rates and risk factors of liver fibrosis progression in patients with chronic hepatitis C. Journal of Hepatology.

Transmission of Hep C

The hepatitis C virus is found in blood. Blood containing the virus must enter the bloodstream of another person for transmission to take place. This is called blood-to-blood contact. Even invisible (microscopic) amounts of blood can transmit hepatitis C. This section outlines some of the more common ways of transmitting hepatitis C through blood-to-blood contact.

Understanding how hepatitis C is transmitted is equally important for people who are already hepatitis C positive so they can reduce the chance of:

  • being infected with another genotype of hepatitis C;
  • being reinfected with the same genotype of hepatitis C; and
  • transmitting hepatitis C to another person.
Injecting Equipment

Currently in Australia, the greatest risk for the transmission of hepatitis C is through blood-to-blood contact involving the sharing or re-using of injecting equipment such as needles and syringes. Other injecting equipment, surfaces used for mixing up, disposal containers, hands and puncture sites can become contaminated during the injecting process and also pose a risk of transmission. Some people who have only injected drugs once or twice in their life have become infected with hepatitis C. Some people choose other ways of consuming drugs, such as snorting or swallowing which are not considered high risk.

There are a number of ways the risk of hepatitis C, and other infections passed on by blood to blood contact (such as HIV and hepatitis B) can be reduced. These include:

  • Wiping down the preparation area 1 part bleach to 10 parts water;  
  • clean hands (wash your hands thoroughly);
  • a clean injecting space;
  • a new fit (syringe);
  • new sterile water;
  • new swabs (at least one to swab your spoon and one to swab your injecting site – remember to swab in one direction only, rubbing back and forth with a swab spreads dirt and germs);
  • your own tourniquet – never share;
  • new filter;
  • a clean spoon; and
  • an approved disposal bin (always dispose of your fits in a puncture-proof container).

For more information on safer injecting practices please contact your local peer-based user group for copies of the Guide to Safer Injecting developed by the Australian Injecting and Illicit Drug Users League.

Blood Transfusions and Blood Products

The Australian Red Cross Blood Bank now tests all donated blood and blood product for hepatitis C virus and antibodies. Screening for hepatitis C began in February 1990. Before this time, some people were infected with hepatitis C when they received blood or blood products contaminated with the virus.

Tattoos and Body Piercing

A small number of people have been infected with hepatitis C through unsterile tattooing, or body piercing procedures. Anyone considering a piercing or a tattoo should make sure that their tattoo artist or body-piercer applies infection-control procedures, which means using single-use disposable needles, dye tubs, surgical gloves, and so on. Consumers have the right to ask the practitioner about their use of standard infection control procedures and their understanding of why these procedures are important.

Receiving a tattoo or piercing in a juvenile detention centre, prison, by a backyard operator, and overseas tattoos and body piercing increase the risk of hepatitis C infection. Often the equipment is not sterile and may have been used on more than one client. It is recommended not to get a tattoo or piercing in these settings.

Pregnancy and Breastfeeding

Research shows that the risk of transmission to a baby during pregnancy or childbirth is low. The risk is about 6% if the mother has detectable levels of the virus in her blood, that is if she has a PCR test that shows the presence of the virus in her blood. (Dore GJ, Kaldor JM, McCaughan W. – 1997)

Women with very low levels of the virus (where PCR test showed negative for the presence of hepatitis C in the blood) are highly unlikely to transmit hepatitis C to their baby. However, women co-infected with both HIV and hepatitis C have a higher risk of transmitting hepatitis C to their baby.

There are no confirmed reports of hepatitis C transmission from mother-to-baby through breast milk and the current scientific opinion remains that there is no significant evidence of HCV transmission through breastfeeding. Scientists have found traces of the virus in some breast milk and colostrum (the breast fluid produced by the mother in the first few days of breastfeeding) but not enough to transmit hepatitis C. Damage to the nipples such as cracked and bleeding nipples could pose a possible risk to the baby if blood-to-blood contact occurs through small tears or scratches in or around the baby’s mouth. Therefore, it is recommended that women with hepatitis C who have cracked or bleeding nipples should express and discard their breast milk while their nipples are cracked.

