When a person is infected with hepatitis C, the
virus often lives in the liver for decades. It often gives few signs it has
entered the body or is attacking the liver. Up to 80% of people who have
hepatitis C notice no symptoms.
The virus has reached epidemic proportions,
infecting an estimated 4 million Americans and 170 million people worldwide.
Hepatitis C is a leading cause of cirrhosis and liver cancer, and is the most common
reason for liver transplants in the
It can take decades for symptoms such as
jaundice, fatigue, dark urine, abdominal pain, loss of appetite and nausea to
occur, and at this point the liver may be badly damaged. When the liver is
failing badly, often the only option still available is a liver transplant. It
is important to get tested before symptoms occur, to allow for early treatment
of the disease before too much damage is done.
Among those at greatest risk for hepatitis C
are: Hemophiliacs, intravenous drug users, current or past dialysis patients,
transfusion/transplant patients, healthcare workers and those engaging in
high-risk sexual activities. The CDC estimates that hepatitis C is responsible for
eight to ten thousand deaths per year. This amount is expected to triple during
the next ten years.
Source: Ortho-Clinical
Diagnostics; Johnson & Johnson, Sept. 28, 2001 and the Mayo Clinic staff,
July 22, 2005
HepCBC
- HEPV-L HEPATITIS C FAQ v8.3
September 2009
This FAQ is dedicated to the
memory of David H. Kehrer, LTC John Heintz (Peters) and his wife Patricia,
Daniel Bodiford, Dr. Horst Irmler, Jude Saucier, Capt. Kevin Donnelly, Ron
Thiel, ”Uncle” Dave Lang, Guy Thisdelle, “Apache” Pat Davis , Frank Darlington,
Dave FitzGerald and Sandra Tara Balduf (Ane Palmo).
0.01 Introduction
0.02 Disclaimer
I.0.1 What
is Hepatitis?
I.0.2 What
Are the Different Types of Hepatitis?
I.0.3 What
Happens in the Body?
I.0.4 What
is the Incubation Period?
I.0.5 How
Does Hepatitis C Usually Begin?
I.0.6 What
is the Function of the Liver?
I.0.7 Hepatitis
C (HCV)
I.0.7a When
was Hepatitis C Discovered?
I.0.8 Who
Gets Hepatitis?
I.0.9 How
is it Transmitted?
I.0.9a How
is it NOT Transmitted?
I.1.0 HCV
and Blood Transfusion
I.1.1 HCV
and Intravenous Drug Use
I.1.2 HCV
and IV Immunoglobulin
I.1.3 Neonatal
Transfer of HCV
I.1.4 Other
Means of HCV Transmission
I.1.4a Sexual
Transmission
I.1.4b Occupational
Exposure (Health Care Workers)
I.1.4c Toothbrushes/Razors/Nail
Clippers
I.1.4d Hemodialysis
I.1.5 Highly
Speculative Modes of Transmission
I.1.5a Tears,
Saliva, Urine, Other Body Fluids
I.1.5b Cat
Scratches
I.1.5c Mosquitoes
I.1.5d Alternative
Medical Procedures
I.1.5e Household
Transmission
I.1.5f Unknown
Causes
I.1.5g Is
HCV Anything Like HIV?
I.1.6 Prevention
I.1.6a When
and How Long Can it be Spread?
I.1.6b How
Can the Spread of HCV be Prevented?
I.1.6c Cleaning
Up Blood Spills
I.1.6d What
to do in Case of an Accidental Needlestick
I.1.7 Whom
Should I Tell?
I.1.8 Can
You Get Hepatitis More Than Once?
II.0.1 How
Do I Find Good Medical Care for Hepatitis
II.0.2 Hepatologists
and Gastroenterologists (see
Appendix D for
regional list)
II.1.0 How
is it Diagnosed?
II.1.1 Antibody
Tests
II.1.2 What
is a PCR?
II.1.2a What
is a Genotype?
II.1.3 Could
the test results be Wrong?
II.2.0 Biopsy
II.2.0a What
is a Liver Biopsy
II.2.0b What
Are the Dangers of Liver Biopsy?
II.2.0c Will
it Hurt?
II.2.1 Chronic
Active and Chronic Persistent
II.2.2 What
Are the Main Symptoms of HCV?
II.2.2a Fatigue
II.2.2b Right-Side
Pain
II.2.2c Loss of Libido
II.2.2d Red Palms
II.2.2e Nausea
II.2.2f Brain
Fog (Confusion/Forgetfulness)
II.2.2g Itching
II.2.2h Vision
Problems
II.2.2i Dizziness
II.3.0 It’s
Not All In Your Head!
II.3.1 What
is the Evolution of the Disease?
II.4.0 What
Other Medical Problems Are Related to HCV?
II.4.0a Cryoglobulinemia
II.4.0b Thyroid
and Autoimmune Problems
II.4.0c Rheumatoid
Arthritis-Like Symptoms
II.4.0d Fibromyalgia
II.4.0e Dermatological
Manifestations
II.4.0f Porphyrins
II.4.0g Lichen
Planus
II.5.0 Cycles
and Flare-ups
II.6.0 Should
I be Vaccinated Against Other Types?
II.7.0 HCV
and Women’s Concerns
II.7.1 How
Does HCV Relate to Pregnancy?
II.8.0 How
Does HCV Affect Children?
II.9.0 What
Are the Different Clinical Indications?
II.9.1 Elevated
Liver Enzymes
II.9.1a
Elevated Alpha-Fetoprotein Levels
II.9.2 Jaundice
II.9.3 Hepatomegaly/Splenomegaly
II.9.4 Spider Nevi
II.9.5 Ascites
II.9.6 Portal
Hypertension/Varices
II.9.7 Hepatic
Encephalopathy
II.9.8 Cirrhosis
II.9.9 Fulminant
Hepatitis
II.9.10 Does
HCV Increase the Likelihood of Cancer?
II.10.0 How
Many of Us Are There?
II.11.0
Long-Term Prognosis (Am I Going
to Die?)
PART
III: TREATMENT
(Conventional Medicine)
III.1.0 STANDARD TREATMENT
III.1.1 Interferon/pegylated IFN and
Ribavirin Combined
III.1.2 Side effects and other
considerations
III.1.3 Is treatment worth it?
III.1.4 When is interferon treatment not
indicated?
