Hepatitis C—A Silent Killer

JARUN011/ISTOCK/THINKSTOCK
With increasing numbers of hepatitis C virus infections, oral health professionals need to advise their baby boomer patients to seek testing.
By Kandis V. Garland, RDH, MS, and Rachelle Williams, RDH, MS
Hepatitis is a viral infection caused by
one of several common strains of the hepatitis virus A through E. A serious
threat to health, hepatitis infection can lead to inflammation of the liver,
with a possible progression to cirrhosis, liver failure, and cancer.1
This article will focus on the hepatitis C virus (HCV), which was known as
non-A non-B hepatitis until 1992 when it was classified as HCV, after which
serological testing was developed.2
Prior to 1965, the incidence of HCV was
very low, with only 18 cases per 100,000 individuals. By the 1980s, this number
had increased to 130 cases per 100,000.2 Between 1992 and 2004, new
cases of HCV declined and remained steady for many years. Some of this decline
was attributed to safer injection practices among intravenous (IV) drug users.2 Beginning in 2011, however, the number
of HCV cases has risen each year (Table 1).3

HCV is a bloodborne infection that can be acute or chronic. Acute HCV
infection is rare, with only 20% to 30% of individuals developing symptoms.
Chronic infection is considerably more common, with 75% to 85% of cases
developing into chronic infection.4 As of 2014, approximately 2.7
million to 3.9 million individuals are chronically infected with HCV.4
In 2014, 2,194 new HCV cases were reported in the United States, which were
part of the estimated 30,500 total cases.3 The difference in actual
reported cases vs estimated cases is related to several factors, including
underreporting due to extended incubation time and lack of symptomology. The US
Centers for Disease Control and Prevention (CDC) reports 15% to 25% of newly
infected patients clear the virus, while 60% to 70% of chronically infected
individuals develop chronic liver disease.4 Of those with chronic
liver disease, 5% to 20% may develop cirrhosis over 20 years to 30 years, and
1% to 5% will die from cirrhosis or liver cancer.4
In 2014, 19,659 deaths were attributed to HCV.4 Mortality
related to HCV continues to increase. In 2007, HCV caused 15,106 deaths—more
than the 12,734 deaths attributed to human immunodeficiency virus/acquired
immune deficiency syndrome (HIV/AIDS).5 Currently, individuals age
55 to 64 account for more than half of HCV deaths in the US.2
Transmission
HCV
transmission occurs through exposure to blood contaminated with the virus,
generally through multiple percutaneous exposures.6 The sharing of
needles and syringes among current and former IV drug users is the most common
culprit.4 Transmission may also occur via sexual contact;
childbirth; sharing of personal items, such as razors and toothbrushes; and
occupational exposures, such as sharps injuries.4,6 Groups at
highest risk for contracting HCV include: former and current IV drug users;
those on long-term dialysis; recipients of blood transfusions and organ
transplants prior to 1992; health care workers; infants born to infected
mothers; and those with HIV (Table 2).4,6

The
incubation period for HCV infection generally ranges from 45 days to 180 days,
with an average of 45 days.4 Many patients infected with HCV have
few or no symptoms during the incubation period. This becomes problematic, as
they are less likely to seek medical attention. The lack of treatment leads to
slow diagnosis and underreporting.6 When symptoms occur, they are
generally mild, nonspecific, and flu-like, such as fever, fatigue, nausea,
abdominal pain, loss of appetite, joint pain, dark urine, gray-colored stool,
and jaundice.6
Early detection is challenging due to the asymptomatic nature of HCV,
with some cases remaining undiagnosed for as many as 20 years or more.
Asymptomatic patients are at high risk for cirrhosis and liver cancer because
they might not be diagnosed for several years or even decades, by which time
irreversible liver damage may have already occurred.6 Those at risk
for HCV infection must be screened and tested early. The CDC recommends HCV
testing for those at increased risk, such as baby boomers born between 1945 and
1965, current and former IV drug users, recipients of blood transfusions or
organ transplants prior to 1992, individuals with HIV, patients on long-term
dialysis, patients with liver disease, and children born to HCV-infected
mothers.6 Testing is also recommended for those with known
exposure—particularly health care workers after occupational exposure
incidents, such as sharps injuries involving HCV-infected blood.6
Hepatitis
C Virus Testing
Individuals
at risk for HCV infection should follow the recommended sequencing for testing
(Figure 1). Initially, laboratory testing was required to detect HCV
infection. In 2010, the US Food and Drug Administration (FDA) approved a rapid
HCV antibody test, which has similar sensitivity and specificity as the
FDA-approved anti-HCV laboratory testing methods.7 The rapid
antibody testing can be performed with finger capillary blood samples or
venipuncture samples. The ease of use associated with this method enables HCV
testing to occur in nontraditional settings, such as medical offices and public
health departments. There are limitations, however, to both rapid and
laboratory-based testing methods. These include the inability to determine if
the positive results for antibodies are related to a current HCV infection or a
past exposure. HCV RNA testing is required for a positive anti-HCV result to
determine active or nonactive HCV infection.