Transmission in Health Care Setting

Some people in Australia contracted hepatitis C through unsterile medical injections (such as vaccinations) and other medical procedures in their country of origin. The risk of transmission of hepatitis C through unsterile medical procedures has been virtually eliminated in Australia since the introduction of standard infection-control procedures (Standard Precautions).

Standard Precautions are guidelines for infection control and assume that all blood and body fluids are contaminated.

Some Standard Precautions Include:
  • using gloves when cleaning up blood spills;
  • carefully wiping up any blood spills with a paper towel, and washing the area with soapy water and then, if there is a possibility of bare skin contact, disinfecting the area with household bleach;
  • completely covering any cuts or wounds with a waterproof dressing or a band-aid; and
  • placing bloodstained tissues, sanitary towels or other bloodstained dressings in a leak-proof plastic bag before disposal.

The Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in the Health Care setting, 2004 edition, have now been superseded by the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010). These guidelines, published by the National Health and Medical Research Council (NHMRC) are available through their website.

The risk of acquiring hepatitis C from a needle stick (or sharps) injury in a healthcare setting where the needle (or sharp) was used in a procedure on someone with hepatitis C is 3%. Health care and custodial workers are advised to practice standard infection-control procedures at all times and should consider getting vaccinated against hepatitis A and B.

Other Activities Where Blood May Be Involved

Transmission of hepatitis C through safer sex is unlikely, and hepatitis C is not classified as a sexually transmissible infection (STI). However, where there is a risk of blood-to-blood contact during foreplay, or sex, or where there is a risk of the transmission of sexually transmissible infections, it is recommended you practice safer sex.

Personal grooming items used for everyday hygiene may present a possible transmission risk if blood is present. To minimise the risk of transmission, it is suggested that people do not share razor blades, clippers, toothbrushes (due to the possibility of bleeding gums) and sharp personal grooming aids.

Stepping on a used needle in a public place, such as a street, a park or a beach, is regarded as an unlikely source of transmission.

Finally, remember hepatitis C is transmitted through blood-to-blood contact. Thus for transmission to take place, blood containing the virus must enter the bloodstream of another person. In the ordinary course of life, hepatitis C is not easily transmitted, however, it is worth thinking about any instances in which blood-to-blood contact may take place and subsequently take appropriate precautions.

Hepatitis C CANNOT be caught from sharing:

  • hugs
  • kisses
  • food
  • cups
  • gym equipment
  • office space
  • public transport

There is no risk contracting hepatitis C from a mosquito or other blood-sucking insects.

Preventing the Spread of Hepatitis C

People with hepatitis C can take simple precautions to minimise the risk of transmitting the virus to others. These include:

  • reducing any opportunity where other people may come in contact with infected blood;
  • not sharing injecting equipment;
  • not sharing personal toiletry items like toothbrushes, razors, nail clippers or any items able to puncture the skin and draw blood;
  • having a first aid kit at hand;
  • keeping cuts, abrasions or wounds clean and covered with waterproof dressings;
  • cleaning up any blood spills with paper towels and soapy water or undiluted bleach; and
  • securing all bloodstained items, such as wound dressings, tampons and sanitary pads in a plastic bag before putting them in a rubbish bin.

References

Dore GJ, Kaldor JM, McCaughan W. (1997)
‘Systematic review of role of polymerase chain reaction in defining infectiousness among people infected with hepatitis C virus’. British Medical Journal.

The National Health and Medical Research Council (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare.

 

Treatment for Hep C

Introduction

A new generation of direct-acting antiviral medications are now available to Australians living with chronic hepatitis C. They are more effective, easier to take and have fewer side-effects than the older medications. The Australian Government has listed these medicines on the Pharmaceutical Benefits Scheme (PBS), ensuring they are accessible and affordable to people with hepatitis C. This is a leap forward in the management and treatment of hepatitis C and positions Australia as a world leader in publicly-funded access to these new, highly effective medicines.

