Thursday, 8 October 2015

Hepatitis C: Chronic & Acute infections

World Health Organisation - Hepatitis C

Hepatitis C virus (HCV) causes both acute and chronic infection. Acute HCV infection is usually asymptomatic, and is only very rarely 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 15–30% within 20 years.

Key Facts:
  • Hepatitis C is a liver disease caused by the hepatitis C virus: the virus can cause both acute and chronic hepatitis infection, 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 unsafe injection practices; inadequate sterilization of medical equipment; and the transfusion of unscreened blood and blood products.
  • 130–150 million people globally have chronic hepatitis C infection.
  • A significant number of those who are chronically infected will develop liver cirrhosis or liver cancer.
  • Approximately 500 000 people die each year from hepatitis C-related liver diseases1.
  • Antiviral medicines can cure approximately 90% 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.
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What is Hepatitis C?

Hepatitis C is a contagious liver disease that ranges in severity from a mild illness lasting a few weeks to a serious, lifelong illness that attacks the liver. It results from infection with the Hepatitis C virus (HCV), which is spread primarily through contact with the blood of an infected person. Hepatitis C can be either “acute” or “chronic.”
  • Acute Hepatitis C virus infection is a short-term illness that occurs within the first 6 months after someone is exposed to the Hepatitis C virus. For most people, acute infection leads to chronic infection.
  • Chronic Hepatitis C virus infection is a long-term illness that occurs when the Hepatitis C virus remains in a person’s body. Hepatitis C virus infection can last a lifetime and lead to serious liver problems, including cirrhosis (scarring of the liver) or liver cancer.
What are the symptoms of acute Hepatitis C? Approximately 70%–80% of people with acute Hepatitis C do not have any symptoms. Some people, however, can have mild to severe symptoms soon after being infected, including:
  • Fever
  • Fatigue
  • Loss of appetite
  • Nausea
  • Vomiting
  • Abdominal pain
  • Dark urine
  • Clay-colored bowel movements
  • Joint pain
  • Jaundice (yellow color in the skin or eyes)
What are the symptoms of chronic Hepatitis C? Most people with chronic Hepatitis C do not have any symptoms.
  • However, if a person has been infected for many years, his or her liver may be damaged.
  • In many cases, there are no symptoms of the disease until liver problems have developed.
  • In persons without symptoms, Hepatitis C is often detected during routine blood tests to measure liver function and liver enzyme (protein produced by the liver) level.
Can acute Hepatitis C be treated?
  • Yes, acute hepatitis C can be treated. Acute infection can clear on its own without treatment in about 25% of people. If acute hepatitis C is diagnosed, treatment does reduce the risk that acute hepatitis C will become a chronic infection. Acute hepatitis C is treated with the same medications used to treat chronic Hepatitis C. However, the optimal treatment and when it should be started remains uncertain.
Can chronic Hepatitis C be treated?
  • Yes. There are several medications available to treat chronic Hepatitis C, including new treatments that appear to be more effective and have fewer side effects than previous options. The Food and Drug Administration (FDA) maintains a complete list of approved treatments for Hepatitis C.
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Public not told earlier ‘as there were no signs of acute hepatitis C cases’

As shocked Singaporeans digested the news about the hepatitis C virus outbreak in Singapore General Hospital (SGH) and began asking many questions, such as why it took the authorities so long to inform the public of the situation, the Ministry of Health (MOH) said yesterday (Oct 7) that there had been no signs earlier to suggest that these were cases of acute viral hepatitis C.

Under the Infectious Diseases Act, cases of acute viral hepatitis C have to be reported to the ministry within 72 hours, whereas chronic cases need not be reported.

In the case of the outbreak at SGH, which saw 22 renal patients infected with the hepatitis C virus possibly because of a lapse in the use of multi-dose medication vials, the MOH had received earlier notifications of these cases from the hospital’s laboratory.

Timeline on outbreak of hepatitis C infections at SGH
WP asks MOH why it took months to make outbreak public
Relative of woman infected at SGH tells of family’s anguish

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Doctors in shock over news of hepatitis C outbreak at SGH

The medical fraternity was shocked by news of the hepatitis C outbreak in Singapore General Hospital (SGH), given that hospitals here have established robust systems for handling medical equipment.

