by Agatha Lau, MD, Mark Levstik, MD
In the fall of 2006, the government of Ontario launched a provincewide public education campaign outlining risks associated with contracting hepatitis C, current methods of treatment, and ways individuals can help in preventing further spread of the disease.
Earlier this month, the government launched a new phase of the campaign. To help promote the campaign’s message, the Ministry of Health and Long-Term Care is airing television spots to guide viewers to the new hepatitis C website (www.hepcontario.ca).
The main feature of the website is a self-assessment tool that will help people assess their risks of exposure to the hepatitis C virus (HCV).
As part of the campaign, physicians across Ontario will be receiving an information package containing a guide for assessing a patient’s risk of exposure to hepatitis C, a patient brochure that includes a printed version of the self-assessment tool, as well as a general fact sheet on HCV.
In addition, the Ministry will be preparing a series of articles from specialists in the field of hepatitis C for publication in future issues of the Ontario Medical Review. The series will examine a number of issues related to HCV, including patient diagnosis, testing, treatment and care.
The following case study and additional information will help physicians in reviewing risk factors associated with hepatitis C, and provide a brief overview of current testing available for diagnosis.
A 49-year-old financial analyst, married with two children, sees his family physician due to vague abdominal pain that has persisted for one month, without any other symptoms. The patient also complains of increasing fatigue, as well as a mild loss of appetite.
The patient’s doctor decides to check some routine blood work. To the doctor’s surprise, the liver enzymes are mildly elevated with an AST 152, ALT 180, Bilirubin 23 and ALP 153, in keeping with a primarily liver-related inflammation. All other routine blood tests are normal.
The patient’s previous blood tests showed more minor elevations attributed to modest work lunches with rich food, and a little alcohol over-indulgence.
The patient denies any history of regular excessive alcohol intake, injection drug use, high-risk sexual behaviour, tattoo or blood transfusions. However, he does recall a few “parties” in university, marked with cocaine use.
The patient denies any recent travel history, sick contact, or herbal medication use. He did receive hepatitis A and B combined vaccinations years earlier, prior to a family trip to Mexico.
The patient’s past medical history is unremarkable, with no known history of hepatitis.
Further blood work, including viral and autoimmune hepatitis screening, and ultrasound, are performed. Hepatitis C serology comes back positive.
The patient is then referred to a hepatologist for further investigation and potential treatment. He has no other causes of liver test abnormalities, and is found to have minor scarring in his liver on biopsy.
The patient elects to undergo treatment, and after 12 months of pegylated interferon and ribavirin, is cleared of the virus.
The patient’s family members are also checked and are found to be free of HCV, as is usually the case.
In Canada, there are currently between 240,000 to 300,000 people infected with the hepatitis C virus, with Ontario accounting for approximately 110,000 cases.
Each year, approximately 5,000 Canadians become newly infected with hepatitis C. More than one-third of people with HCV are unaware of their infection, and the majority have never felt unwell due to the virus.
In most cases, HCV is transmitted from blood to blood. Historically, the majority of people acquire the infection through intravenous drug use (>60 per cent).
About six per cent of infected cases in Canada are solely related to blood transfusion.
Since the adoption of highly sensitive testing for hepatitis C virus antibodies in 1990, the risk of HCV infection from blood transfusion is estimated to be less than one in three million units transfused.
The infection is not passed through casual contact.
Unfortunately, hepatitis C infection is silent. While less than 20 per cent of people are acutely sick when first infected — and are thus potentially diagnosed — more than 80 per cent have no symptoms at all, and never learn of their infection until much later, perhaps after complications have arisen.
Of all those infected, about 75 per cent will never be rid of the virus without medical intervention. Approximately one in five people will develop cirrhosis of the liver. Once scarred, the liver slowly fails or develops cancer at a rate of four per cent per year, leading to death.
The challenge for the physician is determining which hepatitis C patients will do well, and which will run into difficulty. Fortunately, antiviral treatment can clear the virus in 42 per cent to 88 per cent of cases (depending on the genotype).
Government bodies and physicians’ groups are working together to make the diagnosis and treatment of hepatitis C accessible to everyone. The key is early diagnosis and treatment for people with risk factors for acquiring HCV. Risk factors include:
Treatment of HCV is best handled by specialized treatment centres, or experienced treaters who can address all aspects of a patient’s medical needs.
To obtain further information on hepatitis C, visit the Ministry of Health and Long-Term Care website (www.hepcontario.ca).
Dr. Agatha Lau is a GI resident at the University of Western Ontario. Dr. Mark Levstik is an assistant professor GI/liver, at the University of Western Ontario.