Hepatitis C: Symptoms, Causes & Treatment

Hepatitis C (HCV) is a viral infection caused by the Hepatitis C virus, transmitted primarily through blood exposure. When the virus enters the body, it targets liver cells and causes inflammation ranging from acute (short-term) to chronic (long-term). An estimated 80% of newly infected individuals develop chronic infection, which without treatment can lead to cirrhosis, liver failure, and liver cancer.

In the Middle East and Arab world, including Jordan, Hepatitis C is a significant public health concern, with prevalence rates estimated at 1-3% of the population depending on the region. Many cases remain undiagnosed because symptoms may be mild or absent in early stages. However, with the availability of direct-acting antiviral drugs (DAAs), treatment is now highly effective, safe, and easy to manage, dramatically changing the disease's natural course.

The virus does not spread through food, drink, or ordinary social contact, but rather through direct exposure to contaminated blood. The acute phase may pass without noticeable symptoms, and infected individuals may remain unaware of their status for years.

In acute Hepatitis C (first 6 months of infection), 70-80% of infected individuals show no symptoms, making early diagnosis difficult. When symptoms appear in acute phase, they resemble other viral hepatitis. In chronic phase, symptoms may be mild or absent for decades but emerge as complications like cirrhosis develop.

• Fatigue and general weakness: Most common symptom, may persist long-term even with treatment.
• Joint and muscle pain: Common in acute phase, similar to flu symptoms.
• Low-grade fever: Usually below 38.5°C, occurs in acute phase.
• Nausea and vomiting: Especially upon waking or after fatty meals.
• Loss of appetite: May lead to unintended weight loss.
• Pain or discomfort in upper right side: Indicates liver inflammation.
• Jaundice: Yellowing of skin and eyes from elevated bilirubin; occurs in 20-30% of acute cases.
• Dark urine: May resemble strong tea.
• Pale stools: Indicates impaired bile secretion.
• Itchy skin: Especially in those developing early cirrhosis.
• Abdominal swelling or leg edema: Late signs indicating liver failure.
• Easy bleeding or bruising: From low platelets and impaired clotting.

• Contaminated blood transfusion: Before 1992, reliable blood screening was unavailable, leading to HCV spread through transfusions and blood products, especially in hemophilia patients.
• Sharing contaminated sharp instruments: Needle sharing among intravenous drug users is a major transmission route, especially in areas without safe disposal programs.
• Occupational exposure: Healthcare workers may face needlestick injuries or cuts from contaminated sharp instruments.
• Unsafe medical and cosmetic procedures: Dental cleaning, tattooing, piercing, or surgery in unsterilized clinics.
• Mother-to-child transmission: During pregnancy or childbirth (risk ~5%), not through breastfeeding.
• Sexual contact: Rare but possible, especially with wounds or mucosal inflammation.
• Sharing personal care items: Toothbrushes, razors, or nail clippers if there is gum or skin bleeding.

• Intravenous drug use: Most affected group globally; needle sharing increases risk 200-fold.
• Healthcare workers: Repeated exposure to blood and body fluids increases infection risk.
• Blood product recipients before 1992: Particularly hemophilia and thalassemia patients.
• Medical or cosmetic procedures in unsterilized centers: Dialysis, surgery, tattooing in unlicensed clinics.
• Incarcerated individuals: Higher prevalence due to poor hygiene and high-risk behaviors.
• People with HIV: Worsens outcomes if untreated.
• Sharing sharp personal care tools: Especially in families with high infection rates.
• Children born to infected mothers: Vertical transmission risk 3-5%.
• Sexual partners of HCV-positive individuals: Low but present risk, especially with wounds.
• Accidental needlestick with contaminated blood: Post-exposure risk ~0.3%.

Hepatitis C diagnosis relies on laboratory tests and clinical evaluation. Diagnosis cannot be made on symptoms alone as they may be absent or vague. The first step is testing for antibodies to the virus (Anti-HCV), and if positive, active infection is confirmed with HCV RNA testing.

• Anti-HCV antibody test: Initial screening for viral exposure. Positive even after spontaneous clearance or cure. Normal value: negative.
• HCV RNA PCR test: Confirms active current infection; gold standard for diagnosis and monitoring. Normal value: negative (less than 15 copies/mL).
• HCV Genotyping: Identifies virus type (1-6), crucial for selecting appropriate treatment regimen and duration.
• Liver function tests: Include ALT (SGPT), AST (SGOT), bilirubin, albumin, and alkaline phosphatase. Acute phase may show very high elevations; chronic infection may have normal values despite active viremia.
• Platelet count: Reduction may indicate cirrhosis. Normal: 150-400 × 10³/μL.
• Abdominal ultrasound: Shows liver size, texture, presence of cirrhosis, ascites, or portal hypertension signs.
• Transient Elastography (FibroScan): Non-invasive measure of liver fibrosis in kPa. Normal: less than 6 kPa; advanced cirrhosis: over 9.6 kPa.
• Liver biopsy: Rarely used now but remains gold standard for assessing inflammation and fibrosis.