Doctors interviewed today (Oct 6) said that the use of multi-dose vials — small containers with more than one dose of medication intended for injection or infusion — is common for injecting insulin and vaccines such as the BCG, and practitioners should be well-acquainted with the standard protocol for using them.

SGH first stepped in to investigate after the fifth case of infection — within less than a month — was detected on May 14, and subsequently took action including stopping the use of multi-dose vials. In late August, the hospital informed the Ministry of Health (MOH) of an “unusually large cluster” of hepatitis C patients. About a month later, it submitted a final report to the ministry. Today, it made public the outbreak after 22 cases of infections had surfaced so far.

SGH to take responsibility, pay for treatment needed by infected patients
4 dead after 22 infected in SGH hepatitis C outbreak
What is hepatitis C?
Timeline on outbreak of hepatitis C infections at SGH

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What is hepatitis C?

The hepatitis C virus can cause liver disease. Acute infection is usually asymptomatic — a patient is a carrier but experiences no symptoms. It is very rarely associated with life-threatening disease.

Based on the World Health Organization fact sheet on hepatitis C, about 15 to 45 per cent of infected persons spontaneously clear the virus within six months of infection without any treatment. The remaining will develop chronic infection, with a 15 to 30 per cent risk of cirrhosis — or hardening — of the liver within 20 years. Some develop liver cancer.

The hepatitis C virus is blood-borne, and the incubation period is between two weeks and six months.

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Chronic Hepatitis C: The Basics

This long-lasting liver infection is caused by the hepatitis C virus. During the first 6 months, it's called acute hepatitis. For most people who get it -- up to 80% -- the illness moves into a long-lasting stage. This is called a chronic hepatitis C infection.

Who Gets It?
  • Most people catch the hep C virus when blood from someone who has it gets into their body. This can happen if you share needles to use drugs, or get stuck by one because you work in a hospital or doctor's office. People born to a mother who has it will probably get it, too.
What Are the Symptoms? You can have the disease and not have symptoms for years. You may not find out you have it until your doctor does a blood test for some other reason and notices a problem with your liver enzymes. If you have chronic hepatitis C, your may notice:
  • Fatigue
  • Upset stomach
  • Drop in appetite
  • Joint and muscle pain
  • Jaundice (yellowing of the skin and eyes)
  • Dark yellow urine
  • Bleeding or bruising easily
How Is it Treated? Treatment is different for every person. You may not need or get help from medications. Some people can’t handle their side effects. The FDA has approved:
  • Boceprevir (Victrelis)
  • Interferon alfa-2b (Intron A)
  • Ombitasvir, paritaprevir, dasabuvir, ritonavir (Viekira Pak)
  • Peginterferon alfa-2a (Pegasys, Pegasys Proclick)
  • Peginterferon alfa-2b (PEG-Intron, PEGIntron, Peg Intron RP, Sylatron)
  • Ribavirin (Copegus, Moderiba ,Rebetol, RibaPak, RibaTab, Ribasphere Ribasphere Ribapak, Ribavirin)
  • Simeprevir (Olysio)
  • Sofosbuvir (Sovaldi)
  • Sofosbuvir, ledipasvir (Harvoni)
  • Telaprevir (Incivek)
What’s Your Outlook?
  • In the best case, the hepatitis C virus won't show up in a blood test 6 months after treatment ends. Although the virus isn't gone, it stops growing. After treatment, make sure you stick with healthy habits and see your doctor regularly.
  • The outlook for most people with chronic hepatitis C is good. People who get cirrhosis and liver disease may need a liver transplant.
What is Hepatitis?
The Facts About Hepatitis C
What Hep C Treatment Looks Like
Hepatitis C: Get Treated, Get Cured
Treating Hepatitis C: Questions, Actions, and Options
Your Future With Hepatitis C
Quiz: Myths and Facts About Hepatitis C

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Acute Hepatitis C Virus Infection

Acute infection with hepatitis C virus (HCV) is a frequent but underrecognized problem among substance users, because it produces few symptoms. Despite this fact, a good deal has been learned recently from studies of cohorts of persons with acute HCV infection. Intensive study of these cohorts has suggested that there is a higher frequency of spontaneous clearance among persons with symptomatic infection and persons with vigorous adaptive immune responses. Similarly, polymorphisms for genes involved in innate immunity also appear to influence the outcome of acute HCV infection. Data on injection drug users with repeated exposures to HCV reveal the presence of partially protective immunity, which suggests that vaccine-based approaches may be feasible. Finally, antiviral therapy with interferon-based regimens for acute HCV infection produces significantly higher sustained virological responses than observed for chronic infection. Further work is needed to develop more-accurate assays for acute HCV infection, to define host and viral factors that predict outcome and to define the optimal duration and regimen of therapy.

