WHAT IS HEPATITIS?
Hepatitis is an inflammation of the liver. "Hepato" is Greek for "liver," and "itis" means "inflammation." The different types of hepatitis are caused by different things, but they all produce inflammation of the liver. Viral hepatitis refers to several common contagious diseases caused by viruses that attack the liver. The most important types of viral hepatitis are hepatitis A, hepatitis B, and hepatitis C. Newly discovered forms of viral hepatitis also include hepatitis D, E, and G. Non-viral forms of hepatitis can be caused by toxic agents (drugs or chemicals), alcohol, or autoimmune processes. Another form of hepatitis is toxic hepatitis. Toxic hepatitis can be caused by viruses or by liver damage due to toxic substances. Toxic hepatitis is a deterioration of the liver cells caused by chemicals, alcohol, drugs, and industrial compounds. Alcohol abuse is a common cause of toxic liver damage.

WHAT HAPPENS IN THE BODY?
The hepatitis A and E viruses first enter the gut and begin reproducing. They spread to the liver and multiply in liver cells. Hepatitis B, C, D, and G enter the bloodstream; when they pass through the liver, they nter liver cells and begin to reproduce. The body attacks the infected cells, which causes the liver to become inflamed. In hepatitis B infection, the liver usually repairs itself, leaving antibodies to the surface antigen, which shows that the infection occurred, but that the ody defeated it. When someone catches the hepatitis C virus, their body produces antibodies to try to destroy it. More often than not, the antibodies fail to identify the hepatitis C virus properly. The infection then remains long-term. Most infected people don't know they have the virus. This is because for some people there will be no symptoms and for others, symptoms may take an average 13 years to develop. Some people may have hepatitis C for 20 years or more before finding out.

The way that hepatitis affects people is different for different people. Some are not affected by the condition, but others are affected very badly.

Hepatitis C infection doesn't always make people sick. When someone does get sick, symptoms take a long time to develop (approximately 13 years). Symptoms often stay at a certain level and don't always get worse. They can come and go with no real pattern.

Some people with chronic infection don't have any noticeable liver damage or symptoms. These people remain well, but *THEY ARE INFECTIOUS AND SHOULD TAKE CARE TO REDUCE ANY RISK OF TRANSMITTING THE VIRUS TO OTHERS.*

Data on the clinical course of HCV is limited because the onset of infection often goes unrecognized, and the early course of the disease is indolent and protracted in many individuals. Prospective cohort studies are few, typically small, include relatively few subjects whose date of infection can be well documented, (e.g.blood transfusion recipients and victims of accidental needle sticks), and have relatively short followup. The natural history of disease appears to differ according to geography, alcohol use, virus characteristics, (e.g., genotype, viral load), coinfection with other iruses, and other unexplained factors. - National Institutes of Health Statement on Hepatitis C 1997

WHAT IS THE INCUBATION PERIOD?
After initial exposure, HCV RNA can be detected in blood in 1-3 weeks. Within an average of 50 days (range 15-150 days), virtually all patients develop liver cell injury, as evidenced by elevation of serum alanine aminotransferase (ALT). The majority of patients are asymptomatic and anicteric. Only 25-35 percent develop malaise, weakness, or anorexia, and some become icteric. Fulminant liver failure following HCV infection has been reported but is a rare occurrence. Antibodies to HCV (anti-HCV) almost invariably become detectable during the course of illness. Anti-HCV can be detected in 50-70 percent of patients at the onset of symptoms and in approximately 90 percent of patients in 3 months after onset of infection. HCV infection is self-limited in only 15 percent of cases. Recover is characterized by disappearance of HCV RNA from blood and return of liver enzymes to normal. - National Institutes of Health Statement on Hepatitis C 1997

HOW DOES HEPATITIS C USUALLY BEGIN?
For a slight majority of patients, the illness begins suddenly as though one had come down with the flu. Except that this "flu" doesn't seem to completely go away. For many other patients, the onset appears gradually over a long period of time. Infants and young children often have no symptoms at all. Many other symptoms may also be present, however they will typically be different among different patients. These include: fatigue, low-grade fever, headaches; slight sore throat, loss of appetite, nausea, vomiting, sensitivity to light, and stiff or aching joints. Many people develop a pain in the right side, over the liver area. The urine may become dark brown, and the feces may be pale. In severe acute infections, some people may develop jaundice in which the skin and whites of the eyes become yellowish.