What are the new medicines?

The new, direct-acting antiviral (DAA) medicines available on the PBS include:

  • Daklinza® (daclatasvir)
  • Epclusa® (sofosbuvir + velpatasvir)    
  • Harvoni® (sofosbuvir + ledipasvir)
  • Ibavyr® (ribavirin)
  • Sovaldi® (sofosbuvir)
  • Viekira Pak® (paritaprevir + ritonavir + ombitasvir + dasabuvir)
  • Viekira Pak RBV® (paritaprevir + ritonavir + ombitasvir + dasabuvir + ribavirin)
  • Zepatier®  (grazoprevir + elbasvir)

Following a clinical assessment, these medicines are used independently or in combination with other medicines depending on the person’s particular situation. For most people, this will mean treatment without the need to use interferon.

Are the new medicines better than the previous ones?

Yes, the new DAA medicines are:

  • more effective, resulting in a cure for 90-95% of people
  • taken as tablets only, and have very few side-effects
  • taken for as little as 8-12 weeks in most cases, and;
  • provide interferon-free treatment options for all genotypes in Australia

Are the new medicines available for all people with Hepatitis C? 
Yes, treatment using the new DAA medicines is available through the PBS for all people living with hepatitis C over the age of 18 and who have a Medicare Card. However, the particular combination of medicines used will depend on a range of individual factors which may include genotype, prior treatment experience and whether or not you have developed cirrhosis (liver scarring).    

What about people who currently inject drugs? 
There are no restrictions applied to people who inject drugs as they are a priority population for hepatitis C treatment. Whether or not a person currently injects drugs should not be used as criteria for restricting access to the new medicines.  

Can people in prison access the new medicines?
Yes, people in prison are a priority population for hepatitis C treatment. The Australian Government has ensured the new medicines will be funded for people in prison. There may be some criteria depending on a prisoner’s length of stay as to whether they will be able to access the treatments whilst incarcerated.    

Are there interferon-free options available for all genotypes?
Yes there are interferon-free options available for all genotypes.    

What information will the doctor need to know about your health before treatment can be prescribed?
There are a number of tests the doctor may conduct, and may also request specific information before treatment can be prescribed. These include:

  • undergoing blood tests to confirm you have active hepatitis C infection
  • undergoing  tests to determine the genotype (strain)
  • undergoing an assessment to see if you have developed cirrhosis (liver scarring)
  • discussing any previous treatments for hepatitis C under taken,
  • identifying any other illnesses or health complaints a client may have such as HIV, and;
  • discussing any other prescription medications, over-the-counter medications or substances a client may be taking. This is important to avoid any possible drug interactions. 

It is very important that medicines are taken as instructed, so the doctor or nurse may also talk with you about your readiness to start treatment and discuss things that may impact on your ability to take the medicine regularly, as prescribed.

What does treatment with the new medicines involve? 
The treatment regimens for the new DAA medicines range between 8 and 24 weeks for a complete course of treatment, depending on the genotype, treatment history, whether cirrhosis has occurred and the combination of medicines used.
(Refer to the table at the end).

Some treatments require only 1 to 2 tablets once or twice a day. For some treatment regimens, more medicines may be required to be used together. Depending on treatment history and genotype, a very small percentage of people may still need to include an injection (of peg-interferon) as well as taking tablets. Your doctor will explain the options available to you in more detail.

Will you need to have more tests during treatment?
Yes, the doctor will need to do blood tests to monitor how the body is responding to the medicines. This means checking if the medicine is working effectively against the hepatitis C virus and that it is not negatively affecting overall health.    

Can General Practitioners (GPs) prescribe treatment for hepatitis C?
Yes, GPs in Australia can prescribe the new medicines. Before prescribing any medicines, the GP will be required to collect information and conduct tests (see above) to establish which combination of medicines will be the most effective.   This means it is likely you will need a couple of appointments before receiving a prescription. In some cases, where there are other significant health factors to consider, the GP may refer the client to a specialist before treatment is commenced.    