It is estimated that nearly 30,000 incident cases of acute infection with hepatitis C virus (HCV) occur annually. Not surprisingly, many of these acute infections occur among persons with ongoing injection or intranasal substance use. Acute HCV infection produces a wide range of clinical presentations, from asymptomatic to icteric illness. Fulminant hepatic failure attributable to acute HCV infection is rarely observed.

Diagnosis of Acute HCV Infection - Although there are no formal criteria for the diagnosis of acute HCV infection, the following criteria are often used in defining clinical cohorts for treatment studies of acute HCV infection: an acute increase in levels of alanine aminotransferase (ALT) to <10 times the upper limit of normal, with or without increases in total bilirubin level; positivity for HCV RNA; and an exposure to HCV during the preceding 2–12 weeks. Results of testing for anti-HCV may be positive or negative, depending on the phase of acute illness. Most commonly, patients will be seronegative, and subsequent seroconversion will signal the diagnosis. Occasionally, the patient may seroconvert at the time of presentation because of the overlap period between symptomatic presentation and time to seroconversion. In these cases, because of the inability to reliably distinguish seroreactivity to acute and chronic infection, the diagnosis of acute HCV infection may rely on documentation of prior seronegativity and/or the absence of detectable HCV RNA. Unfortunately, no reliable serological assay to detect an IgM subclass anti-HCV response has been developed to accurately distinguish acute from chronic infection.

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Acute Hepatitis C: Causes, Symptoms, Treatments & More

There are two types of hepatitis C: acute and chronic. What Is the Difference Between Acute and Chronic Hepatitis C? Acute hepatitis C is a contagious disease caused by the hepatitis C virus (HCV), which is spread through contact with infected blood and bodily fluids. This disease damages a person’s liver. Acute hepatitis C is a short-term viral infection. People with acute hepatitis C are infectious for a small window of time, often just several months. Most people infected with the acute form of hepatitis C will experience illness and symptoms like fatigue and vomiting within the first six months after exposure. In many cases, the disease never even causes symptoms. When it does, symptoms are typically mild. The disease may improve or resolve without treatment. However, it leads to chronic infection in 75 to 85 percent of cases. The chronic form may cause long-term problems in the liver, including liver damage and liver cancer.

How Is Acute Hepatitis C Transmitted? HCV is spread through direct contact with an infected person’s blood or certain bodily fluids such as semen. However, hugging, kissing, and holding hands with an infected person are safe. Sharing eating utensils or glasses is not a way the virus is spread, and neither is coughing or sneezing. Most new cases of acute hepatitis C occur in intravenous drug users who use contaminated needles. Other people at risk for transmission of HCV include:
  • healthcare workers get stuck with a needle that has been used in an infected person
  • children born to infected mothers
  • people who get a tattoo or body piercing with unsterile equipment
  • patients undergoing hemodialysis
  • family members of a person with hepatitis C (Direct exposure to blood is higher in a household with an HCV-positive person)
  • people who share personal hygiene products, such as razors or toothbrushes, with infected people
  • sexually active people who engaged in sexual contact with multiple partners and without proper barrier protection (condoms or dental dams)
What Are the Symptoms of Acute Hepatitis C? Symptoms don’t always appear immediately. Symptoms may be noticeable within 14 days in some people. Others may take as long as six months to produce any sign. According to Centers for Disease Control and Prevention (CDC), the average period is six to seven weeks. However, 75 percent of people who contract acute hepatitis C will never experience any symptoms. Symptoms of acute hepatitis C range from very mild to severe. They include:
  • nausea
  • vomiting
  • loss of appetite
  • fever
  • fatigue
  • abdominal pain
  • joint pain
  • dark urine
  • light (clay-colored) bowel movements
  • jaundice (yellowing of the skin and eyes)
Your doctor will draw blood to check for HCV antibodies to diagnose hepatitis C. Antibodies are substances produced by your body when it’s fighting an infection. If you have HCV antibodies, your doctor may order a second test to confirm that the virus is still present. If your second test is also positive, you have hepatitis C. If you are positive, your doctor may want to check your liver enzyme levels. This lets them know if the disease has affected your liver. Some people infected with the virus will have normal levels.

