Hepatitis C
Main facts
. Hepatitis C is a disease of the liver caused by a virus, HCV, which can lead to acute hepatitis such as chronic hepatitis. The severity of hepatitis C is variable and can range from a mild form, lasting only a few weeks, to serious illness that sets in for life.
. Hepatitis C is a major cause of liver cancer.
. The hepatitis C virus is transmitted through the blood: the most common modes of infection are through exposure to small amounts of this fluid, especially during injection drug use, risky injection practices , unsafe health care, transfusion of untested blood and blood products, or sexual practices resulting in exposure to blood.
. Globally, an estimated 71 million people are chronic carriers of hepatitis C.
. A significant number of them will subsequently develop cirrhosis or cancer of the liver.
. WHO estimates that in 2016, around 399,000 people died from hepatitis C, most often from cirrhosis or hepatocellular carcinoma (primary liver cancer).
. Antiviral drugs can cure more than 95% of people infected with the hepatitis C virus, reducing the risk of death from cirrhosis or liver cancer, but access to diagnosis and treatment is limited.
. There is currently no effective vaccine against hepatitis C; however, research is underway in this area.
The hepatitis C virus (HCV) can cause both acute and chronic infections. New HCV infections are usually asymptomatic. Some people get acute hepatitis without it progressing to a life-threatening disease. About 30% (15% to 45%) of infected people get rid of the virus spontaneously within 6 months of infection without receiving any treatment.
For the remaining 70% (55% to 85%) of those infected, the infection will progress to the chronic form of the disease. Among these chronic patients, the risk of cirrhosis of the liver is 15% to 30% over a period of 20 years.
Geographical distribution
Hepatitis C is found all over the world. The most affected WHO regions are the Eastern Mediterranean Region and the European Region, with an estimated prevalence in 2015 of 2.3% and 1.5%, respectively. The prevalence of HCV infection in other WHO regions ranges from 0.5% to 1.0%. Depending on the country, infection with the hepatitis C virus may be concentrated in certain populations. For example, 23% of new HCV infections and 33% of HCV mortality are attributable to injection drug use. Yet people who inject drugs and those in prison are rarely covered by national interventions.
In countries where infection control practices are weak or where they were in the past, HCV infection is often widespread in the general population. There are multiple strains (or genotypes) of this virus, the distribution of which varies from region to region. However, in many countries the distribution of genotypes remains unknown.
Transmission
The hepatitis C virus is transmitted through the blood. This transmission takes place most often by:
. injecting drug use with sharing of injection equipment;
. the reuse or incomplete sterilization of medical equipment, in particular syringes and needles, in healthcare settings;
. the transfusion of blood and blood products that have not been screened;
. sexual practices resulting in exposure to blood (for example, sex between men, especially if they are individuals infected with HIV or taking pre-exposure prophylaxis against HIV infection).
HCV can also be transmitted sexually and from an infected mother to her child; however, these modes of transmission are rarer.
Hepatitis C is not spread through breast milk, food, water or casual contact (hugging or kissing), or sharing food or drink with an infected person.
According to a WHO estimate, in 2015 there were 1.75 million new HCV infections worldwide (or 23.7 new infections by this virus per 100,000 inhabitants).
Symptoms
The incubation period for hepatitis C ranges from 2 weeks to 6 months. After initial infection, about 80% of individuals are asymptomatic. Those with an acute form have the following symptoms: fever, fatigue, lack of appetite, nausea, vomiting, abdominal pain, darker urine, grayish discolouration, joint pain and jaundice (yellowing of the skin and the whites of the eyes).
Screening and diagnosis
As new infections with hepatitis C virus are usually asymptomatic, few people are diagnosed when their infection is still recent. In those whose infection progresses to chronic hepatitis C, it is often beyond diagnosis because it remains asymptomatic for decades before symptoms appear resulting from severe liver damage.
HCV infection is diagnosed in two stages:
1 Screening for antibodies to HCV with a serological test can identify people who have been infected with the virus.
2 If this test is positive for hepatitis C antibodies, a nucleic acid amplification test (NAT) for HCV ribonucleic acid (RNA) is needed to confirm chronic infection. In fact, 30% of people infected with HCV spontaneously evacuate this infection thanks to a strong immune response, without requiring treatment. Even if they are no longer infected, these people continue to test positive for antibodies to HCV.
Once a chronic HCV infection has been diagnosed in an individual, the degree of liver damage (fibrosis or cirrhosis) should be assessed, either by biopsy or by various non-invasive tests.
The degree of liver involvement helps guide treatment decisions and disease management.
Screening
Early diagnosis helps prevent health problems that could result from the infection and prevents the transmission of the virus. WHO recommends screening people potentially at increased risk of infection, including:
. people who inject drugs;
. people detained in prison and other closed settings;
. drug users using routes other than injection;
. men who have sex with men;
. people who have received infected blood products or have been the subject of invasive procedures in health-care establishments where infection control practices are insufficient;
. children born to mothers infected with HCV;
. people infected with HIV;
. prisoners or people who have been imprisoned in the past; and
. people who have tattoos or piercings.
In settings where the seroprevalence of anti-HCV antibodies is high in the general population (high seroprevalence being defined as> 2% or> 5%), the WHO recommends that all adults be made available for HCV testing and that Offer them this test in conjunction with the hepatitis prevention, care and treatment services.
Of the estimated 37 million people worldwide living with HIV, 2.3 million (6.2%) have had serologic tests revealing past or current HCV infection. Chronic liver disease is a major cause of morbidity and mortality in people infected with HIV.
Treatment
A new infection with HCV does not always have to be treated because in some people the immune response will clear the infection. However, when HCV infection becomes chronic, treatment is required. This one aims at healing.
