For health professionals: Hepatitis C

Get detailed information on hepatitis C for health professionals.

What health professionals need to know about hepatitis C

Hepatitis C is not a vaccine-preventable disease.

Hepatitis C is reportable by laboratories and clinicians to local public health authorities in all provinces and territories.

In Canada:

hepatitis C antibody and nucleic acid amplification testing (NAAT) methods for screening the blood supply were implemented in 1992

prior to this implementation, thousands were infected with the hepatitis C virus (HCV) after receiving blood or blood products

universal blood supply screening has:

virtually eliminated the hepatitis C transmission risk via transfusion
significantly improved the quality of the blood supply

Consult the national case definition for additional information.

Screening and testing

We recommend screening individuals for HCV using a risk-based approach.

Health care providers in Canada are encouraged to provide risk-based screening.
In addition to risk-based screening, testing is recommended for individuals with symptoms or clinical clues of liver disease, or abnormal liver biochemistry.
Hepatitis C testing is also indicated for individuals who are diagnosed with viral hepatitis B (HBV) or human immunodeficiency virus (HIV).

Risk factors

Screening is recommended for individuals with potential exposure to HCV through the following risk factors:

injection, intranasal or inhalation drug use with shared equipment, even once
exposure to non-sterile medical, dental or personal services equipment via:

hemodialysis
occupational injuries (e.g., health care workers exposed to blood from needle stick injuries)
unsafe tattooing or body piercing practices using non-sterile equipment
shared personal care items
surgical procedures

receipt of blood, blood products or organ transplant before 1992 in Canada
receipt of invasive medical procedures in countries where infection prevention and control practices are not standardized
engaging in sexual behaviour where blood may be present (e.g., condomless anal intercourse)
being born in, travelled to, or lived in a region with high hepatitis C prevalence, such as:

East Asia and Pacific
Eastern Europe and Central Asia
Latin America and the Caribbean
the Middle East and North Africa
Sub-Saharan Africa

being born to a mother who is HCV-positive

Some populations are disproportionately affected by HCV:

gay, bisexual and other men who have sex with men (gbMSM)
currently or previously incarcerated individuals
unstably housed and homeless individuals
Indigenous peoples
individuals from countries with high HCV prevalence

Clinical manifestations

Hepatitis C can have different clinical manifestations depending on whether it is an acute or a chronic infection.

Acute hepatitis C infection

Acute hepatitis C infection is asymptomatic in most individuals (60% to 75%).

If symptoms/signs are present, they can include:

nausea
malaise
anorexia
jaundice
vomiting
elevated serum alanine aminotransferase (ALT)
right upper quadrant (RUQ) abdominal discomfort

These symptoms may last for 2 to 12 weeks.

Chronic hepatitis C infection

Approximately 25% of those infected with the HCV will spontaneously clear the virus within 6 months. However, in most cases (75%), the infection will become chronic. Chronic hepatitis C is often asymptomatic.

Some individuals with chronic hepatitis C infection experience:

nausea
pruritus
malaise
abdominal pain

Fluctuating alanine aminotransferase (ALT) levels are characteristic. In addition, thrombocytopenia (low platelet count) may be an indication of cirrhosis. Thrombocytopenia is known to increase with the severity of liver disease.

The late sequelae of chronic hepatitis C infection include:

liver fibrosis or cirrhosis
hepatocellular carcinoma (liver cancer)

Cirrhosis and hepatocellular carcinoma may develop over a period of 20 to 30 years depending on factors such as sex, age, and level of alcohol consumption. Approximately 1% to 5% of individuals with chronic hepatitis C infection will develop hepatocellular carcinoma.

If cirrhosis develops, individuals may experience:

ascites
jaundice
splenomegaly
oesophageal varices
hepatic encephalopathy

Extrahepatic manifestations are uncommon, but may include:

lichen planus
Sjogren's syndrome
porphyria cutanea tarda
non-Hodgkin's lymphoma
membranous glomerulonephritis
mixed essential cryoglobulinemia
membranoproliferative glomerulonephritis

Diagnostic tests

The diagnosis of hepatitis C requires 2 types of tests:

hepatitis C antibody (anti-HCV) test
hepatitis C ribonucleic acid (RNA) test

HCV antibody testing

HCV antibody testing detects HCV antibodies. A reactive (positive) result indicates that the individual has been exposed to HCV at some point but does not distinguish between current or past infection. HCV antibody testing can be done using standard serology or a licensed point-of-care test. All reactive (positive) HCV antibody tests require additional confirmatory testing.

Window period: It may take 5 to 10 weeks for HCV antibodies to be detected in the blood following exposure. Repeat anti-HCV testing may be required.

HCV RNA testing

HCV RNA testing is used to detect the presence of virus and confirm current HCV infection. It is also used to measure viral load.

Immunocompromised individuals may not develop hepatitis C antibodies and may need to undergo hepatitis C RNA testing to confirm infection.

Treatment

Hepatitis C is considered a curable infection.

There are 6 major strains (genotypes) of HCV and the distribution of genotypes varies by region. Treatment regimen, duration, and efficacy may vary depending on the genotype.

In Canada, HCV genotype 1 is the most common.

The goal of hepatitis C treatment is to achieve a sustained virologic response (SVR), which is an undetectable viral load in the blood following treatment.

In recent years, hepatitis C treatment has evolved to include a combination of drugs called direct-acting antivirals (DAAs). These medications are better tolerated and more effective than previous treatment regimens.

The short-course interferon-free DAA treatments:

have high SVR (>90%),
range from 8 to 24 weeks, and
have few adverse effects.

Individuals with chronic hepatitis C infection will need further assessment and should be considered for treatment, regardless of fibrosis score. A hepatologist, gastroenterologist, or health care provider with experience in the management of viral hepatitis should be consulted.

Clinicians should consult with their provincial/territorial hepatitis C programs for more information on coverage of treatment through provincial/territorial formularies.

For more information

Disclaimer: The links to websites outside of PHAC are provided for convenience only. PHAC is not responsible for ensuring the availability or quality of materials from external websites. The views and opinions expressed at external websites are not necessarily those of PHAC.

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