III.1.5
Interferon
Breakthrough, Non-response and Relapse
III.1.6
Re-treatment
III.1.7
Transplant
and post-transplant treatment
III.1.8 Spontaneous
Clearance
III.2.0
INTERFERONS
III.2.1 Interferon
Monotherapy
III.2.2 Pegylated Interferon
III.2.2a
Pegylated Intron A (Peg-Intron
A)
III.2.2b
Peginterferon Alpha-2a (Pegasys)
III.2.3a Consensus
Interferon
III.2.3b
Alferon
III.2.3c Omega
Interferon
III.2.3d
Albuferon
III.2.3e Belerofon
III.2.3f Maxygen
III.2.3g Locteron
III.2.3h Oral
PEG-interferon lambda (IL-29)
III.2.3i Glycoferon
III.2.3j IFN
alpha-2b XL (Medusa IFN)
III.2.3k
ViraferonPeg
III.2.3l
Oral Interferon
III.3.0
TREATMENT
STRATEGIES
III.3.1 Dosage
III.3.1a
Mega Dosing
III.3.1b
Maintenance Dosing
III.3.1c Induction
Dosing
III.3.2
Early Treatment
III.3.3
Longer Treatment
III.3.4.Retreatment
III.4.0
Iron Reduction Therapy
PART
IV: RESEARCH
IV.1.0 HCV PROTEIN-BASED THERAPIES
IV.1.1
Protease
Inhibitors
IV.1.1a Telaprevir (VX-950)
IV.1.1b Boceprevir (SCH 503034)
IV.1.1c IDN-6556
IV.1.1d
ITMN-191
IV.1.1e TMC435
IV.1.1f MK-7009
IV.1.1g SCH-900518
IV.1.1h PHX1766
IV.1.1i BI
201335
IV.1.1j ACH-1625
IV.1.2
Polymerase
Inhibitors
IV.1.2a R7128
IV.1.2b R1626
IV.1.2c PSI-6130
IV.1.2d MK-0608
and MK-3281
IV.1.2e VCH-759
IV.1.2f VCH-916 and VCH-222
IV.1.2g GS-9190
IV.1.2h Filibuvir (FBV-formerly PF
00868554
IV.1.2i BILB 1941
IV.1.2j ABT-333
IV.1.2k ANA598
IV.1.2l BI 207127
IV.1.2m IDX184
IV.1.2n Others of interest
IV.1.2o Protease-Polymerase Combo
IV.1.3
Helicase
Inhibitors
IV.1.4
Interferon
Alpha Gene Therapy
IV.1.5
IRES
Inhibitors
IV.1.6
Antisense
Based Therapies
IV.1.7
RNAi-Based
Therapies
IV.1.8 Entry
Inhibitors
IV.2.0
VACCINES
IV.2.1
ChronVac-C
IV.2.2 Chiron Vaccine
IV.2.3 Chimigen
IV.2.4 VIDO Vaccine
IV.2.5 Toray Vaccine
IV.2.6 TG4040 Vaccine
IV.2.7 Intercell
vaccine IC41
IV.2.8 Kurume
peptide vaccine
IV.2.9 Tarmogen
(GI-5005)
IV.2.10 PeviPROTM/PeviTERTM
vaccine
IV.3.0
OTHER
THERAPIES
IV.3.1 Viramidine
IV.3.2 Thymosin (Zadaxin)
IV.3.3 Amantadine
IV.3.4 Alinia
(Nitazoxanide)
IV.3.5 MX-3253 (Celgosivir)
IV.3.6 HCV Monoclonal Antibodies (mAb’s)
IV.3.7 Toll-like
Receptor Agonists IMO-2125 and ANA773
IV.3.8 DEBIO-025
IV.3.9 NS5A
Inhibitors
IV.3.10
Oglufanide
IV.3.11 NOV-205
IV.3.12 JKB-122
IV.3.13 CB5300
IV.3.14 MitoQ
IV.3.15 CTS-1027
IV.3.16 Interleukins
IV.3.17 UDCA (ursodeoxycholic acid)
IV.3.18 Rosiglitazone
IV.3.19 CF102
IV.3.20 SCY-635
IV.3.21 Clemizole
IV.4.0 Drug Pipeline Quick Reference Chart
PART V: TREATMENT (Alternative
Medicine)
V.0.0 Known
Herb-Drug Interactions
V.0.1 Acupuncture
V.0.2 Chiropractic
V.0.3 Energy
Healing
V.0.4 Reflexology
V.0.5 Homeopathy
V.0.6 Reticulose
V.0.7 Traditional
Chinese Medicine (TCM)
V.0.8 Ozone
Therapy
V.1.0 Herbal
Treatments and Vitamins
V.1.1 Kombucha
Tea
V.1.2 Reishi/Shitake
Mushrooms
V.1.3 Dandelion
V.1.4 Milk
Thistle
V.1.5 Artichoke
V.1.6 Licorice
Root
V.1.7 Spirulina
V.1.8 Garlic
V.1.9 Thymic
Factors
V.1.10 Vitamin C
V.1.11 Vitamin B12
V.1.12 Vitamin E
V.1.13 Natural
Interferon Boosters
V.1.14 Other
Herbs or Vitamins
V.1.15 Grapefruit
V.1.16
Water
V.2.0 Exercise
V.3.0 Stress Management
V.4.0 Positive Attitude
V.5.0 Tai Chi/Chi
Kung/Yoga/Meditation
V,5,1 Tai Chi
V.5.2 Yoga
V.6.0 Other
Ways to Keep Yourself Healthy
VI.1.0 What
Should I Do About Nutrition?
VI.1.1 Foods
to Avoid
VI.2.0 Nutrition
and Cirrhosis
VI.3.0 Coffee,
Tea, Caffeine and Other Stimulants
VI.4.0 Salt
VII.1.0 Alcohol
VII.2.0 Tobacco
VII.3.0 Marijuana
VII.3.1 Cocaine
VII.4.0 What
are the Effects of Recreational Drugs?
VII.4.1 Intravenous
Drug Use Precautions
VII.4.2 Cleaning
Syringes
VII.4.3 Methadone
PART VIII: HOW CAN HCV AFFECT MY
EMOTIONAL LIFE?
VIII.1.0 How is Depression Related to
Hepatitis?
VIII.2.0 Dealing with a Chronic Disease
VIII.2.0a Accepting
VIII.2.0b Dealing with a Lower Level of Energy
VIII.2.0c
Irritability
VIII.3.0 How Can HCV Affect My Sex
Life?
VII.4.0 Helping a Friend with Hepatitis
C
VIII.4.0a What Can I Say?
VIII.4.0b What Shouldn’t I Say?
PART X: DEALING WITH INTERFERON
THERAPY
X.1.0 General
Tips From Schering
X.2.0 How
Does Interferon Work?
X.2.1 What
Will Interferon Achieve?
X.2.2 Clinical
Trials
X.2.3 Will
I Be Able To Continue Work?
X.2.4 How
Will I Know If The Interferon Is Working?
X.3.0 Side
Effects
X.3.0a
Nausea
X.3.0b
Hair Loss
X.3.0c
Fatigue
X.3.0d
Mouth Problems
X.3.0e
Infections
X.4.0 Importance
of Water
X.5.0
Traveling With Interferon
X.6.0 Timing
of Injections
X.7.0 Injection
Hints
X.8.0 Help!
I Think I Hit a Vein!
X.9.0 What
do I do when I Can’t Afford the Interferon
PART XI: EMPLOYMENT AND
DISABILITY
XI.1.0 Income
Security: Job and/or Disability Benefits
XI.1.1 How
Do I Handle Problems About My Job?
XI.1.2 Problems
in Seeking Disability Benefits
XI.1.3 Applying
for SSI/SSDI
XI.1.4 Winning
Your Social Insurance Claim: 15 Mistakes You Cannot Afford to Make
XI.1.5 Applying
for Disability in British Columbia
PART XII: IMPORTANT INFORMATION
XII.1.0 What Else is Important to Know
about HCV?
XII.2.0 HCV Information Resources and
Support Groups
XII.2.1 USA
XII.2.2 Canada
XII.2.3 Argentina
XII.2.4
Australia
XII.2.5
Austria
XII.2.6 Belgium
XII.2.7 Bulgaria
XII.2.8 Columbia
XII.2.9
Croatia
XII.2.10 Egypt
XII.2.11 France
XII.2.12 Germany
XII.2.13 Israel
XII.2.14 Italy
XII.2.15 Netherlands
XII.2.16 New Zealand
XII.2.17 Poland
XII.2.18 Portugal
XII.2.19 Romania
XII.2.20 Spain
XII.2.22 Uruguay
XII.2.23 United Kingdom
XII.2.24 Others
XII.3.0 HCV
Resources on the Internet and Usenet
XII.4.0 Bibliography: Suggested Reading
XII.5.0 Newsletters, Magazines and Videos
APPENDIX A: Where can I get the current version of the
FAQ?
APPENDIX B: Common Abbreviations and Medical Terms
APPENDIX C: Some Recommended World Wide Web Sites
APPENDIX D: A List of Canadian Doctors Specializing in
the treatment of HCV
APPENDIX E: History of Blood Safety,
APPENDIX F: The Double Challenge of HIV/HCV Co-infection
APPENDIX
G: What is a Clinical Trial?
===============================================================
Subject: Part 0: Administrivia
Subject: 0.00 Copyright
Peppermint Patti’s FAQ V8.3
is copyright© 1996-2010 by Dr. C.D. Mazoff, PhD, Patricia Johnson,
and Joan King on behalf of HepCBC, the HepCAN list, and the HEPV-L Internet
Mailing List. Permission is granted to redistribute or quote this document for
non-commercial purposes provided that you include an attribution to HEPV-L and
HepCBC, the contact address of HEPVL@COMCAST.NET,
INFO@HEPCBC.CA or HEPVL-REQUEST@MAELSTROM.STJOHNS.EDU, the FAQ’s version number and date, and at
least two locations from which a current version of this FAQ may be retrieved
(see Appendix A). For
any other use, permission must be obtained in writing from Joan King (jking@hepcbc.ca), or Patricia Johnson (hepvl@comcast.net).
