Diagnosis and testing
What is hepatitis C?
Hepatitis C is a
liver disease caused by the hepatitis C virus (HCV), which is found in the blood
of persons who have this disease. HCV is spread by contact with the blood of an
Is there a vaccine for the
prevention of HCV infection?
What blood tests are
available to check for hepatitis C?
There are several
blood tests that can be done to determine if you have been infected with HCV.
Your doctor may order just one or a combination of these tests. The following
are the types of tests your doctor may order and the purpose for each:
(antibody to HCV)
- EIA (enzyme
immunoassay) or CIA (enhanced chemiluminescence immunoassay)
Test is usually done first. If positive, it should be confirmed
(recombinant immunoblot assay)
A supplemental test used to confirm a positive EIA test
does not tell whether the infection is new (acute), chronic (long-term)
or is no longer present.
|b) Qualitative tests to detect presence or absence of virus (HCV RNA)
|c) Quantitative tests to detect amount (titer) of virus (HCV RNA)
positive PCR test indicates infection with HCV. A single negative test does not
prove that a person is not infected. Virus may be present in the blood and just
not found by PCR. Also, a person infected in the past who has recovered may have
a negative test. When hepatitis C is suspected and PCR is negative, PCR should
Can you have a "false positive"
anti-HCV test result?
A false positive test means the test looks as if it is positive, but it is
really negative. This happens more often in persons who have a low risk for the
disease for which they are being tested. For example, false positive anti-HCV
tests happen more often in persons such as blood donors who are at low risk for
hepatitis C. Therefore, it is important to confirm a positive anti-HCV test with
a supplemental test as most false positive anti-HCV tests are reported as
negative on supplemental testing.
Click here for more
information on Guidelines for Laboratory Testing and Result Reporting of
Antibody to Hepatitis C Virus.
Can you have a "false
negative" anti-HCV test result?
Yes. Persons with
early infection may not as yet have developed antibody levels high enough that
the test can measure. In addition, some persons may lack the (immune) response
necessary for the test to work well. In these persons, research-based tests such
as PCR may be considered.
How long after exposure to
HCV does it take to test positive for anti-HCV?
Anti-HCV can be found
in 7 out of 10 persons when symptoms begin and in about 9 out of 10 persons
within 3 months after symptoms begin. However, it is important to note that many
persons who have hepatitis C have no symptoms.
How long after exposure to
HCV does it take to test positive with PCR?
It is possible to
find HCV within 1 to 2 weeks after being infected with the virus.
Who should get tested for
- persons who ever
injected illegal drugs, including those who injected once or a few times
many years ago
- persons who were treated
for clotting problems with a blood product made before 1987 when more
advanced methods for manufacturing the products were developed
- persons who were
notified that they received blood from a donor who later tested positive for
- persons who received a
blood transfusion or solid organ transplant before July 1992 when better
testing of blood donors became available
- long-term hemodialysis
- persons who have signs
or symptoms of liver disease (e.g., abnormal liver enzyme tests)
- healthcare workers after
exposures (e.g., needle sticks or splashes to the eye ) to HCV-positive
blood on the job
- children born to HCV-positive
What is the next step if
you have a confirmed positive anti-HCV test?
the level of ALT ( alanine aminotransferase, a liver enzyme) in the blood. An
elevated ALT indicates inflammation of the liver and you should be checked
further for chronic (long-term) liver disease and possible treatment. The
evaluation should be done by a healthcare professional familiar with chronic
Can you have a normal liver
enzyme (e.g., ALT) level and still have chronic hepatitis C?
is common for persons with chronic hepatitis C to have a liver enzyme level that
goes up and down, with periodic returns to normal or near normal. Some persons
have a liver enzyme level that is normal for over a year but they still have
chronic liver disease. If the liver enzyme level is normal, persons should have
their enzyme level re-checked several times over a 6 to 12 month period. If the
liver enzyme level remains normal, your doctor may check it less frequently,
such as once a year.
Can I donate blood if I have had
any type of viral hepatitis?
If you had any type
of viral hepatitis since aged 11 years, you are not eligible to donate blood. In
addition, if you ever tested positive for hepatitis B or hepatitis C, at any
age, you are not eligible to donate, even if you were never sick or jaundiced
from the infection.
How is HCV spread from one person to another?
How could a person have
gotten hepatitis C?
