Hepatitis C: the silent epidemic
Though frequently asymptomatic in its initial stages, hepatitis C infection can have serious consequences, including cirrhosis, liver failure, cancer, and death. Early detection of the virus is beneficial, as it enables women to take advantage of increasingly effective treatments and alerts them to the need for preconception counseling.
TABLE 2
Characteristics of hepatitis viral infection in the U.S. population
| HEPATITIS | HEPATITIS | HEPATITIS | HEPATITIS | HEPATITIS | |
|---|---|---|---|---|---|
| A | B | C | D | E | |
| Source/route of transmission | Feces/Fecal-oral | Blood and blood-derived body fluids/Percutaneous, permucosal | Blood and blood-derived body fluids/Percutaneous, permucosal | Blood and blood-derived body fluids/Percutaneous, permucosal | Feces/Fecal-oral |
| No. of acute infections (per year) | 125,000-200,000 | 140,000-320,000 | 35,000-180,000 | 6,000-13,000 | Rare in the the United States |
| No. of chronic infections | 0 | 1-1.25 million | 3.5 million | 70,000 | 0 |
| Deaths from chronic liver disease (per year) | 0 | 5,000 | 8,000-10,000 | 1,000 | NA |
| Symptoms | Fatigue, nausea, pain near liver or in upper-abdominal area, dark urine, light stools, fever, jaundice | Same as hepatitis A. However, almost 50% of people infected with hepatitis B are asymptomatic. | Same as hepatitis A. However,most people are asymptomatic | Similar to other types of viral hepatitis | Similar to other types of viral hepatitis |
| Prevention | Good personal hygiene and proper sanitation. Also pre- or postexposure immunization | Pre- or post-exposure immunization | Blood donor screening; risk behavior modification | Pre- or post-exposure immunization | Ensure safe drinking water |
| Comments | Typically lasts about 3 weeks, but may persist for as long as 6 months | — | Originally defined in the 1970s as non-A non-B hepatitis. Renamed hepatitis C in 1989. | Requires the hepatitis B virus to exist* | Usually associated with fecally contaminated drinking water. U.S. cases usually involve a history of travel to areas with endemic hepatitis E infection |
| *Hepatitis D infection can be acquired either as a co-infection with the hepatitis B virus or as a superinfection in persons with chronic hepatitis B infection. Persons coinfected with the B and D viruses may have more severe acute disease and a higher risk of fulminant hepatitis (2% to 20%) compared with those infected with hepatitis B alone. However, chronic hepatitis B infection appears to occur less frequently in persons coinfected with the B and D viruses. Chronic hepatitis B carriers who acquire hepatitis D superinfection usually develop chronic hepatitis D infection. In long-term studies of chronic hepatitis B carriers with hepatitis D superinfection, 70% to 80% have developed evidence of chronic liver diseases with cirrhosis compared with 15% to 30% of patients with chronic hepatitis B infection alone. | |||||
| Source: American Liver Foundation, Centers for Disease Control and Prevention | |||||
How will hepatitis C affect my pregnancy?
Perinatal transmission occurs in women with chronic HCV infection at an average rate of 5%.22-24 Small studies suggest that the level of HCV viremia may affect the risk of viral transmission.22,25 However, in 2 large studies, no significant difference in HCV viremia levels was found between women who transmitted the virus to their children and women who did not.23,24 Women co-infected with HIV have 2 to 3 times the rate of HCV transmission compared with women infected only with HCV.26,27 The natural history of HCV infection in children is not well understood, but 50% to 80% of HCV-positive children develop chronic infection.28
Currently, no intervention is available to decrease perinatal HCV transmission.
Currently, no intervention is available to decrease perinatal HCV transmission, although an unclear association with mode of delivery exists. One study of 441 mother-infant pairs showed that elective cesarean delivery may be associated with a lower transmission risk.29 However, another study of 370 mother-infant pairs found no difference in risk.24
The effect of pregnancy on the progression of hepatitis C infection also is unclear. In studies of HCV-positive pregnant women—as compared to HCV-positive non-pregnant women—researchers reported a decrease in serum alanine aminotransferase (ALT) and an increase in HCV RNA during pregnancy,30 as well as a deterioration of hepatitis C disease after pregnancy, as confirmed by liver biopsy.31 In prospective cohort studies comparing infected and uninfected pregnant women, serum aminotrans-ferases flared postpartum in one study32 but remained normal in another.33
Not much is known regarding the effect of chronic hepatitis C infection on pregnancy outcome, although 1 case-control study reported an association between hepatitis C infection and cholestasis of pregnancy.34
Although HCV RNA has been detected in colostrum,35 studies of breastfed infants with HCV-positive mothers have found no cases of transmission secondary to breastfeeding.35,36 Thus, both the American Academy of Pediatrics and ACOG conclude that breastfeeding does not appreciably increase the risk of transmission to the neonate and should not be prohibited.37,38 However, pending further studies, practitioners may choose to advise against breastfeeding if nipples are cracked and bleeding.
- Approximately 25% of people with chronic HCV infection are asymptomatic with normal liver function tests and benign histology.
- Only 10% of people recognize acute infection when they acquire HCV. In the vast majority of cases, the disease is subclinical.
- The “epidemic” of HCV infection represents greater identification of chronic cases rather than increasing numbers of new outbreaks.
- Most new cases of hepatitis C occur in young adults, ages 25 to 40, who may not learn for years or even decades that they are infected.
- African Americans are twice as likely as non-Hispanic whites to be infected with HCV. Hispanics, too, are more likely than non-Hispanic whites to be infected.
- Infection with the human immunodeficiency virus (HIV) appears to accelerate the course of HCV, as does co-infection with the hepatitis B virus.
- Due to improvements in blood bank screening and a decrease in the use of IV drugs, the number of new cases of HCV diagnosed in 1997 was only about 37,000—an 80% decline. Nevertheless, over the next 1 to 2 decades, the HCV mortality rate is expected to double.
- Total expenditures for HCV therapy are thought to range from $10,000 to $12,000 when the costs of interferon, ribavirin, laboratory studies, and office visits are taken into account.