This is a document whose
development is in progress. Please make comments to help improve it. Please
send suggestions for additions, corrections, or changes privately to the
authors (Patricia Johnson) at address hepvl@comcast.net,
or to Joan King at jking@hepcbc.ca.
If you want your
contribution to be anonymous, please state so.
============================================================
HEPV-L is a list devoted to people with chronic
hepatitis, and related liver diseases. Its address is HEPV-L@listserv.icors.org; HepCBC can be reached through www.hepcbc.ca.
Subscribe by addressing a
message to: listserv@listserv.icors.org
and in the body of the message, on the first line, type: SUB HEPV-L FIRSTNAME LASTNAME (substituting
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HepCBC (www.hepcbc.ca) is
an association of independent grassroots organizations in
0.01 INTRODUCTION
This document answers
frequently asked questions (FAQ) about the hepatitis C virus (HCV), its treatment,
and related complications. We have made every effort to provide the most
current and most accurate information.
This updated version (FAQ
v8.0) reflects the international nature of the hepatitis C community. Although the home of the HEPV-L list is in
the
Thanks to a grant from the
Legal Services Society of British Columbia, this edition includes information
on Disability Benefits for residents of BC. Hopefully, this section will expand
to include all of
----
0.02 DISCLAIMER
The information presented
in this document was written and developed by patients and members of the
HEPV-L mailing list.
It represents an informal
catalogue of accumulated knowledge by people who for the most part are not
medical professionals. As this file is developed further, we hope to include
references and citations which will document more of the statements that are
made here. Much of the information contained in this FAQ was compiled from the
varied and personal experiences and opinions on the HEPV-L and HepCAN mailing
lists, and from original research published in the hepc.bull. As useful
as this information may be, it must not be considered medical advice, and must
not be used as a substitute for medical advice. And as always, don’t forget to
use your common sense. It is important that anyone who has, or thinks they may
have, hepatitis should consult with a licensed health care practitioner who is
familiar with liver disease and systemic disorders.
Thanks are due to
the many contributors to this new official version of the FAQ. Below, in no particular order:
Alan Franciscus (HCV
Advocate), Brad Kane (HepCBC), Andi Thomas (Hep-C-Alert), Anne Karim, Bruce
Bennett, Bryce Brogan, Paul Harvey, Cindy Torchin, David Lang† (HEP Seattle),
Frank Smith, Joe Shaw, Joan King (HepCBC), Kathryn Morse, Eileen
Caldwell-Martin (FHCQ), Ken Benjamin, Kevin, Kunga Palmo (USHA), Sue White (Mid
Island HepC), Capt. Kevin Donnelly†, Bruce Devenne (HepCNS), Leslie Gibbenhuck
(Children’s Liver Alliance), Marjorie Harris (HepCure), Darlene Morrow (HepC
VSG), Lucinda Porter, Pat Buchanan (LiverHope),**Peppermint Patti,**
Sara Amber (HEP Seattle), Scott Warren (aka Reezer), C.D. Mazoff, aka “Squeeky”
(HCV Advocate), Rivaud (Hepv-l), Sheree Martin (Hep B List), Sybil†, Smilin’
Sandi, Marie Stern, Brian D. Klein (HAAC), John & Matti Kirk, Rick Crane,
and our mothers for making us possible.
=============================================================
I.0.1 WHAT IS HEPATITIS?
Hepatitis is an inflammation of the liver. It is
a symptom a many different diseases and conditions. Poisons, viruses, bacteria,
parasites, auto-immune disorders, and drugs can all cause hepatitis.
Hepatitis A, B, and C are all forms of viral
hepatitis. Although their names sound the same, they are actually very
different viruses, causing different symptoms and require different treatments.
Other viruses that cause hepatitis are hepatitis D, E, and G; these are less
common, and were discovered more recently than hepatitis A, B and C.
Non-viral hepatitis can be caused by toxic agents or
autoimmune disease. Autoimmune disease is the body attacking itself, treating
its own tissues like foreign invaders. Toxic hepatitis is a deterioration of
the liver cells caused by chemicals, alcohol, drugs, or industrial compounds.
Toxic hepatitis is another way of saying liver inflammation due to poisoning.
Alcohol abuse is one of the most common causes of toxic liver damage.
---
I.0.2 WHAT ARE THE DIFFERENT TYPES OF HEPATITIS?
The different types of
VIRAL hepatitis are:
A (formerly called infectious hepatitis,
or yellow jaundice)
B (serum hepatitis)
C (formerly called non-A, non-B
hepatitis)
D (delta hepatitis)
E (transmitted through the feces of an
infected person)
G (a virus transmitted through infected
blood products)
CRYPTOGENIC (or Non-A,B,C,D,E,G)
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.
Types of NON-VIRAL
hepatitis are:
Autoimmune disease (the
body attacking its own tissues)
Wilson’s disease (a genetic
disorder causing too much copper in the liver or brain)
Hemochromatosis (a genetic disorder causing
too much iron in the bloodstream)
Drug, chemical, or alcohol
induced hepatitis.
---
I.0.3 WHAT HAPPENS IN THE BODY?
Different hepatitis
infections enter the body in different ways. The hepatitis A and E viruses
enter through the gut, whereas B, C, D, and G enter through the bloodstream.
All forms of viral hepatitis attack the liver, and reproduce in the liver
cells.
Hepatitis A and E thrive in
unsanitary conditions. There is a vaccine for hepatitis A. It usually resolves itself, but can be fatal
in children, the elderly, or the chronically ill. Hepatitis A can prove fatal
to people with hepatitis C. Hepatitis E is found mainly in the third world. It
also resolves itself, but it can pose a serious danger to pregnant women.
As hepatitis B, C, D, and G
infect liver cells, the body attacks them, which causes the liver to become
inflamed. With hepatitis B, the liver usually repairs itself, leaving behind
antibodies. Antibodies are proteins produced by the body as a part of its
defense against viruses. If you have only the antibodies for a disease it means
that you either have it now, or you had it at one time and got over it.
Recent studies show that
hepatitis B may resurface many years later in individuals who have supposedly
cleared the virus, much like the “post-polio syndrome.” Up to 90% of those
infected with hepatitis B will clear the virus. There is a vaccine for
hepatitis B.
There is no vaccine for
hepatitis C. In most people who get hepatitis C the immune system doesn’t
defeat the virus. More often than not, the antibodies fail to identify the
hepatitis C virus properly. The
infection remains long-term. Most infected people don’t know they have it. This
is because for some people there will be no symptoms and for others, symptoms
could take 13 years to develop. Some people have hepatitis C for over 20 years
before they find out they have it.
Hepatitis C affects different people different ways.
From what we know, if 100
people catch hepatitis C:
·
15-20 will have an acute infection. These people will get
over the virus the same way a person gets over flu.
·
80-85 will get a chronic infection. This infection doesn’t
go away without treatment.
Of those people with chronic infections:
·
60 will never show any more than a moderate level of liver
damage, if they show any at all.
·
20-25 will progress to serious liver disease.
Of those who progress to serious liver disease:
·
10-will
remain stable
·
15 will
progress to liver failure or liver cancer after another 5 years According to an
article in Gut 2000; 47:131-136, the 5 year rate for progression to
hepatocellular cancer is 13.4% and the 5 year rate for progression to death is
15.3%.
Hepatitis C infection
doesn’t always make people sick. When someone does get sick, symptoms take a
long time to develop (approximately 13 years). Even when a person is showing
symptoms, the pattern changes so much from person to person, the condition may
be mistaken for something else. People often don’t get tested until they are showing
symptoms of end-stage liver disease. It is important to get tested if you have any reason to believe that you ever had blood-to-blood contact with
another person. Everyone should take
precautions to prevent the spread of hepatitis C, even people who think they
don’t have it.
Studies that follow the
progress of the disease are few, include relatively few subjects, and only
follow people over a short period of time.