The degree of severity can differ widely among patients, and will also vary over time for the same patient. Severity can vary between getting unusually fatigued following stressful events, to being totally bedridden and completely disabled. The symptoms have a tendency to wax and wane over time.

WHAT ARE THE DIFFERENT TYPES OF HEPATITIS?

The different types of VIRAL hepatitis are: A (formerly called infectious hepatitis), B (serum hepatitis), C ( formerly called non-A, non-B hepatitis), D (delta hepatitis), E (transmitted through the feces of an infected person) Cryptogenic (or Non-A,B,C,D,E,G) G (a virus transmitted through infected blood products)

More hepatitis viruses are being discovered, but may be less common.

Other viruses, such as Yellow Fever, Epstein-Barre virus, Cytomegalovirus, as well as parasites and bacteria, can cause hepatitis as a secondary effect.

Other types of non-viral hepatitis are: Autoimmune, Wilson's disease, hemochromatosis, drug or chemical induced, alcoholic hepatitis.

WHAT IS THE FUNCTION OF THE LIVER?
The liver:

1. Stores iron reserves, as well as vitamins and minerals
2. Makes bile to help digest food
3. Detoxifies poisonous chemicals, including alcohol, beer, wine, and drugs - prescribed and over-the-counter as well as illegal substances. Acts as a filter to convert them to substances that can be used or excreted from the body
4. Converts food we eat into stored energy, and chemicals necessary for life and growth
5. Makes your blood
6. Manufactures new proteins
7. Makes clotting factors to help blood clot
8. Removes poisons from the air, exhaust, smoke and chemicals we breathe.
9. Manufactures and exports important body chemicals used by the body. One of these is bile, a greenish-yellow substance essential for the digestion of fats in the small intestine.

WHEN WAS THE HEPATITIS C VIRUS DISCOVERED?

WHO GETS HEPATITIS?
People who have ever had blood transfusions or blood products before screening was introduced (1990), and people who have ever shared injecting equipment for drugs should be tested for the hepatitis C virus. Other people who should consider having the test done are those who have been tattooed, had body piercing or a needlestick injury. People with abnormal liver function tests with no apparent cause would also benefit from having a hepatitis C antibody test. Healthcare workers who perform "exposure prone procedures" should also be tested.

Hepatitis C currently causes between 150,000 and 250,000 new cases of chronic infection in the United States each year. Hemophiliacs and intravenous drug users are at the greatest risk, but anyone, of any status or age, and in any walk of life, is at risk for acquiring the hepatitis C virus. Researchers have found that many people infected with hepatitis C don't even know it. From 20 to 40 percent of patients in inner-city hospitals are infected, as are 80 percent of intravenous drug users.

HOW IS IT TRANSMITTED?
Most people with hepatitis C contracted it either through a blood transfusion or receiving a blood product (plasma, etc.) that was contaminated with hepatitis C, or by sharing needles with intravenous drug users that were infected with hepatitis C. Prior to 1990 blood could not be screened for HCV. Thanks to HCV testing with modern sensitive methods, the risk of acquiring hepatitis C from blood transfusion is now less than 1%. The other people who acquire hepatitis C include health care and laboratory workers that may get stuck with an infected needle or instrument, people receiving medical/dental procedures, people receiving hemodialysis, body piercing, sharing razors, toothbrushes, nail clippers or people who have had tattoos or manicures that were performed with poorly sterilized equipment. Infected mothers can pass the virus to the fetus in utero but this occurs less than 1% of the time. It may occur more readily if the mother is also infected with the human immunodeficiency virus (HIV) that causes AIDS. Cases of hepatitis C with no evidence of exposure through blood transfusions, needle sticks or needle sharing are called "sporadic". How these individuals became infected is unknown.

Forty percent of all cases of hepatitis C were contracted through unknown means by people who have are in no current risk category. What this means is that we are *all* at risk for contracting hepatitis C.