HCV is spread
primarily by direct contact with human blood. For example, you may have gotten
infected with HCV if:
- you ever injected street
drugs, as the needles and/or other drug "works" used to prepare or inject
the drug(s) may have had someone else's blood that contained HCV on them.
- you received blood,
blood products, or solid organs from a donor whose blood contained HCV.
- you were ever on
long-term kidney dialysis as you may have unknowingly shared
supplies/equipment that had someone else's blood on them.
- you were ever a
healthcare worker and had frequent contact with blood on the job, especially
- your mother had
hepatitis C at the time she gave birth to you. During the birth her blood
may have gotten into your body.
- you ever had sex with a
person infected with HCV.
- you lived with someone
who was infected with HCV and shared items such as razors or toothbrushes
that might have had his/her blood on them.
How long can HCV live outside the
body and transmit infection?
Recent studies suggest that HCV may survive on environmental surfaces at room
temperature at least 16 hours, but no longer than 4 days.
What do you use to remove HCV from
should clean up any blood spills - including dried blood, which can still be
infectious - using 1:100 dilution of one part household bleach to 100 parts of
water for disinfecting the area. Use gloves when cleaning up any blood spills.
Is there any evidence that HCV has
been spread during medical or dental procedures done in the United States?
Medical and dental procedures done in the United States generally do not pose a
risk for the spread of HCV. However, there have been a few situations in which
HCV has been spread between patients when supplies or equipment were shared
Can HCV be spread by sexual
Yes, but this does
not occur very often. See section below on counseling for more information on
hepatitis C and sexual activity.
Can HCV be spread by oral
There is no
evidence that HCV has been spread by oral sex. See section on counseling for
more information on hepatitis C and sexual activity.
Can HCV be spread within a
Yes, but this does
not occur very often. If HCV is spread within a household, it is most likely due
to direct exposure to the blood of an infected household member.
Can you get Hepatitis C
from getting a tattoo?
possible when poor infection control practices are used, there is no evidence
that hepatitis C virus (HCV) has been spread through tattooing.
Since more advanced tests
have been developed for use in blood banks, what is the chance now that a person
can get HCV infection from transfused blood or blood products?
Less than 1 chance
per 2 million units transfused.
and Breast feeding
Should pregnant women be
routinely tested for anti-HCV?
No. Pregnant women have no greater risk of being infected with HCV then
non-pregnant women. If pregnant women have risk factors for hepatitis C, they
should be tested for anti-HCV.
What is the risk that HCV
infected women will spread HCV to their newborn infants?
About 5 out of every 100 infants born to HCV infected women become infected.
This occurs at the time of birth, and there is no treatment that can prevent
this from happening. Most infants infected with HCV at the time of birth have no
symptoms and do well during childhood. More studies are needed to find out if
these children will have problems from the infection as they grow older. There
are no licensed treatments or guidelines for the treatment of infants or
children infected with HCV. Children with elevated ALT (liver enzyme) levels
should be referred for evaluation to a specialist familiar with the management
of children with HCV-related disease.
Should a woman with
hepatitis C be advised against breast-feeding?
No. There is no
evidence that breast-feeding spreads HCV. HCV-positive mothers should consider
abstaining from breast-feeding if their nipples are cracked or bleeding.
When should babies born to
mothers with hepatitis C be tested to see if they were infected at birth?
Children should not be tested for anti-HCV before 18 months of age as anti-HCV
from the mother might last until this age. If diagnosis is desired prior to 18
months of age, testing for HCV RNA could be performed at or after an infant's
first well-child visit at age 1-2 months. HCV RNA testing should then be
repeated at a subsequent visit independent of the initial HCV RNA test result.
How can persons infected
with HCV prevent spreading HCV to others?
- Do not donate blood,
body organs, other tissue, or semen.
- Do not share personal
items that might have your blood on them, such as toothbrushes, dental
appliances, nail-grooming equipment or razors.
- Cover your cuts and skin
sores to keep from spreading HCV.
How can a person protect
themselves from getting hepatitis C and other diseases spread by contact with
- Don't ever shoot drugs.
If you shoot drugs, stop and get into a treatment program. If you can't
stop, never reuse or share syringes, water, or drug works, and get
vaccinated against hepatitis A and hepatitis B.