Generally, they only track those people whose date of infection can be
well documented, (e.g., blood transfusion recipients and victims of accidental
needle sticks). The progress of the disease appears to differ according to
geography, alcohol use, virus characteristics, (e.g., genotype, viral load),
co-infection with other viruses, age, age at infection, gender, weight, and
other unexplained factors. - National
Institutes of Health Statement on Hepatitis C 1997 and Gut 2004; 53:451-455
---
I.0.4 WHAT IS THE INCUBATION PERIOD?
The amount of time it takes
for symptoms to appear varies between the different types of hepatitis. People
with hepatitis A and E may start to develop symptoms as soon as 2 weeks after
exposure, but it usually takes four weeks for symptoms to be noticeable. For
hepatitis B and C it tends to take much longer. The average for hepatitis B is
2-3 months. In experiments on chimpanzees, hepatitis D developed two to ten
weeks after infection.
1-3 weeks after the initial
exposure, HCV RNA can
be detected in blood. Virtually all patients develop liver cell injury within
15-150 days (50 days is the average). They check the level of liver damage by
looking for an elevation of serum alanine aminotransferase (ALT—an enzyme which leaks out of the
damaged cells into the bloodstream). The majority of patients is asymptomatic
(doesn’t show symptoms) and anicteric (whites of the eyes are clear). Only
25-35 percent develops discomfort, weakness, or anorexia, and some develop
jaundice in the whites of their eyes. Rapid onset 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. HCV antibodies 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. When
a disease goes away without treatment it is called self-limited; HCV is
self-limited in 15% of cases. Recovery 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.
---
I.0.5 HOW DOES HEPATITIS C USUALLY BEGIN?
Different people react to
the HCV virus
differently. For a few patients, the illness begins suddenly as though one had
come down with the flu, except that this “flu” doesn’t seem to get completely
better. 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 be
present; typically they are 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 severity of symptoms
can differ widely among patients, and will also vary over time for the same
patient. It can range from getting unusually fatigued following stressful
events, to being totally bedridden and completely disabled. The symptoms have a
tendency to wax and wane over time.
---
I.0.6 WHAT IS THE FUNCTION OF THE LIVER?
The liver many functions,
including these:
· Stores iron reserves, as well as vitamins and
minerals
· Detoxifies poisonous chemicals, including
alcohol and drugs (prescribed and over-the-counter medicines as well as illegal
substances). Acts as a filter to convert them to substances that can be used or
excreted from the body
· Converts the food we eat into stored energy and
chemicals necessary for life and growth
· Makes blood products
· Manufactures new proteins
· Makes clotting factors to help blood clot
· Manufactures bile, an enzyme used in breaking
down fats and in waste disposal
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I.0.7 HEPATITIS C VIRUS (HCV)
Hepatitis C is a form of
hepatitis caused by an RNA virus of the Flaviviridae family that targets the
liver. HCV accounts
for the majority of the hepatitis cases previously referred to as non-A, non-B
hepatitis, and is responsible for 150,000 to 250,000 new cases of hepatitis each
year.
Those infected with the
virus can show symptoms such as fatigue, nausea, loss of appetite, dark urine,
and jaundice. If left untreated it can lead to liver failure, liver cancer and
death. HCV is also a trigger for a host of autoimmune disorders and various
other diseases, such as diabetes, non-Hodgkin’s lymphoma, retinal complications
and thyroiditis (inflammation of the thyroid gland). According to a recent
report by a committee sponsored by the National Institutes of Health, nearly
four million individuals in the
---
I.0.7a WHEN WAS THE HEPATITIS C VIRUS DISCOVERED?
In 1987, Michael Houghton
and colleagues at Chiron Corporation in
In mid-1995 the hepatitis C
virus was seen for the first time ever by scientists with the aid of an
electron microscope. It is linear, single-strand RNA (ribonucleic acid) virus
40-50 nanometers in size.
It is covered with a lipid
envelope and is encased with glycoprotein peplomers or “spikes”.
According to Bruce Devenne of Hepatitis Nova
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I.0.8 WHO GETS HEPATITIS?
You should be tested for
hepatitis C if you have ever:
·
Received
a blood transfusion or blood products before screening was introduced (1986 in the
·
Shared
injecting equipment for drugs
·
Been
tattooed or had body piercing
·
Had a
needle stick injury or performed “exposure-prone procedures”
People with abnormal liver
function tests with no apparent cause would also benefit from having a
hepatitis C antibody
test. We (HepCBC) also recommend that anyone who has had dental procedures
where blood was present, or who has had manicures or pedicures be tested. Studies
(Minerva
Urol Nefrol. 2005 Sep; 57(3):175-97)
show that persons undergoing hemodialysis are still at risk, as are many cured
cancer patients.
Hepatitis C currently
causes between 150,000 and 250,000 new cases of chronic infection in the
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I.0.9 HOW IS IT TRANSMITTED?
“Relax...you have
cooties...but they aren’t as bad as you are imagining.” - Cindy Torchin: cindyt@cpcug.org
Listowner HEPV-L
---
Most people with hepatitis
C contracted it through either a contaminated blood transfusion or product
(plasma, gammaglobulin, etc.) or by sharing contaminated needles. Prior to
1990, the official line was that blood in
Cases of hepatitis C with
no evidence of exposure through blood transfusions, needlesticks or needle
sharing are called “sporadic.” How these individuals became infected is
unknown. As early as 1956 the Merck
Manual stated that Non-A/Non-B hepatitis could be spread through the use of
glass syringes and other then current medical testing and mass vaccination
devices.
Forty percent of all cases of hepatitis C were
contracted through unknown means by people who are in no current risk category.
What this means is that we
are all at risk for contracting hepatitis C.
1. The virus is
in the blood of an infected person.
2. Hepatitis C
can be spread by using something with infected blood on it such as:
a. razors, nail clippers or scissors
b. tooth
brushes and water pics
c. tattoo or
body piercing needles
d. illicit IV
drug needles and paraphernalia (cottons, spoons, etc.)
e. tampons or
sanitary napkins
3. The virus
must enter through a break in the skin or mucous membrane.
---
1.0.9a HOW HCV IS NOT TRANSMITTED
1. The
hepatitis C virus is NOT airborne.
2. It is NOT
spread by:
a. sneezing and
coughing
b. holding
hands
c. kissing
(unless there is deep-kissing and open sores present)
d. using the
same toilet
e. eating food
prepared by someone with HCV
f. holding a
child in your arms
g. swimming in
the same pool
---
I.1.0 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. Blood banks began screening donors for certain markers as early as 1986,
but contaminated blood still found its way through to patients. In May 1990,
screening tests for the hepatitis C virus came into use, and the risk is now
thought to be 1 in 3,300 or 0.12% for the typical recipient of a transfusion. A
typical recipient is one who does not have other conditions that would make it
more likely for them to catch the virus (like HIV infection). -
HCV acquired through blood transfusion
tends to be more severe than through other modes of transmission.
---
I.1.1 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.)
Studies in
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I.1.2 HCV AND IV IMMUNOGLOBULIN (GAMMAGARD/POLYGAM/FACTOR D)
Contaminated batches of
Gammagard and Polygam, drugs used in intravenous immunoglobulin therapy, may
have caused thousands across the
Patients who received
immunoglobulin therapy should contact their doctor immediately to have liver
function tests performed.
---
I.1.3 NEONATAL TRANSFER OF HCV
The following is from the HepCBC pamphlet HCV & Pregnancy.
Reducing the Risk of Transmission During and After
Pregnancy
A woman living with Hep C
who wishes to become pregnant may be worried about the health of her baby. The
chance of the virus being transmitted to the baby is 0-10%, but higher in
persons who have HIV or use IV drugs. If
a mother also has AIDS, the chances can increase up to 36 in 100. The risk may
be even greater in mothers who are infected with both Hep B and Hep C.
Transmission to the baby can happen before or during
birth.
Present information shows
that transmission may be slightly more likely in infants born to mothers with genotype 1.
Most doctors and midwives
will be helpful and supportive to a woman with Hep C who wants a child. Pregnancy with Hep C is not officially
discouraged.
A woman may wish to take
treatment for hepatitis C before becoming pregnant. She MUST wait at least 6
months after stopping treatment before getting pregnant, to avoid birth
defects. Infected men on treatment should use birth control during, and for at
least 6 months after treatment for the same reason.