Can you still see your specialist to access the new medicines?
Yes, gastroenterologists, hepatologists or infectious diseases physicians experienced in the treatment of chronic hepatitis C will continue to prescribe the new medicines.  These specialists will also provide advice to GPs prescribing the new medicines, so you may consider seeing your GP if this is more convenient for you.

Where can you get your prescription filled?
This will depend on the type of prescription receive and the doctor will provide more details. There are two types of prescriptions known as either s100 or s85.

Most people will receive the s85 prescription, which can usually be filled by a local pharmacy. However, it is important to note that some pharmacies may not have the medicines in stock and people may need to wait up to 72hrs to collect them. This is due to the very high cost the pharmacies have to outlay to keep the medicines in stock. If a pharmacy cannot fill the prescription, request a referral to a pharmacy that can, or contact HepatitisWA for assistance.

Some people accessing specialists may receive the s100 type of prescription. These prescriptions can only be filled through hospital-based pharmacies and not local, community-based pharmacies. Most pharmacies will only dispense 1 month of the drug at a time. Therefore, it is important for people to plan ahead so they don’t run out of medicine.

How much do the medicines cost?
Prescriptions attract the usual co-payment price for the dispensing fee of each prescription. This is currently $38.80 for general patients and $6.30 for concessional patients. This fee is reviewed each year.

Remember, as these medicines are “PBS Authority required” the doctor can only prescribe one medicine on each prescription. This means people may be required to pay the dispensing fee for each medicine.

What if treatment is not effective for you?
For most people, it is highly likely the new DAA medicine will be effective. If the new treatment does not work, the doctor will discuss options and may choose to refer to a specialist for further assessment prior to commencing any further treatment.    

Where can you get further information?
You can talk to your GP, specialist, clinic nurse or call HepatitisWA on (08) 9227 9800.

Treatment options available on the PBS
The treatment options below are based on the Australian recommendations for the management of hepatitis C virus infection: a consensus statement 2017. You can view this at hepcguidelines.org.au

Some variations to these regiments may be required depending on a person’s individual clinical history or health status and Interferon containing regiments are only shown where there are no other PBS option is currently approved. For more detailed information discuss options with a doctor. 

Hepatitis C Treatment Chart

* As per the Australian approved label for Viekira Pak-RBV: GT1B patients with cirrhosis should receive Ombitasvir, Paritaprevir, Ritonavir and Dasabuvir and Ribavirin.
 

Don’t put your health at risk by waiting too long. 

It’s easy to understand why people may have waited for the new interferon-free treatments to become available. However, now treatment is much simpler, by waiting, a person could be putting thier health at risk. If 40 years of age or over is living with hepatitis C, they are likely to experience an accelerated rate of liver damage which increases the risk of developing cirrhosis, liver cancer or liver failure. This is called the “Liver Danger Zone”. A person should also bear in mind that symptoms of liver disease may not be felt until the liver is significantly scarred. It is not advisable to put for people to put their health at risk by waiting too long for treatment. It is recommended to make an appointment with a doctor or HepatitisWAs Deen Clinic to have a liver health assessment and to discuss treatment options.

What does a liver health assessment involve?

The doctor will conduct a clinical examination and blood tests. They may also send the client for an ultrasound which is a non-invasive test that measures the level of liver scarring to determine the severity of liver disease. For further information on the liver health assessments see our: Liver Assessment Factsheet – download now (PDF 184kb)

Video of a liver health assessment – view now If a person has chronic hepatitis C and particularly if they are in the “Liver Danger Zone”, ask the doctor about having a regular liver health check-up today. A liver check-up is nothing to worry about, it is simple, easy and it can save lives.

Tests for Hep C

This section provides a brief introduction to the most common tests available to test for and monitor hepatitis C.

Testing for Hepatitis C

The initial screening test for hepatitis C is a blood test which checks for antibodies. The human body produces antibodies in response to the virus.