Evaluation of the Hepatitis C Virus–Infected Patient: The Initial Encounter

Clinical Infectious Diseases, Mar 2013

Deaths from hepatitis C virus (HCV)–related disease are increasing, now exceeding those from human immunodeficiency virus. Up to 7 million Americans (2.3%) may be infected with HCV, and more than half are undiagnosed. Proposed expansion of hepatitis C screening to include all persons born between 1945 and 1965 will lead to many new diagnoses, and infectious diseases physicians have a unique opportunity to be part of managing these patients. Apart from a liver-focused history and examination, the initial evaluation includes determination of the liver function via serum tests and assessment of liver fibrosis and necroinflammation through biopsy or noninvasive means. Patients with cirrhosis require screening for esophageal varices and for liver cancer. Nonimmune patients need vaccinations against hepatitis A and B, and alcohol abstinence is critical. Initial counseling on therapy emphasizes viral cure rates of currently 70%–80% as well as expected side effects. New treatments with fewer side effects and potentially higher cure rates are currently in development.

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Evaluation of the Hepatitis C Virus–Infected Patient: The Initial Encounter

CID Evaluation of the Hepatitis C Virus-Infected Patient: The Initial Encounter Camilla S. Graham Section Editor Norbert Bräu 0 1 0 Bronx VA Medical Center , Bronx , New York 1 Divisions of Liver Diseases and Infectious Diseases, Mount Sinai School of Medicine , New York , USA Deaths from hepatitis C virus (HCV)-related disease are increasing, now exceeding those from human immunodeficiency virus. Up to 7 million Americans (2.3%) may be infected with HCV, and more than half are undiagnosed. Proposed expansion of hepatitis C screening to include all persons born between 1945 and 1965 will lead to many new diagnoses, and infectious diseases physicians have a unique opportunity to be part of managing these patients. Apart from a liver-focused history and examination, the initial evaluation includes determination of the liver function via serum tests and assessment of liver fibrosis and necroinflammation through biopsy or noninvasive means. Patients with cirrhosis require screening for esophageal varices and for liver cancer. Nonimmune patients need vaccinations against hepatitis A and B, and alcohol abstinence is critical. Initial counseling on therapy emphasizes viral cure rates of currently 70%-80% as well as expected side effects. New treatments with fewer side effects and potentially higher cure rates are currently in development. chronic hepatitis C; screening; clinical assessment; counseling Chronic hepatitis C is the most common etiology of chronic liver disease in the Western world. In the third National Health and Nutrition Examination Survey (NHANES III), conducted by the Centers for Disease Control and Prevention (CDC) in sentinel counties, the prevalence of chronic hepatitis C virus (HCV) infection in the United States. has been estimated at 1.33% or about 4 million persons [ 1 ]. A subsequent study that adjusted for the omission of institutionalized persons in NHANES III estimated the HCV prevalence in the United States at 1.7%–2.3%, or 5.2–7.0 million persons [ 2 ]. Many HCVinfected patients are undiagnosed, and in one study 50% of HCV-infected patients were unaware of their diagnosis [ 3 ] Progression to cirrhosis occurs in about 25% of HCV-infected patients, but this process is slow and on average takes 20–30 years. Once cirrhosis has developed, 29% of patients develop liver failure over 10 years and 14% develop hepatocellular carcinoma (HCC). The 5-year survival rate for compensated cirrhosis is still fair at 91%, but after the onset of liver decompensation begins, the 5-year survival rate declines to 50% [ 4 ]. In the United States and other Western countries, a sharp rise in deaths from HCV-related disease has been observed over the last decade (Figure 1) [ 5 ], and since 2007, deaths related to HCV infection have even exceeded deaths from human immunodeficiency virus (HIV) disease [ 6 ]. This is the consequence of a large cohort of patients who were infected in the 1960s and 1970s, mainly through injection drug use, that now, 3–4 decades later, reaches the time point when HCV infection has progressed to liver failure and HCC. Most of these patients were born between 1945 and 1965 and are now the target of the CDC’s universal HCV screening recommendation as described below. Infectious diseases physicians with their long experience of managing the complexities of HIV disease are in a unique position of taking on a growing role in the care of patients with chronic hepatitis C. DIAGNOSIS Chronic hepatitis C is largely asymptomatic, with perhaps chronic fatigue as one nonspecific complaint affecting some patients [ 7 ]. However, timely intervention with antiviral therapy and lifestyle counseling even in the absence of symptoms is critical to prevent advanced and fatal liver disease. Therefore, an active screening program is necessary to identify patients with HCV infection. Until recently, the CDC has recommended testing all persons who have 1 or more risk factors for HCV. However, it has been recognized that this approach still leaves a large number of HCV-infected individuals undiagnosed. On 17 August 2012, the CDC published a new recommendation to expand HCV testing from risk groups to a birth cohort, namely, to test all persons born between 1945 and 1965 regardless of risk factors (Table 1) [ 8 ]. In the United States, 75% of cases of chronic hepatitis C fall within this cohort, so universal testing in this group is likely to yield a significant number of new diagnoses. In a prior study, this approach has been found to be cost-effective [ 9 ]. This change in screening method is similar to the previous implementation of universal screening for HIV infection in 2006 [ 10 ]. Initial testing for HCV is performed by HCV antibody testing via enzyme-linked immunosorbent assay, which in its current generation has a sensitivity of close to 100% to detect chronic HCV infection. Chronic HCV infection is confirmed by plasma HCV RNA testing, which also gives quantitation of (...truncated)


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Camilla S. Graham, Norbert Bräu. Evaluation of the Hepatitis C Virus–Infected Patient: The Initial Encounter, Clinical Infectious Diseases, 2013, pp. 853-860, 56/6, DOI: 10.1093/cid/cis957