Having a Caesarian section
does not usually reduce the risk of transmission. However, it is possible that
if a woman has an acute case of Hep C or is co-infected with HIV, there is more
of a risk of her baby being infected.
Viral Load and
Mother-to-Baby Transmission
Viral load is the amount of
Hep C in the blood. If a woman with Hep C has low viral load (less than 1
million copies/mL), it is less likely that the virus will be passed to her baby
than if she has high viral load, but there is still a chance that Hep C will be
transmitted. If the mother has no virus, the baby will not be infected.
It looks like a female baby
is twice as likely to be infected as a male baby.
(www.medicalpost.com/mpcontent/article.jsp?content=20060115_181536_2940
January 17, 2006 Volume 42 Issue 02)
Breastfeeding
It is not yet known whether
the breast milk of a woman with Hep C contains enough virus to infect a baby
during breast feeding. Generally, women with Hep C are not advised to avoid
breast feeding. No studies have documented transmission of Hep C infection to
infants by breast-feeding. One study showed breast-fed infants were slightly
less likely to have HCV. Mothers should not breastfeed when their nipples are
cracked or bleeding, just in case.
A European study enrolling
1,479 mother-and-child pairs, and a
(www.medicalpost.com/mpcontent/article.jsp?content=20060115_181536_2940
January 17, 2006 Volume 42 Issue 02)
Children with Hep C
(See also II.8.0 How Does HCV Affect Children?)
In children, viral
infection is usually silent, although children as young as 8 years old can
become quite ill from HCV.
Children are less likely
than adults to have symptoms of infection with Hepatitis C, and thus may be
able to transmit the virus unknowingly.
Having hepatitis C does not
seem to affect a child’s growth.
All children, with or
without hepatitis C, should be taught proper hygiene.
Children and
Advanced Liver Disease
Chronic hepatitis C
eventually causes cirrhosis
or cancer. However, it can take 10 to 20 years or more before cirrhosis may
occur. Liver cancer rarely occurs in children.
Treatment in
Children (Also see II.7.1)
The AASLD recommends:
1. Diagnosis, testing, and
liver biopsy of children thought to have HCV.
2. Because of the high
spontaneous clearance rate during the first year of life, children of
HCV-infected mothers should be tested at 18 months or later.
3. Healthy children with
HCV ages 3-17 may be given interferon alfa-2b and ribavirin by specialists in
treating children
4. Children under the age
of 3 should not be treated.
There are still many
questions about Hepatitis C in children. More studies are necessary to learn
more about how the disease progresses and about different treatments.
Talking to Health
Care Workers
Doctors and midwives can be
helpful and supportive to a woman with Hep C who wants a child. It can be very
hard for a woman with Hep C to tell her health care workers she is pregnant or
wants to be, if she suspects they will try to change her mind. Health Care
workers with experience in helping women who have Hep C are likely to be the
best informed and most supportive.
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I.1.4 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.
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I.1.4a SEXUAL TRANSMISSION
Is HCV transmitted sexually? The
answer is not as clear as we would like. Transmission in monogamous,
heterosexual couples is considered to be 3% or less. There have been outbreaks
of HCV in mostly HIV-infected males who engage in homosexual sex in Europe
(MSM), but not in the
There was an article in the May
2007 HIV Medicine that reported 352
cases of HCV acquired in the previous 3 years in MSM examined between 2002 and
2006 a 20% increase during that period. Another study in the May 11, 2007 issue
of AIDS reported 111 such MSM cases,
and investigated to see if the virus strains were related. 7 clusters were
identified, all within the HIV population. The HCV was associated with sexual
transmission risk factors rather than IVDU.
Risk factors were the number of sex partners, risky sexual practices, sharing
of drugs nasally or anally, and group sex, which was the best predictor of HCV
infection, especially when combined with high-risk practices.
In the
Practicing safer sex is always a good idea for people
with multiple partners. People who engage in high-risk sexual behavior have a
greater risk of contracting STDs which can cause open sores and lesions. Open
sores and lesions mean a greater risk blood to blood contact and a higher risk
of contracting hepatitis C. If you have herpes, you are at a greater risk of
catching hepatitis C. It might be possible that HCV piggybacks on the genital
herpes virus through genital lesions. If you have multiple partners, use
condoms. People with acute illness, or with compromised immune systems, should
be more careful as these conditions can raise the level of virus in the
bloodstream, and can mean a greater risk of infection. Sex during the menstrual
period should be avoided, because of the blood in menstrual fluid.
A report from Health
1.
People with multiple partners should practice safer
sex.
2.
Longstanding sexual partners do not need to
change sexual practices if one of them is found to be infected with hepatitis C
“Hepatitis C virus is linked with existing hepatitis B
virus and HIV infection and oral-genital transmission.”
Hepatitis C can be spread through anal or even oral
sex rarely, but it is much more common if the person is co-infected with HBV or
HIV. (www.medscape.com/viewarticle/580034 Sept. 4,
2008)
---
I.1.4b OCCUPATIONAL EXPOSURE
The general consensus is
that HCV is a greater threat to healthcare workers than HIV. The risk that
healthcare workers will become infected with hepatitis C virus (HCV) following
an accidental needlestick injury is 20 to 40 times greater than their risk of
HIV infection. (According to data presented at the International Conference on
Emerging Infectious Disease, Sponsored by the US Centers for Disease Control
and Prevention and the American Society for Microbiology in July 2000.
HCV exposure is possible in
any occupation that could involve contact with infected blood, (i.e., nurses,
phlebotomists, emergency medical technicians, firemen, and police to name a
few). 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.
Current recommendations are
that "both private and public health providers be made aware of the risk,
and above all that all source patient providers be tested for hepatitis
C." (Dr. Robert
T. Ball
www.hepnet.com/hepc/news072000.html)
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I.1.4c 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. It is safer not to share personal
items, especially for people infected with hepatitis C. Recently concern was
expressed over the sharing of electric razors in a VA hospital and in prisons. A study in Hepatology showed that 19%
of veterans tested in a VA hospital in
---
I.1.4d HEMODIALYSIS
Patients on hemodialysis
have higher rates of hepatitis C viral infection. It is vital that hospitals
stick to strict infection control practices and that hemodialysis patients be
tested regularly for HBV and HCV. (Minerva
Urol Nefrol. 2005 Sep;57(3):175-97.)
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I.1.5 HIGHLY SPECULATIVE MODES OF TRANSMISSION OF HCV
The following are
considered highly speculative because there have either been no studies, or
conflicting studies. 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.
---
I.1.5a TEARS, SALIVA, URINE, AND OTHER BODY FLUIDS
“The presence of the RNA in the tear
fluid was independent of the severity of the hepatitis and of the viral load as
measured by the branched DNA assay…These findings suggest that tear fluid may
transmit HCV but the source of HCV RNA in this fluid needs to be better
understood.” (Med Virol. 1997 Mar;
51(3):231-3.)
HCV has been found in all
body fluids, but not in all patients, and in varying amounts. The question
remains as to whether or not the virus can be spread through these fluids. Blood in the fluids can definitely spread the
disease, as with saliva from patients with bleeding gums. Another factor may be
whether or not there are HCV-receptor cells in the mouth lining, and whether or
not the body’s immune system fights off the virus in these quantities. (Oral Dis.
2005 Jul; 11(4):230-5.)
A report suggests that a health
care worker contracted HCV and HIV from a patient. The worker had chapped
hands, did not use gloves, and was in frequent contact with the patient’s urine
and feces. (Am J Infect Control.
2003 May; 31(3):168-75)
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I.1.5b 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.
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I.1.5c MOSQUITOES
Researchers have determined
that the hepatitis C virus is not transmitted by mosquitoes. 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
mosquitoes 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.