Results
demonstrating nonactive HCV infection do not require further testing among
individuals without clinical symptoms of HCV or no suspected exposure within
the past 6 months. HCV RNA results demonstrating current infection require
additional testing to determine the HCV genotype. Various types of HCV exist
and genotyping provides the information needed to recommend the best treatment
approach.
Centers
for Disease Control and Prevention Recommendations
Lengthening
the life spans of those infected with HCV depends on early diagnosis and
treatment.2 The 1998 CDC recommendations for HCV testing included
all individuals with an increased risk of exposure to HCV. Due to the increased
HCV incidence and mortality in the baby boomer generation, the CDC updated the
recommended HCV testing guidelines in 2012 to include all individuals born
during 1945 and 1965, regardless of known risk. Following a review of the
literature, the US Preventive Service Task Force also recommended a one-time
HCV screening for those born between 1945 and 1965.8 Increased risk
factors for this generation are related to the lack of widespread testing of
blood and organs prior to 1992.2 Oral health professionals should
follow the CDC recommendations and highly encourage patients born between 1945
and 1965 to follow the recommended testing sequence for identification of
asymptomatic HCV infections.
Treatment of hepatitis
c infection
Once the
diagnosis of active HCV is determined, patients can start the recommended
antiviral treatments (Table 3). The first step prior to beginning treatment is
to receive hepatitis A and hepatitis B vaccinations and screening for alcohol
consumption/abuse. Then, the physician will recommend a genotype-specific HCV
treatment. Over the past several years, there have been substantial advances in
HCV antiviral treatments. Originally, intravenous pegylated interferon (alone
or combined with ribavirin) was the only choice for HCV treatment. Interferon
had significant side effects such as anemia, fever, headache, muscle pain,
anxiety/depression, and gastrointestinal symptoms, causing many people to
discontinue treatment.9 Since 2011, various FDA-approved
medications—specific to genotype—have provided shorter treatment durations,
reduced side effects, and increased cure rates for individuals with active HCV.9
Currently, epclusa is an HCV antiviral medication for genotypes 1 to 6 that is
taken once daily for 12 weeks (can be administered at a 24-week dosage). This
new medication demonstrated a 98% cure rate in individuals with genotypes 1 to
6 without cirrhosis and an 83% cure rate in individuals with decompensated
cirrhosis. Rates for individuals with decompensated cirrhosis increased to 94%
when epclusa was combined with ribavirin.9 This new antiviral
medication can seriously slow the heart rate. Death can occur if all health
conditions and current medications related to decreased heart rate are not
identified prior to treatment.9 Advances in treatment strategies are
encouraging for individuals with HCV infection. Oral health professionals
should inform patients born between 1945 and 1965 of the new successful HCV
treatment options and identify the benefits of early testing.

Implications for Oral
Health Professionals
To reduce the
risk of bloodborne disease transmission, such as HCV, oral health professionals
must use standard precautions for safety in the workplace. The 2003 CDC Guidelines
for Infection Control in Dental Health-Care Settings provide comprehensive
guidance regarding standard precautions that include proper hand hygiene,
personal protective equipment, safe work behaviors and safety devices,
vaccination for hepatitis A and hepatitis B, and treating all patients as
infectious.10 There is no vaccine for HCV at this time, so the use
of standard precautions is required.
Conclusion
HCV is a silent killer, with most liver injury
occurring without symptoms until the damage is significant. Identification is
now easily accessible to patients with a rapid test and advancements in oral
antiviral medications offer higher cure rates with shorter treatment durations.9
Oral health professionals must be knowledgeable about HCV in order to safely
treat patients.
References
- Centers for Disease Control and Prevention. Viral Hepatitis-Hepatitis
C Information. Available at: cdc.gov/hepatitis/hcv/index.htm. Accessed December
16, 2016.
- Smith BD, Morgan RL, Beckett GA, et al. Recommendations for the
identification of chronic hepatitis C virus infection among persons born during
1945-1965. MMWR Recomm Rep. 2012;61(RR–4):1–32.
- Centers for Disease Control and Prevention. Statistics and Surveillance.
Available at: cdc.gov/hepatitis/hcv/statisticshcv.htm. Accessed December 16,
2016.
- Centers for Disease Control and Prevention. The ABCs of Hepatitis.
Available at: cdc.gov/hepatitis. Accessed December 16, 2016.
- Centers for Disease Control and Prevention. Surveillance for Viral
Hepatitis-United States 2014. Available at:
cdc.gov/hepatitis/statistics/2014surveillance/ commentary.htm#summary. Accessed
December 16, 2016.
- Centers for Disease Control and Prevention. Hepatitis C: FAQs for
Health Professionals. Available at: cdc.gov/hepatitis/hcv/hcvfaq.htm. Accessed
December 16, 2016.
- Centers for Disease Control and Prevention. Testing for HCV
infection: An update of guidance for clinicians and laboratorians. MMWR Morb
Mortal Wkly Rep. 2013;62:362–365.
- United States Preventive Service Task Force. Final Update Summary:
Hepatitis C Screening. Available at:
uspreventiveservicestaskforce.org/Page/Document/
UpdateSummaryFinal/hepatitis-c-screening. Accessed December 16, 2016.
- American Liver Foundation. Advances in Medications to Treat Hepatitis
C. Available at:
hepc.liverfoundation.org/treatment/the-basics-about-hepatitis-c-treatment/advances-in-medications.
Accessed December 16, 2016.
- Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection
control in dental health-care settings—2003. MMWR Recomm Rep.
2003;52(RR–17):1–61.
From Dimensions of Dental Hygiene. January 2017;15(1): 29-30, 32-33.