HOW HCV IS *NOT* TRANSMITTED

1. The hepatitis C virus is NOT airborne
2. It is NOT spread by:

• sneezing and coughing
• holding hands
• kissing
• using the same toilet
• eating food prepared by someone with HCV
• holding a child in your arms
• swimming in the same pool
• The virus IS in the blood of an infected person.

• razors, nail clippers or scissors
• tooth brushes and water pics
• tattoo or body piercing needles
• illicit IV drug needles and paraphenalia (cottons, spoons, etc.)
• tampons or sanitary napkins

HCV AND BLOOD TRANSFUSIONS
Anyone who received a blood transfusion or a blood product before 1992 is considered to be in a high risk group. Chance of infection by transfusion today is said to be 0.12%. Blood banks began screening donors for certain markers as early as 1986. In May 1990, screening tests for the hepatitis C virus came into use, and the risk is now thought to be one in 3,300 units of blood, or 0.12% for the typical recipient of a transfusion. - California at Berkeley Wellness Letter, May 1993 HCV acquired through blood transfusion tends to be more severe than through other modes of transmission.

In a group of patients seen at a referral center, chronic post-transfusion hepatitis C infection was a progressive disease and, in some patients, led to death from either liver failure or hepatocellular carcinoma - N Engl J Med 1995;Vol 332, Iss 22:1463-1466

HCV AND INTRAVENOUS DRUG USE
Investigators at Johns Hopkins report that injection drug users are at high risk for contracting hepatitis B and C, and that many contract hepatitis B or C within the first year of IV drug use. Dr. David Vlahov and colleagues studied 716 volunteers who had been injecting for six years or less. Seventy-seven percent of them were infected with HCV and 65.7% were infected with HBV. Roughly 20% were HIV-positive. Hepatitis C was more prevalent among those who reported injection drug use for less than four months than among those who reported injecting drugs for 9 to 12 months.- Am J Pub Health 1996;86:642-646

NEONATAL TRANSFER OF HCV
Physicians are not very concerned about hepatitis C transmission during birth, and many HCV positive women have given birth to children who were HCV negative. The likelihood of transmission from breast milk is also very small for both HCV and HBV. Physicians do not advise against breastfeeding.

Neonatal transfer among women infected with the hepatitis C virus has been reported in 5% of pregnancies, but can be as high as 25% if the mother is also HIV positive. Japanese studies, (where a much more severe HCV genotype is prevalent) showed that only 6% of the babies born to HCV positive mothers contracted hepatitis C. Many showed antibodies at birth, but were clear of the virus by 18 months. This is not the case if the transmission is simultaneous with HIV or HBV infection, of if the mother is infected by multiple strains of hepatitis C virus.

Mother-to-baby transmission of HCV may be increased if the mother is also infected with HIV or HBV or has a high titer of HCV in the blood. In the latter circumstance, Japanese researchers have estimated that the risk of transmission can be approximately 10%.

Full recovery from perinatal hepatitis C virus infection is rare, as chronic hepatitis generally develops even in children with prolonged intervals of remission. - "Natural History of Perinatal HCV Infection," Clinical Infectious Diseases, July 1996;23:47-50

According to an abstract by V. Papaevangelou from the 35th Interscience Conference on Antimicrobial Agents and Chemotherapy, "Mother-to-Infant Transmission of Hepatitis C in Children Born to Mothers Coinfected with HIV and HCV," the rate of HCV vertical transmission was not affected by the mode of delivery (vaginally or by C-section).

Recent technological advances have led to the development of several types of invasive procedures in the fetus principally for the diagnosis and management of fetal disorders. There is probably a small but finite risk of transmission of maternal viral infections such as human immunodeficiency virus, hepatitis B and C, cytomegalovirus and herpes simplex during invasive procedures. - "Risk of Fetal Infection from Invasive Procedures," Journal of Hospital Infection 1997 Mar;35(3):169-173

OTHER MEANS OF HCV TRANSMISSION
Like hepatitis B, hepatitis C is spread through exposure to blood from an infected person, such as through a blood transfusion or sharing needles. There is no evidence that the hepatitis C virus can be transmitted by casual contact, through foods or by coughing or sneezing.