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I.1.5d ALTERNATIVE MEDICAL PROCEDURES
Alternative medical
procedures involving invasive medical procedures, particularly those performed
in non-medical settings (i.e., acupuncture), or involving
autologous blood (such as the ozone-enrichment of blood) may transmit the
hepatitis C virus. (“Transmission of
Hepatitis C by Ozone Enrichment of Autologous Blood,” Lancet, 1996; 347:541). A cross sectional survey in
---
I.1.5e HOUSEHOLD TRANSMISSION
Household
transmission of hepatitis C is rare. It can occur where blood-to-blood contact
happens. This could involve a person’s 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. Wiping a surface with isopropyl alcohol and
leaving it to air dry will also kill the virus. (See I.1.7c Cleaning Up Blood Spills)
A person can not spread the
virus through hugging, touching, sneezing, or coughing, or sharing food,
dishes, or bathrooms.
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I.1.5f UNKNOWN CAUSES
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 or shared cocaine paraphernalia many
years ago which they have forgotten or are unwilling to discuss. It is possible that many persons were
infected in the early 50s during mass vaccination programs in schools and
camps. As well, programs for the poor often used cost cutting measures which
included the recycling of medical devices (syringes, needles) which should have
been thrown away. Furthermore, blood products
have been used in the making of many vaccines and in the 50s and 60s these
products were not screened for HCV.
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I.1.5g IS HCV ANYTHING LIKE HIV?
Both HIV and HCV are RNA
viruses. Their genetic code is carried in RNA strands instead of DNA, like some
other viruses. HCV is more like HIV than some other forms of hepatitis, but
they are from completely different families. 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 every time
the cell copies its own DNA. Retro means that the virus reverts to a DNA virus
once it is in the cell. Other retro viruses 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. (See Double Jeopardy: The HIV/HCV Co-Infection
Handbook).
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I.1.6 PREVENTION
Prevention: avoid risk behaviors. Shots of gamma
globulin (now hopefully safe) 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)
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I.1.6a WHEN, AND FOR HOW LONG, IS A
PERSON ABLE TO SPREAD THE HEPATITIS C VIRUS?
Eighty-five to ninety
percent of all HCV carriers
will have it for life, or until a cure is found. There is still a debate over
whether people who have had a sustained viral response after treatment are
cured, or if they are just in remission. All carriers of HCV can transmit the
disease to others via his or her blood. 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.
A study at
the Center for Disease Control and Prevention,
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I.1.6b 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.
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I.1.6c CLEANING UP BLOOD SPILLS
A 10% bleach solution (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. For cleaning up blood on the skin, use isopropyl (rubbing) alcohol.
Dispatch Hospital Cleanser
Disinfectant with Bleach (www.caltechind.com/dispatch/index.asp) and
Spartan Chemical’s HDQ
NEUTRAL7 (www.spartanchemical.com)
both claim to kill HCV.
From the hepc.bull Dec 1999, Issue 18.
“BLOOD SPILLS: DO YOU KNOW HOW TO SAFELY CLEAN UP A
SPILL OF BLOOD OR BODY FLUID? THIS ARTICLE WILL TELL YOU HOW”, by Mark Bigham,
MD, FRCPC,
Hepatitis C virus (HCV) is transmitted mainly by
exposure to HCV-contaminated blood. HCV infection is not generally associated
with exposure to other body fluids, such as saliva, urine, feces or vomit, but
if HCV-contaminated blood is present in these or other body fluids, then the
risk of infection will be greater. Therefore, it’s important to treat any environmental
contamination of blood or body fluid as potentially infectious. The simple
principles of cleaning and disinfecting, which are effective against HCV, are
also very effective against other micro-organisms.
Viruses can only reproduce inside cells and HCV
will not survive very long outside the human body (usually no more than a few
hours). Survival of HCV in the environment is limited by such factors as lower
temperature and dryness. HCV is also readily killed by standard household
products, such as 5% household bleach or 70% isopropyl alcohol.
If you encounter a spill of blood or body fluid,
the most important infection control principle is to avoid direct contact. This
is easily and effectively achieved by wearing rubber gloves—preferably single
use, disposable vinyl gloves, or even household rubber gloves. Litter, such as
broken glass should be picked up first. Try not to handle broken glass that
could tear the gloves. Pieces of stiff cardboard or newspaper folded over can
be used to pick up glass. When disposing of glass, wrap it in a newspaper
before throwing it in the garbage bag, to protect municipal waste disposal
workers from being cut when handling the bag.
Next, clean up the visible blood or body fluid
with plain water and disposable paper towel. Using water will dilute the spill,
reduce its infectivity, and facilitate wiping up the spill. Cleaning the
visible spill will also remove organic matter that can reduce the effectiveness
of disinfectants. The used paper towel can be put in a plastic bag (double bag
if very wet and dripping) and disposed of in the regular household
garbage.
A disinfectant should then be used. Regular
5.25% household bleach is an excellent disinfectant choice—it is inexpensive;
has low toxicity and is not usually irritating to the skin; is fast acting; and
is very effective not only against HCV, but also other blood-borne viruses
(e.g., HIV, Hepatitis B virus), bacteria and fungi. It can be diluted with
water to make a 1:10 to 1:100 bleach solution. The diluted solution should be
prepared fresh, since bleach degrades over time when exposed to air or light.
It can be wiped onto the surface with a towel and left to air dry, or poured
onto the affected area and then wiped up with disposable paper towels after 10
minutes. An effective, alternative disinfectant for use on colour-sensitive
fabrics or materials is 70% isopropyl alcohol, full strength, and applied in
the same manner as described for bleach.
Gloves can then be carefully removed and
disposed of in the regular household garbage along with the used paper
towels. Reusable gloves can be rinsed
in water and dipped or wiped in disinfectant and allowed to air dry. Finally,
don’t forget to wash your hands.
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I.1.6d WHAT TO DO IN CASE OF AN ACCIDENTAL NEEDLESTICK
Because there is no
effective neutralizing antibody
or vaccine for preventing 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 mega units). 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.)
Another
study showed 100% 2-year sustained viral response with alfa interferon monotherapy for acute
hepatitis C. In a small study with seven
patients, high-dose treatment for one year (5 mil daily for was 12 weeks,
followed by 3 MIU 3-times weekly for 40 weeks. This represents a total alfa
interferon dose of 780 MIU. The results were that all seven of the seven
treated patients (100%) with acute HCV infection had a sustained viral response
two years after completing therapy. By contrast, only two of ten (20%) of those
with chronic hepatitis C in the comparative arm achieved a sustained viral
response. The difference was statistically significant (Digestive Disease Week 2000).
One
health worker was treated successfully with short term therapy of IFN alpha plus ribavirin for 3 months. (Acta Gastroenterol Belg. 2005
Jan-Mar;68(1):104-6.)
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I.1.7 WHOM SHOULD I TELL?
If you have hepatitis C,
you are under no legal obligation to tell others. However, the law may change.
Right now, 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 whom they inform, in the 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.
Recent
cases where patients have been infected by physicians has raised the ethical
issue of whether or not infected physicians should be banned form performing
invasive procedures. So far nothing has
been done in this respect (Milbank Q 1999;77(4):511-29) Infected
physicians and invasive procedures: national policy and legal reality; Rev Med Virol 2000 Mar;10(2):75-78
Surgeons who test positive for hepatitis C should be transferred
to low risk duties).
Surgeons infected with HCV in
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I.1.8 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, or you can become co-infected with more than one
genotype. Because there are so many different genotypes of hepatitis C, and
because the virus mutates so rapidly, natural immunity is not developed.
Studies have shown chimpanzees that have recovered from acute hepatitis C
became sick again when re-exposed to the same strain of the virus.
---
II.0.1 HOW DO I FIND GOOD MEDICAL CARE FOR HEPATITIS?
It is very important to
find a health practitioner who is familiar with this illness. The symptoms of
hepatitis can be mimicked by other illnesses, such as autoimmune illnesses,
cancer, chronic fatigue syndrome, lupus, arthritis, etc... If you in fact have
another illness that is not properly diagnosed, you may be losing out on
getting treatment that might be effective for you.
It is still an uphill
struggle to find a doctor who is experienced in diagnosing and treating
hepatitis C. A hepatologist specializes in diseases of the liver, and is the
best choice, followed by a gastroenterologist (a digestive disease specialist),
or an infectious disease specialist. If there is a hepatitis support group nearby,
it could be an excellent resource for identifying local doctors who may be
familiar with hepatitis. You can also contact the American Liver Foundation
(ALF), the HEP project in Seattle, the Hepatitis C Support Project in
If your own doctor is sympathetic but doesn’t have a
lot of experience with Hep C, you might gather together some medical articles
on hepatitis and hepatitis treatments and encourage your doctor to study
them. You can also give him or her a
copy of the FAQ.