- Do not share
toothbrushes, razors, or other personal care articles. They might have blood
- If you are a healthcare
worker, always follow routine barrier precautions and safely handle needles
and other sharps. Get vaccinated against hepatitis B
- Consider the health
risks if you are thinking about getting a tattoo or body piercing: You can
get infected if:
- the tools that are
used have someone else's blood on them.
- the artist or
piercer doesn't follow good health practices, such as washing hands and
using disposable gloves.
HCV can be spread by sex, but
this does not occur very often. If you are having sex, but not with one steady
- You and your partners
can get other diseases spread by having sex (e.g., AIDS, hepatitis B,
gonorrhea or chlamydia).
- You should use latex
condoms correctly and every time. The efficacy of latex condoms in
preventing infection with HCV is unknown, but their proper use may reduce
- You should get
vaccinated against hepatitis B.
Should patients with
hepatitis C change their sexual practices if they have only one long-term steady
No. There is a
very low chance of spreading HCV to that partner through sexual activity. If you
want to lower the small chance of spreading HCV to your sex partner, you may
decide to use barrier precautions such as latex condoms.
The efficacy of latex condoms in preventing infection with HCV is unknown, but
their proper use may reduce transmission. Ask your doctor about having your sex partner
What can persons with HCV
infection do to protect their liver?
- Stop using alcohol.
- See your doctor
- Don't start any new
medicines or use over-the-counter, herbal, and other medicines without a
- Get vaccinated against
hepatitis A if liver damage is present.
What other information
should patients with hepatitis C be aware of?
- HCV is not spread by
sneezing, hugging, coughing, food or water, sharing eating utensils or
drinking glasses, or casual contact.
- Persons should not be
excluded from work, school, play, child-care or other settings on the basis
of their HCV infection status.
- Involvement with a
support group may help patients cope with hepatitis C.
Should persons with chronic
hepatitis C be vaccinated against hepatitis B?
If persons are in risk groups for whom hepatitis B vaccine is recommended, they
should be vaccinated. (A Comprehensive Strategy for
Eliminating Transmission in the United States Through Universal Childhood
Consequences of HCV Infection
What are the chances of
persons with HCV infection developing long term infection, chronic liver
disease, cirrhosis, liver cancer, or dying as a result of hepatitis C?
Of every 100 persons
infected with HCV about:
- 55-85 of persons might
develop long-term infection
- 70 persons might develop
chronic liver disease
- 5-20 persons might
develop cirrhosis over a period of 20 to 30 years
- 1-5 of persons might die
from the consequences of long term infection (liver cancer or cirrhosis)
Hepatitis C is a leading
indication for liver transplants.
Do medical conditions
outside the liver occur in persons with chronic hepatitis C?
percentage of persons with chronic hepatitis C develop medical conditions
outside the liver (this is called extrahepatic). These conditions are thought to
occur due to the body's natural immune system fighting against itself. Such
conditions include: glomerulonephritis, essential mixed cryoglobulinemia, and
porphyria cutanea tarda.
and Treatment of Chronic Hepatitis C
When might a specialist
(gastroenterologist, infectious disease physician, or hepatologist) be consulted
in the management of HCV-infected persons?
A referral to
or consultation with a specialist for further evaluation and possible treatment
may be considered if a person is anti-HCV positive and has elevated liver enzyme
levels. Any physician who manages a person with hepatitis C should be
knowledgeable and current on all aspects of the care of a person with hepatitis
What is the treatment for chronic
Combination therapy with pegylated interferon and ribavirin is the treatment of
choice resulting in sustained response rates of 40%-80%. (up to 50% for patients
infected with the most common genotype found in the U.S. [genotype 1] and up to
80% for patients infected with genotypes 2 or 3). Interferon monotherapy is
generally reserved for patients in whom ribavirin is contraindicated. Ribavirin,
when used alone, does not work. Combination therapy using interferon and
ribavirin is now FDA approved for the use in children aged 3-17 years.
What are the side effects
of interferon therapy?
persons have flu-like symptoms (fever, chills, headache, muscle and joint aches,
fast heart rate) early in treatment, but these lessen with continued treatment.
Later side effects may include tiredness, hair loss, low blood count, trouble
with thinking, moodiness, and depression. Severe side effects are rare (seen in
less than 2 out of 100 persons). These include thyroid disease, depression with
suicidal thoughts, seizures, acute heart or kidney failure, eye and lung
problems, hearing loss, and blood infection. Although rare, deaths have occurred
due to liver failure or blood infection, mostly in persons with cirrhosis. An
important side effect of interferon is worsening of liver disease with
treatment, which can be severe and even fatal. Interferon dosage must be reduced
in up to 40 out of 100 persons because of severity of side effects, and
treatment must be stopped in up to 15 out of 100 persons. Pregnant women should
not be treated with interferon.