SEXUAL TRANSMISSION
The risk of sexual transmission of hepatitis C virus has not been thoroughly investigated but appears to be minimal. Some studies have shown no risk of passing hepatitis C on to a sexual partner, others have shown only a very low risk. The United States Centers for Disease Control and Prevention (CDC) do not recommend a change in sexual practices for those engaged in a long-term relationship with one sexual partner. However, people with acute illness and multiple sexual partners may be at greater risk and should use condoms to reduce the risk of acquiring or transmitting hepatitis C as well as other sexually transmitted infections. The risk is increased if the HCV positive partner is immunocompromised because the virus titer in the blood may be increased under those circumstances. Sex during the menstrual period should be avoided, due to the blood contact at that time. There is also some speculation about the possibility of transmission piggybacked on the genital herpes virus through genital lesions.

The reason that many studies say "multiple sexual partners" when referring to the risk of sexual transmission of HCV, is because people who have multiple sexual partners have a greater risk of contracting other sexually transmitted diseases which can cause open sores and lesions. And with those open sores and lesions you are at greater risk for blood contact. Also, it is thought that the hepatitis C virus tends to "piggyback" on the herpes virus, and if you have herpes you are at much greater risk of contracting or transmitting the virus.

According to a report in the Archives of Internal Medicine, sexual transmission of HCV occurs at a rate of about 1% per year in at-risk partners, and shows that periodic serum immune globulin prophylaxis for sexual partners is protective. Transmission of the virus "...occurred only in partners of HCV-infected patients with active liver disease," the researchers report. They add an "intriguing" finding that patients who became infected during the study were older and had longer relationships with their partners compared with those who did not become infected. - Arch Intern Med 1997;157:1537-1544

OCCUPATIONAL EXPOSURE (HEALTH CARE WORKERS)
Occupational exposure to HCV is possible in any occupation in which there is exposure to possibly infected blood, (i.e.,nurses and phlebotomists through needle sticks, emergency medical technicians through blood at accident scenes, etc.). The risk of HCV infection following a needlestick injury with HCV-contaminated blood may be as high as 10%. Nonetheless, the risk of occupational transmission of HCV to Health Care Workers is far less than that of HBV.

Needlestick accidents pose a varying rate of transmission, from 0% in 81 Spanish patients followed for 12 months by radioimmunoblot assay II up to as high as 10% in other studies using detection by PCR. This rate is lower than that of HBV (7% to 30%) but is higher than HIV (0.5%). The resultant hepatitis seems to be mild, transient, and less likely to evolve into a chronic hepatitis. This may reflect a low virus load or different HCV strains. There is no evidence to date to support the use of antiviral therapy for acute exposures. - "Recent Developments in Viral Hepatitis", Current Opinions in Gastroenterology, 1994

TOOTHBRUSHES/RAZORS/NAIL CLIPPERS
It is possible for toothbrushes, razors, nail clippers, tweezers and similar personal care items to come in contact with infected blood. Therefore, sharing of these items is not recommended.

HEMODIALYSIS
Hepatitis C viral infection is a common infection in hemodialysis units, according to a report by Dr. Brian J.G. Pereira of Tufts University in the the January 25, 1996 edition of Family Practice News. Dr. Pereira points to data from eight studies that indicate a 16% prevalence rate of infection in nearly 2,500 dialysis patients without a history of blood transfusion - a rate "considerably higher" than that seen in the general population.

HIGHLY SPECULATIVE MODES OF TRANSMISSION OF HCV
The following are considered highly speculative because either no studies have been done, conflicting studies have been done, or there is scientific reason to believe this is not a mode of transmission, but there still is no conclusive study to rule it out.

TEARS, SALIVA, URINE, AND OTHER BODY FLUIDS
Body fluids from 14 patients with chronic hepatitis C were analyzed for the presence of hepatitis C viral RNA using the polymerase chain reaction. ...The hepatitis C viral genome was not detected in any saliva or semen sample. These findings suggest that body fluids of patients with chronic hepatitis C are rarely, if ever, contaminated with the hepatitis C virus. This may help to explain the infrequent transmission of this disease by sexual or close physical contact. - "Absence of hepatitis C viral RNA from saliva and semen of patients with chronic hepatitis C", Fried MW; Shindo M; Fong TL; Fox PC; Hoofnagle JH; DiBisceglie AM, Gastroenterology 102: 1306-8 (1992)