In 2018, WHO updated the guidelines for treatment with pan-genotypic direct-acting antivirals (DAAs). DAAs can cure most people with HCV infection and treatment is short (usually 12 to 24 weeks), depending on whether or not you have cirrhosis.
WHO recommends that all people over 12 years of age with chronic HCV infection be treated with pangenotypic DAAs. Pangenotypic DAAs remain expensive in many high- and upper-middle-income countries. Nonetheless, their prices have fallen sharply in many countries (mostly low- and lower-middle-income), thanks to the introduction of generic versions of these drugs.
Access to HCV treatment is improving, but it is still too limited. In 2017, of the 71 million people living with HCV infection worldwide, an estimated 19% (13.1 million) were aware of the diagnosis and among those diagnosed as carrying an infection. Chronic HCV, approximately 5 million had been treated with ADD by the end of 2017. Much remains to be done to reach the target of treating 80% of people with HCV infection worldwide. 'by 2030.
Prevention
Primary prevention
There is no effective vaccine against hepatitis C, which is why prevention of HCV infection requires reducing the risk of exposure to this virus in healthcare settings and among populations beyond. high risk, such as people who inject drugs and men who have sex with men, including men who have HIV or are taking pre-exposure prophylaxis for HIV.
Here are some examples of primary prevention interventions recommended by WHO:
. the use of safe and appropriate injections as part of care;
. safe handling and disposal of sharps and waste materials;
. providing people who inject drugs with comprehensive injection harm reduction services, including sterile injecting equipment and dependence treatment that are effective and evidence-based;
. screening of donated blood for hepatitis C and B (as well as for HIV and syphilis);
. prevention of blood exposure during sexual intercourse, in particular with the systematic use of condoms.
Secondary prevention
For people infected with the hepatitis C virus, WHO recommends:
. inform them about the possibilities of care and treatment and advise them;
. vaccinate them against hepatitis A and B to prevent co-infection with the corresponding viruses and protect their liver;
. treat them medically at an early stage and in an appropriate manner, in particular by antiviral treatment if necessary; and
. subject them to regular follow-up to diagnose possible chronic liver disease early.
Screening, care and treatment of people infected with HCV
In July 2018, WHO updated the guidelines for the care and treatment of people with chronic hepatitis C virus infection.
This guide is intended for government officials to use as guidance in developing national-level policies, plans and guidelines against this disease. Those responsible include program managers and health care providers responsible for planning and implementing hepatitis care and treatment programs, especially in low- and middle-income countries.
Summary of the main recommendations
1. Screening for alcohol consumption and advice to encourage patients to reduce their consumption if it is moderate or heavy
It is recommended that all people with HCV infection be assessed for alcohol consumption and then offered a behavioral intervention to reduce alcohol consumption for those with moderate to heavy drinking.
2. Assessment of the degree of hepatic fibrosis or cirrhosis
In resource-limited settings, APRI (aminotransferase score / platelet count) or FIB4 tests should be used to assess liver fibrosis in preference to other non-invasive tests requiring more resources such as elastography. or the Fibrotest ©.
Recommendations for the treatment of hepatitis C
3. Assessment for treatment
All adults and children with chronic HCV infection should be evaluated for the suitability of antiviral therapy.
4. Treatment
WHO recommends that treatment be offered to all people 12 years of age or older who have been diagnosed with HCV infection, regardless of the stage of the infection.
WHO recommends the use of treatment regimens that include pangenotypic DAAs to treat people 18 years of age and older with chronic HCV infection.
In adolescents 12 to 17 years of age or weighing at least 36 kg with chronic HCV infection, the WHO recommends:
. the sofosbuvir / ledipasvir combination for 12 weeks for genotypes 1, 4, 5 or 6 of the virus.
. the sofosbuvir / ribavirin combination for 12 weeks for genotype 2;
. sofosbuvir / ribavirin combination for 24 weeks for genotype 3.
In children under 12 with chronic HCV infection, the WHO recommends:
. to defer treatment until the child is 12 years old.
. to no longer use interferon-based treatment regimens.
New treatment regimens based on pangenotypic oral ADA, highly effective and administered in short course, will be available for children under 12 years of age at the end of 2019 or in 2020. They will make it possible to expand access to treatment and cure a vulnerable group which will benefit from early treatment.
WHO action
In May 2016, the World Health Assembly adopted the first Global Health Sector Strategy for Viral Hepatitis 2016-2021 . This strategy highlights the essential role of universal health coverage and sets targets consistent with the Sustainable Development Goals. Its ambition is to eliminate viral hepatitis as a public health problem. This goal is reflected in the global targets to reduce the number of new cases of viral hepatitis by 90% and the number of deaths associated with the disease by 65% by 2030. Actions to be taken by countries and by the WHO Secretariat to achieve these targets are presented in the Strategy.
To support countries in achieving the global hepatitis elimination targets under the 2030 Agenda for Sustainable Development, WHO is working to:
. raise awareness of this issue, promote partnerships and mobilize resources;
. formulate evidence-based policies and obtain data to guide action;
. improve health equity in the fight against hepatitis;
. prevent transmission; and
. strengthen screening, care and treatment services.
Since 2011, together with national governments, partners and civil society, WHO has organized the World Hepatitis Day campaigns (one of its nine annual flagship campaigns) to raise awareness and understanding of hepatitis viral. The date of July 28 was chosen because it commemorates the obtaining of the Nobel Prize by Dr. Baruch Bloomberg, who discovered the hepatitis B virus and developed a diagnostic test and a vaccine against this virus.
On the occasion of World Hepatitis Day 2020, WHO has chosen “Towards a future without hepatitis” as its theme. The campaign particularly emphasizes the importance of preventing mother-to-child transmission of HBV. On July 28, WHO will release new guidance on preventing mother-to-child transmission of the virus.
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