What are the side effects
of combination (ribavirin + interferon) treatment?
In addition to the
side effects due to interferon described above, ribavirin can cause serious
anemia (low red blood cell count) and can be a serious problem for persons with
conditions that cause anemia, such as kidney failure. In these persons,
combination therapy should be avoided or attempts should be made to correct the
anemia. Anemia caused by ribavirin can be life-threatening for persons with
certain types of heart or blood vessel disease. Ribavirin causes birth defects
and pregnancy should be avoided during treatment. Patients and their healthcare
providers should carefully review the product manufacturer information prior to
Can anything be done to
reduce symptoms or side effects due to antiviral treatment?
You should report
what you are feeling to your doctor. Some side effects may be reduced by giving
interferon at night or lowering the dosage of the drug. In addition, flu-like
symptoms can be reduced by taking acetaminophen before treatment.
Can children receive
interferon therapy for chronic hepatitis C?
Food and Drug Administration has approved the use of the combination anti-viral
therapy for the treatment of hepatitis C in children 3 to 17 years old. For
details please refer to page 11 of AASLD Practice Guideline: Diagnosis,
Treatment, and Management of Hepatitis C.
What does the term genotype
Genotype refers to the genetic make-up of an organism or a virus. There are at
least 6 distinct HCV genotypes identified. Genotype 1 is the most common
genotype seen in the United States.
Is it necessary to do
genotyping when managing a person with chronic hepatitis C?
Yes, as there are 6
known genotypes and more than 50 subtypes of HCV, and genotype information is
helpful in defining the epidemiology of hepatitis C. Knowing the genotype or
serotype (genotype-specific antibodies) of HCV is helpful in making
recommendations and counseling regarding therapy. Patients with genotypes 2 and
3 are almost three times more likely than patients with genotype 1 to respond to
therapy with alpha interferon or the combination of alpha interferon and
ribavirin. Furthermore, when using combination therapy, the recommended duration
of treatment depends on the genotype. For patients with genotypes 2 and 3, a
24-week course of combination treatment is adequate, whereas for patients with
genotype 1, a 48-week course is recommended. For these reasons, testing for HCV
genotype is often clinically helpful. Once the genotype is identified, it need
not be tested again; genotypes do not change during the course of infection.
Why do most persons remain
infected with HCV mount an antibody response to parts of the virus, but changes
in the virus during infection result in changes that are not recognized by
preexisting antibodies. This appears to be how the virus establishes and
maintains long-lasting infection.
Can persons become infected
with different genotypes?
of the ineffective immune response described above, prior infection does not
protect against reinfection with the same or different genotypes of the virus.
For the same reason, there is no effective pre- or postexposure prophylaxis (i.e,
immune globulin) available.
C and Healthcare Workers
What is the risk for HCV
infection from a needle-stick exposure to HCV contaminated blood?
After needle stick or
sharps exposure to HCV positive blood , about 2 (1.8%) healthcare workers out of
100 will get infected with HCV (range 0%-10%).
What are the
recommendations for follow-up of healthcare workers after exposure to HCV
(e.g., interferon) or immune globulin should not be used for postexposure
- For the source, baseline
testing for anti-HCV.
- For the person exposed
to an HCV-positive source, baseline and follow-up testing including
baseline testing for anti-HCV and ALT activity; and
follow-up testing for anti-HCV (e.g., at 4-6 months) and ALT activity.
(If earlier diagnosis of HCV infection is desired, testing for HCV RNA may
be performed at 4-6 weeks.)
- Confirmation by
supplemental anti-HCV testing of all anti-HCV results reported as positive
by enzyme immunoassay.
healthcare workers be restricted in their work?
No, there are
no recommendations to restrict a healthcare worker who is infected with HCV. The
risk of transmission from an infected healthcare worker to a patient appears to
be very low. As recommended for all healthcare workers, those who are HCV
positive should follow strict aseptic technique and standard precautions,
including appropriate use of hand washing, protective barriers, and care in the
use and disposal of needles and other sharp instruments.
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