Previous studies have provided conflicting results on the presence of hepatitis C virus-RNA in saliva. In this study, 23 (62%) of 37 patients tested positive for hepatitis C virus-RNA in saliva, using polymerase chain reaction analysis. A slightly greater proportion had a sporadic rather than a parenteral origin of chronic hepatitis C. These results provide a biological basis for saliva as a possible source of hepatitis C virus (HCV) infection, but do not necessarily imply transmission by this route. - "Detection of HCV-RNA in saliva of patients with chronic hepatitis C", P. Couzigou, L. Richard, F. Dumas, L. Schouler & H. Fleury, Gut 34:S59-60 (1993)

We conclude that HCV RNA is present in the saliva of approximately half of patients with acute and chronic hepatitis C, and the presence of HCV RNA correlates with HCV viremia. The efficiency of HCV transmission is low among spouses. - "Hepatitis C virus RNA in saliva of patients with posttransfusion hepatitis and low efficiency of transmission among spouses", J. T. Wang, T. H. Wang, J. C. Sheu, J. T. Lin, D. S. Chen, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Republic of China.

For up to 20 to 40% of patients chronically infected with hepatitis C virus (HCV), the mode of transmission is still unknown. We demonstrate that tear fluid contains HCV RNA-carrying material with the properties of infectious virus and conclude that smear infection with tear fluid may play a role in HCV transmission. - "Tear fluid of hepatitis C virus carriers could be infectious", H. H. Feucht, B. Zollner, M. Schroter, H. Altrogge, R. Laufs, J Clin Microbiol 33: 2202-2203 (1995)

CAT SCRATCHES
It is unknown if the hepatitis C virus can be transmitted via cat's claws if the cat scratches one person and immediately scratches another.

MOSQUITOS
Researchers have determined that the hepatitis C virus is not transmitted by mosquitos. There is a lack of epidemiological or physical evidence that it is mosquito-borne and experiments to see any HCV replication in mosquito cells have failed. There are two ways that mosquitos can transmit illness to humans. These are "mechanical transmission" in which a small amount of blood may be present on the mosquito's feeding spike. This type of transmission does not occur with serious human diseases such as HCV, HBV, or HIV. The second way mosquitoes transmit disease is called "biological" transmission. Studies show that mosquitoes can swallow viruses into their middle gut, but once there the virus dies and is digested in the same way we digest food - by breaking it down using acid.

ALTERNATIVE MEDICAL PROCEDURES

HOUSEHOLD TRANSMISSION
Household transmission of hepatitis C is rare. It can occur where blood-to-blood contact happens. This could involve your blood spills coming into contact with someone's open cut, or to a lesser extent, the sharing of razor blades, toothbrushes and sharp personal grooming aids. It is advisable to wipe up blood spills with paper towels and bleach, and to keep razors and toothbrushes separate from those belonging to other family members.

OTHER
A proportion of HCV infected individuals do not fall into any currently recognized risk group. It is thought that some of these cases may have had exposure to injected drugs many years ago which they have forgotten or are unwilling to discuss.

IS HCV ANYTHING LIKE HIV?
Yes and No. HIV and HCV are both RNA viruses. That is both use RNA to carry their genetic code until they find a yummy host! However, these viruses belong to two entirely different families. Sort of like whales and humans are both mammals, but boy what a difference. They have completely different strategies for replication and for survival. HIV is a retrovirus, and once the virus is in a human cell it copies itself to DNA and migrates into the cell nucleus and integrates into the host genome and is then copied everytime the cell copies it's own DNA. Retro meaning it reverts to a DNA virus once it is in the cell. Other retroviruses are HTLV viruses like some types of leukemia.

HCV is a flavivirus. It is related to yellow fever and dengue fever viruses. It replicates by making positive and negative RNA strands and does not make DNA or integrate into the host genome.

There are lots of other structural and envelope differences between these two, but the main point is that HIV and HCV are NOT very similar at all--except they both completely screw up the immune system and there is no known cure.