See Appendix D for a list of Hepatologists and Gastroenterologists
in Canada.
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II.0.2 WHAT IS THE DIFFERENCE BETWEEN A GASTROENTEROLOGIST AND A
HEPATOLOGIST?
A hepatologist specializes in treating liver disease.
A gastroenterologist specializes in the gut. Hepatologists are more likely to
be on top of the latest information concerning treatment of hepatitis C. Unfortunately, hepatologists are few and far
between, especially in
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II.1.0 HOW IS IT DIAGNOSED?
There are 4 major blood tests
for HCV.
1) The EIA-3
test detects antibodies
to the virus.
2) The RIBA
test is the confirmatory test for HCV antibodies.
3) The PCR test or TMA, which
measure the amount of virus circulating in a person’s blood stream.
4) The RT-PCR,
or Real Time Reverse Transcription-PCR, which determines the genotype of the
virus.
While the newer HCV
antibody tests are better than before, false positive results still occur.
Further testing should be used to confirm the antibody test. A new TMA test may
now be available in your area. With this test, almost all people with chronic
HCV will test positive. Abnormal liver function tests (LFTs) suggest chronic
disease, but there is no correlation between the level of the liver function
tests and how severe the disease is.
Many physicians (especially primary care physicians) still assume that
people with low LFT’s do not have severe disease, and this has led to
complications and even death because of misdiagnosis. Studies show that testing
for enzyme level elevation is not an accurate diagnostic for the presence of
hepatitis C (Digestive Disease Week 2000).
Before 1990 doctors could
diagnose HCV only by ruling out other possibilities (thus the old name for HCV
was “non-A, non-B hepatitis”).
Hepatitis C antibodies may
not develop for two to six months after infection, so not all patients who go
to the doctor with possible hepatitis C infection can be diagnosed immediately
with blood tests. Diagnosis may have to exclude other possible reasons for
symptoms such as HAV, HBV, cytomegalovirus, Epstein-Barre virus infection, as
well as non-viral liver problems such as fatty liver, or alcohol or
drug-related diseases.
Follow-up blood tests are very important in order to
determine if the disease has become chronic. The blood tests for antibodies are
usually repeated three and six months after the original diagnosis.
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II.1.1 ANTIBODY TESTS
Antibody
tests indicate whether the body has been exposed to the virus and has produced
antibodies to fight it. They do not determine whether or not someone still has
the virus, or how long they’ve been infected. Antibody tests are the most
common method of diagnosing hepatitis C. However, the test can show a false
positive reaction and therefore confirmation is necessary by finding evidence
that the hepatitis C virus is actually in the blood using the polymerase chain
reaction (PCR).
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II.1.2 WHAT IS A PCR?
HCV Polymerase Chain
Reaction (PCR) tests came onto the market in late 1994. HCV PCR tests look for the presence of the
virus. Information gained from the HCV PCR can be useful in interpreting
unclear antibody
test results.
The HCV PCR cannot tell how
long someone has been infected.
A tiny amount of your blood
sample is separated into parts and cleaned. Some of the viral RNA is pulled
out. This goes through the process of PCR. Part of the RNA specific to
hepatitis C is pulled apart by heating it, and new copies are made of this
area. This is done millions of times in just a couple of hours. Your sample can
then be analyzed through many different methods, including being seen under a
UV light, producing that pretty sheet of stripes that you see in forensic crime
shows, Maury Povich and the OJ trial. (Viola
Vatter,
There are at
least three sets: two are the controls--a known HCV-positive sample and an
HCV-negative sample; the other sample is you. If yours matches the positive
sample, you have the virus.
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II.1.2a WHAT IS A GENOTYPE?
A genotype is the “family” to which our specific virus
belongs. Our genotype does not change, but we can be re-infected with a
different genotype. The most common genotypes are: 1a, 1b, 1c, 2a, 2b, 2c, 3a,
3b, 4, and 5. 3a has the highest response rate to interferon. People with this
genotype are generally younger in age, and usually IV drug users. Genotype 1
patients need longer treatment in order to respond.
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II.1.3 IS IT POSSIBLE THE TEST COULD BE WRONG?
Antibody
tests are usually positive or negative, but sometimes they come back unclear.
Tests that come back positive are redone to confirm that they are right.
Unclear results are repeated and if still unclear, different types of blood
tests are done. If you get a positive test result and have no risk background
(for example, blood transfusions or drug use) it’s a good idea to check with
your doctor to make sure that the laboratory double checked the result by using
confirmatory tests.
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II.2.0 BIOPSY
Patients with chronic hepatitis often do not
experience symptoms. On the other hand, others complain of excessive fatigue,
weakness, and a reduced capacity for exercise.
Since liver damage may occur even in asymptomatic
cases (no patient complaints), it is important to perform a biopsy and
determine whether there is ongoing liver damage. As chronic hepatitis
progresses, damage to liver cells may impair liver function. A biopsy of the
damaged liver indicates the degree of cellular necrosis (death of liver cells),
inflammation (cellular infiltration and swelling), and scarring (scar tissue
beginning to replace functioning liver cells).
- “Understanding Chronic Hepatitis” - Schering - 10/92 INH-001/17098403
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II.2.0a WHAT IS A LIVER BIOPSY?
A liver biopsy is a diagnostic procedure used to
obtain a small amount of liver tissue, which can be examined under a microscope
to help identify the cause or stage of liver disease.
The most common way a liver sample is obtained is by
inserting a needle into the liver for a fraction of a second. This can be done
in the hospital with a local anesthetic, and the patient may be sent home
within 3-6 hours if there are no complications.
The physician determines the best site, depth, and
angle of the needle puncture by physical examination or ultrasound. The skin
and area under the skin is anaesthetized, and a needle is passed quickly into
and out of the liver. Approximately half of individuals have no pain
afterwards, while another half will experience brief localized pain that may
spread to the right shoulder.
Some persons, however, have had to be hospitalized
afterwards due to extreme pain, shock or puncture of another organ. Many patients have commented that taking
ativan, a tranquilizer, before the procedure helped reduce the pain, since this
drug will relax the internal muscles and prevent spasms.
Patients are monitored for several hours after a
biopsy to make sure serious bleeding has not occurred. Some patients
occasionally have a sudden drop in blood pressure after a biopsy that is caused
by a vagal reflex and not by blood loss; this is caused by sudden irritation of
the peritoneal membrane. The characteristics that distinguish this from a
bleeding event are: 1) slow pulse rather than rapid, 2) sweating, and 3)
nausea.
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II.2.0b WHAT ARE THE DANGERS OF LIVER BIOPSY?
The risk of a liver biopsy
is minimal. The primary risk is bleeding from the site of needle entry into the
liver, although this occurs in less than 1% of patients. Other possible
complications include the puncture of other organs, such as the kidney, lung or
colon.
Biopsy, by mistake, of the
gallbladder rather than the liver may be associated with leakage of bile into
the abdominal cavity, causing peritonitis. Fortunately, the risk of death from
liver biopsy is extremely low, ranging from 0.01% to 0.1%.
A biopsy should not be done if: 1) you have taken
aspirin in the last 5-7 days, 2) the hemoglobin is below 9-10 grams/dl, 3) the
platelets are below 50,000-60,000, or 4) the prothrombin time INR is above 1.4.
Those with bleeding disorders such as hemophilia, which can be temporarily
corrected with transfused clotting factors, can safely have a biopsy, or they
may be able to have a transjugular biopsy.
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II.2.0c WILL IT HURT?
Most doctors will not do
percutaneous needle liver biopsies under anesthesia. This is because the liver
is directly under the diaphragm and moves as you breathe. When the needle is
inserted through the skin and body wall, the liver must not be moving or else
there is danger of a laceration. To keep the liver from moving, the patient has
to stop breathing momentarily. Doctors prefer to have you alert and able to
follow directions, but if you are very anxious, you may want to ask for a
sedative to help you relax.