How Is Acute Hepatitis C Treated?
  • Acute hepatitis C can be treated. Treatment reduces the risk that the disease will progress to the chronic form. The infection will resolve on its own without treatment in 15 to 25 percent of HCV-positive people. Proper rest, adequate fluids, and a healthy diet may be all that is necessary.
  • Others, however, may need treatment with prescription medicine. The same medications used to treat chronic hepatitis C are prescribed to people with the acute from.
  • The most serious long-term risk of an acute hepatitis C infection is chronic hepatitis C. In 75 to 85 percent of individuals with the acute form, the disease will progress to the more serious chronic hepatitis C. Early detection and treatment is the best way to prevent the more serious form of the disease.
The Future of Hepatitis C Treatment
Hepatitis C in Men: Symptoms, Treatments, and More
Is Hepatitis C Sexually Transmitted?

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Hepatitis C cluster @SGH: 22 infected, 4 have died

The Workers’ Party extends its deepest condolences to the affected families and friends of the four patients who passed away since the outbreak of the Hepatitis C virus infections at the renal ward of the Singapore General Hospital (SGH) that affected 22 patients.

It was reported SGH had been aware of the infection cluster since early June 2015, but information surrounding the outbreak was only made public four months later, in October 2015. An outbreak of Hepatitis C is a potential public health risk. The knowledge of such an outbreak is relevant to all citizens as they weigh their treatment options.

The Workers’ Party would therefore like to seek clarifications from the Minister with regard to the standard protocol in releasing information on such outbreaks, whether or not they occur within a treatment facility. These questions are posed with a view to strengthen Singapore’s infection control protocols in the future.
  • Is there a timeframe within which healthcare institutions must report such incidents to the Ministry?
  • What does the Ministry believe is a permissible interval of time before the public is made aware of such incidents?
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Chronic Hepatitis C
Chronic Hepatitis C: Symptoms, Treatments, Prognosis
Chronic Hepatitis C: Symptoms, Diagnosis, and Treatment
Hepatitis C FAQs for the Public | Division of Viral Hepatitis
How likely is it that acute Hepatitis C will become chronic?
Hepatitis C - Wikipedia, the free encyclopedia
Chronic Hepatitis C infection
Hepatitis C, Chronic Hepatitis C Symptoms | Hepatitis Central
WHO | Hepatitis C
Hepatitis C: Hep C Vaccine Facts, Symptoms, & Treatment
What I need to know about Hepatitis C | National Institute of
Chronic Hepatitis Guide: Causes, Symptoms and Treatment
What is hepatitis C?

Acute Hepatitis C
What is hepatitis? - ‎What is the difference between - ‎What is Hepatitis C?
Hepatitis C FAQs for the Public | Division of Viral Hepatitis
Can acute Hepatitis C be treated?
Acute Hepatitis C: Causes, Symptoms, Treatments & More
Acute hepatitis C infection: Is it serious? - Mayo Clinic
Acute Hepatitis C Virus Infection - Clinical Infectious Diseases
Viral Hepatitis: Background, Pathophysiology, Etiology
Discussion - Acute Hepatitis C - Clinical/Diagnosis
Clinical manifestations, diagnosis, and treatment of acute

In the News:
MOH appoints independent committee to look into Hep C outbreak
MOH sets up Review Committee to look into Hepatitis C cases in SGH
MOH outlines events leading to SGH announcement of Hepatitis C
Public hospitals cease multi-dosing practice in light of Hepatitis C
Hepatitis C cluster at SGH: What you need to know
Late disclosure because there “were no signs of acute hep C cases”: MOH
Getting hepatitis C from blood transfusion 'extremely rare' today
More news for chronic viral hepatitis c
MOH notified of Hep C outbreak in Aug; says asymptomatic cases
Workers' Party seeks clarification from MOH after Hepatitis C cluster
Public hospitals cease multi-dosing practice in light of Hepatitis C cluster
Public not told earlier 'as there were no signs of acute hepatitis C cases'
More news for acute viral hepatitis C

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Sexual transmission of HCV is increasing among gay and bisexual
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Pathogen-Associated Molecular Pattern Recognition of Hepatitis C