PREVENTION
Prevention: avoid risk behaviors. Shots of gamma globulin after a person has been stuck with a needle do not seem to work. There are no current HCV vaccines. With screening of the blood supply, the risk of HCV infection from a transfusion has dropped from 10% (1970's) to less than 1%. "Prevention, Diagnosis, and Management of Viral Hepatitis", AMA

WHEN, AND FOR HOW LONG, IS A PERSON ABLE TO SPREAD THE HEPATITIS C VIRUS?

Some people carry the virus in their bloodstream and may remain contagious for years. The disease may occur in the acute form and be followed by recovery, but the majority of the cases become chronic and cause symptoms for years.

HOW CAN THE SPREAD OF HEPATITIS C BE PREVENTED?

People who have hepatitis C should remain aware that their blood and possibly other body fluids are potentially infective, even when the person carrying the virus is asymptomatic. Care should be taken to avoid blood exposure to others by sharing toothbrushes, razors, needles, etc. Infected people must not donate blood, plasma or semen, and should inform their dental or medical health providers so that proper precautions can be followed.

CLEANING UP BLOOD SPILLS
A 10% bleach (soak for 30 minutes) should be used on all contaminated surfaces. There is no proof that this KILLS everything, but you can't autoclave the world. There are also chemical disinfectants containing phenols and other very expensive ingredients, but for home use bleach is the best we have. Bleach can be VERY VERY corrosive on some surfaces... so be careful what you slop it on.

Pure H2O Bio-Technologies Inc. is currently working on a new germ killing liquid that kills bacteria and some viruses, including hepatitis C .

WHAT TO DO IN CASE OF AN ACCIDENTAL NEEDLESTICK
Because there is no effective neutralizing antibody or vaccine for preventing hepatitis C virus (HCV) transmission, HCV can be transmitted to health care workers through accidental needlesticks. In a study reported in the journal Clinical Infectious Diseases, after the clinical onset of acute hepatitis, two health care workers who had sustained accidental needlesticks were treated with interferon (total dose, similar to 300 megaunits). Neither individual developed chronic hepatitis. This finding raises the possibility that treatment with low-dose interferon following an accidental needlestick may be beneficial, even when it is started after the clinical onset of hepatitis. -"Early Therapy with Interferon for Acute Hepatitis C Acquired Through a Needlestick." Clinical Infectious Diseases, May 1997;24(5):992-994.

WHO SHOULD I TELL?
If you have hepatitis C, you are under no legal obligation to tell others. It is up to you to decide whether to tell anyone of your hepatitis C status. Some people, (and unfortunately some health care providers also) may have judgmental attitudes or unnecessarily exaggerated fears of infection. People should carefully consider who they inform, in light of possible discrimination. How people might have caught the virus is not important. Those who have the hepatitis C virus are covered by anti-discrimination laws.

CAN YOU GET HEPATITIS MORE THAN ONCE?
Once you completely recover from hepatitis A or B you can't get it again, although in some people the condition becomes chronic and can last their whole lives. But since there are at least five different viruses that cause hepatitis, you can get one of the others (though not D if you are immune to B). Becoming infected with B and C at the same time may actually cause a much more severe, dangerous case of hepatitis. A person who has recovered from a case of viral hepatitis could also develop hepatitis again due to other causes, such as alcohol or drugs. If you have had hepatitis C and clear the virus, you *can* become infected with it again. Because there are so many different genotypes of hepatitis C, and because the virus mutates so rapidly, natural immunity is not developed. Studies with chimpanzees have shown that after resolution of an acute hepatitis C infection, rechallenge with the same strain of HCV causes reinfection.

VACCINES
Chiron is preparing to begin clinical trials for a hepatitis C vaccine. Preclinical results have shown promise for this vaccine in preventing HCV disease. If effective, trials will require at least five years to complete. --- Studies of laboratory animals suggest that protective immunity against the hepatitis C virus may not develop: Animals that have recovered from HCV infection have developed hepatitis again after rechallenge with infected material. Another potential obstacle comes from evidence that more than a half-dozen strains of HCV may exist. One strain may predominate in a particular geographic region. Furthermore, different strains are likely to exhibit differing virulence. - Hepatitis C: How Much of a Threat? (Special Issue: Emerging Infectious Diseases). Brown, Edwin A. Patient Care. May 15 1994, v28, n9, p105(8)

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