Medications

• Direct-Acting Antivirals (DAAs): Primary treatment and revolutionary for Hepatitis C. Work directly on the virus, disrupting its lifecycle. Achieve sustained virological response (SVR) over 95% in most cases. Oral tablets for 8-12 weeks depending on genotype and disease stage: Sofosbuvir/Velpatasvir: Effective against most genotypes (1-6), 12-week course. Glecaprevir/Pibrentasvir: Effective against all genotypes, 8-week course. Side effects minimal (fatigue, headache, mild nausea) compared to older treatments.
• Interferon + Ribavirin (Older): Was sole treatment before DAAs, causes severe side effects (flu-like symptoms, insomnia, depression, anemia) with low cure rates (50-60%). No longer recommended except rare cases.

Procedures and Monitoring

• Monitoring during treatment: Liver function tests and HCV RNA at week 4 and 12 to confirm response.
• Post-treatment monitoring: HCV RNA at 12 weeks after treatment completion (SVR12) to confirm cure.
• Regular liver surveillance: Ultrasound and FibroScan every 6-12 months for advanced cirrhosis even after cure to detect liver cancer early.
• Endoscopy: If portal hypertension signs present, to detect and prevent esophageal varices bleeding.

Lifestyle Changes

• Complete alcohol avoidance: Alcohol accelerates cirrhosis; total abstinence necessary before, during, and after treatment.
• Maintain healthy weight: Obesity and fatty liver (NAFLD) increase inflammation and fibrosis.
• Regular physical activity: 150 minutes weekly of light-to-moderate exercise improves liver health.
• Balanced healthy diet: Rich in fruits, vegetables, whole grains; low in salt and saturated fats.
• Protection from other viruses: Vaccinate against Hepatitis A and B if not immunized, preventing coinfection.
• Avoid sharing sharp instruments: Prevent transmission to others.
• Maintain regular medical follow-up: Especially post-cure to monitor late complications.

• Chronic Hepatitis: Inflammation persisting beyond 6 months can gradually lead to cirrhosis over 15-20 years.
• Cirrhosis: 20-30% of chronically infected develop cirrhosis. Liver loses function, leading to GI bleeding, ascites, and hepatic encephalopathy.
• Hepatocellular Carcinoma (HCC): 1-4% of cirrhosis patients develop liver cancer annually. Risk increases with advanced cirrhosis, duration of infection, and coinfections.
• Acute Liver Failure: Rare but may occur in severe acute hepatitis, requiring emergency liver transplant.
• Portal Hypertension: Elevated pressure in portal vein returning blood from stomach and esophagus, causing varices prone to bleeding.
• Autoimmune Liver Diseases: Some HCV patients develop autoimmune conditions affecting liver, joints, and skin.
• Kidney Failure: In some cases, especially with cirrhosis, kidney damage leading to chronic renal failure.
• Immunosuppression and Opportunistic Infections: Especially in HIV/HCV coinfection, worsening outcomes significantly.

• Avoid needle sharing: Primary prevention for drug users. Use sterile new equipment each time. Recovery programs and counseling significantly reduce risk.
• Obtain sterilized medical and cosmetic services only: Ensure dental, medical clinics, tattoo, and piercing facilities are licensed and follow high sterilization standards.
• Safe training for healthcare workers: Must follow strict infection control protocols, use protective equipment, and handle sharp instruments safely.
• Blood screening before transfusion: All blood donors screened for HCV. Routine standard in Jordan and developed countries.
• Regular screening for high-risk groups: Drug users, prisoners, healthcare workers should undergo periodic testing.
• Health education and awareness: Public awareness programs about transmission and prevention, especially in high-prevalence communities.
• No sharing of personal care items: Toothbrushes, razors, nail clippers for single-user only.
• Safe care for pregnant HCV-positive women: Women of childbearing age should be counseled for pre-conception treatment if possible, or supervised treatment during pregnancy.
• No vaccine currently available: Unlike Hepatitis A and B, no HCV vaccine exists; prevention relies on avoiding exposure.
• Early detection and treatment: Anyone diagnosed should be treated promptly, as early cure prevents complications.