The injections of local
anesthetic, and the actual puncture of the liver capsule, itself can be a
little painful for some people, but it only takes a second and is over very
quickly. Other people feel no pain at all, and don’t realize it’s happened
until the doctor tells them they’re finished.
Occasionally there will be
a small to moderate amount of pain afterwards. If you find that you are
uncomfortable, your doctor will generally prescribe a light painkiller
immediately after the biopsy. The pain may be far away from the biopsy site, possibly
in the pit of your stomach or typically in the right shoulder. Be aware that
some doctors are hesitant to give pain killers to those with hepatitis C. It is
advisable to discuss this matter with your doctor before hand to avoid
unnecessary discomfort.
The liver itself has no pain-sensing nerve fibers, but
a small amount of blood in the abdominal cavity or up under the diaphragm can
be irritating and painful. Very occasionally, small adhesions (scar tissue) may
form at or near the biopsy site, and can cause a chronic pain that persists
near the liver area after the biopsy.
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II.2.1 CHRONIC PERSISTENT OR CHRONIC ACTIVE - WHAT’S THE DIFFERENCE?
Hepatitis C is considered
to be “chronic” if it has persisted for longer than 6 months. The term “Chronic
Persistent” used to be used to define hepatitis which persisted for longer than
6 months, but which was not currently causing active damage to the liver. The
term “Chronic Active” was used to define hepatitis which persisted for longer
than 6 months, and which was actively destroying the liver. The distinction
between “persistent” and “active” is not commonly used any more, with the
assumption being that if the virus is present, it is causing damage.
About 85% of HCV-infected
individuals fail to clear the virus by 6 months, and develop chronic hepatitis
with persistent, although sometimes intermittent, viremia. This capacity to
produce chronic hepatitis is one of the most striking features of HCV
infection. The majority of patients with chronic infection have abnormalities
in ALT levels that can
fluctuate widely. About one-third of HCV patients with chronic infection have
persistently normal serum ALT levels. Antibodies to HCV or circulating viral RNA
can be demonstrated in virtually all patients with chronic HCV hepatitis.
Chronic HCV is typically an
insidious process, progressing, if at all, at a slow rate without symptoms or
physical signs in the majority of patients during the first two decades after
infection.
A small proportion of
patients with chronic HCV hepatitis - perhaps less than 20 percent - develop
non-specific symptoms, including mild intermittent fatigue and malaise.
Symptoms first appear in many patients with chronic HCV hepatitis at the time
of development of advanced liver disease.
If by advanced we mean cirrhosis,
then this is most definitely not the case.
Symptoms can occur well before cirrhosis occurs.
Although patients with HCV
infection and normal ALT levels have been referred to as “healthy” HCV carriers, liver
biopsies can show histological evidence of chronic hepatitis in many of these
patients. - National Institutes of Health Consensus Statement on Hepatitis C 1997
It is thus possible to have low enzyme levels and few
if any symptoms and yet have dangerously advanced liver disease. The problem with this scenario is that the
carrier does not know he or she is ill, and does not make modifications to his
or her behavior—alcohol consumption, sexual protection, fatty foods, and so
forth.
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II.2.2 WHAT
ARE THE MAIN SYMPTOMS OF HEPATITIS C?
Acute hepatitis C is almost
indistinguishable from acute hepatitis B infection. Patients with acute
hepatitis C are frequently asymptomatic (meaning that they have no symptoms),
even when liver tests are abnormal. -
“Hepatitis C & E: how much of a threat?” Special Issue: Emerging
Infectious Diseases, Brown, Edwin A., May 15 1994, v28, n9, p105(8).
Soon after contracting the
infection many people have a flu-like illness with fatigue, fever, muscular
aches and pain, nausea and vomiting. About 10% of patients become jaundiced
(their skin turns yellow). Generally these symptoms resolve and the patient has
no symptoms of liver disease for many years. Symptoms may occur from two weeks
to six months after exposure but usually within two months.
The symptoms of chronic
infection range from no symptoms at all, to gradually progressive fatigue and
lack of energy, to complete debility. The effects of the virus vary widely
between individuals.
The symptoms of cirrhosis include
progressive fatigue, jaundice (yellow skin), icterus (yellow eyes), dark urine
(the color of cola), abdominal swelling, muscle wasting, itching, disorientation
and confusion, loss of appetite, and easy bruisability.
In an informal survey of hepatitis C symptoms, Scott Warren swarren@idir.net polled 50 people on the HEPV-L
list and compiled the following results:
FATIGUE, WEAKNESS, TIREDNESS - 72%
JOINT, MUSCLE PAINS - 52%
MEMORY LOSS, MENTAL CONFUSION - 50%
SKIN PROBLEMS-DRY\ITCHY\RASHES\SPOTS - 44%
DEPRESSION, ANXIETY, IRRITABILITY, ETC - 44%
INDIGESTION, NAUSEA, VOMITING, GAS - 34%
SLEEP DISTURBANCES - 32%
PAIN OR DISCOMFORT IN ABDOMEN - 32%
CHILLS, SWEATING, HOT \ COLD FLASHES - 26%
EYE OR EYESIGHT PROBLEMS - 24%
SENSITIVITY TO HEAT OR COLD - 22%
NO SYMPTOMS - 20%
VERTIGO, DIZZINESS, COORDINATION - 18%
FLU LIKE SYMPTOMS - 18%
HEADACHES - 18%
URINARY PROBLEMS, ODOR, COLORATION - 16%
FEVER - 16%
SLOW HEALING AND RECOVERY - 14%
SUSCEPTIBLENESS TO ILLNESS \ FLU - 14%
WEIGHT GAIN, WATER RETENTION - 10%
MENSTRUAL PROBLEMS - 10%
APPETITE \ WEIGHT LOSS - 8%
SWELLING OF STOMACH, LEGS OR FEET - 8%
ORAL, OR MOUTH SORES \ PROBLEMS - 8%
EXCESSIVE BLEEDING - 4%
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II.2.2a FATIGUE
The main symptom of most people with hepatitis C is chronic fatigue,
ranging from simply getting tired easily to extreme, debilitating fatigue. The
fatigue is often not recognized as such.
Many people suffering from this “fatigue” do not have a desire to sleep
because they are tired. Rather, they are suffering a very low level muscle pain
(which often they do not recognize) that just wears them down. Taking a nap really helps. “It took me years to figure out that it was
pain. When nurses would say to me, “You
look tired,” I wouldn’t know what they meant.
I did not always want to go to sleep.
Now much of that has changed. I
do get sleepy-tired and must nap often.” (squeeky).
A study by Goh J, Coughlan B, Quinn J, O'Keane JC, Crowe J Department of
Hepatology,
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II.2.2b UPPER RIGHT QUADRANT (URQ) PAIN (SIDE PAIN)
Even though the liver
itself contains no nerve endings, and does not feel pain, many people with HCV
experience a pain on the upper right side of their body, just beneath the
ribs. It varies from a dull ache and bruised
feeling, to sharp stabbing pain which is quite different from “gas pains.”
This is thought by some to be “referred pain” from the
swelling of the liver capsule due to the disease process. This pain may also be
referred to the right shoulder or to the back between the shoulder blades.
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II.2.2c LOSS OF LIBIDO
Many hepatitis C patients find that they are no longer
interested in sex. This tends to be especially true for those undergoing
interferon treatments. This is not necessarily directly related to the
hepatitis, but is most likely due to the stress, discomfort and exhaustion
caused by the struggle with a chronic illness.
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II.2.2d RED PALMS
Red palms can occur in any chronic liver disease and
are not specifically caused by the virus. The cause for the redness is unknown,
but it’s speculated that it may involve upset hormone metabolism or
microcirculatory changes.
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II.2.2e NAUSEA
A few of the more popular nausea remedies are chewing
candied ginger, putting a (small) drop of peppermint oil on the end of your
tongue, eating small frequent meals, dry crackers and weak tea, and sucking on
popsicles. Sometimes the nausea is
caused by disturbances to the inner ear, in which case your doctor might be
able to prescribe treatment. Many persons on the list have developed autoimmune
inner ear disease as a complication of hepatitis C.
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II.2.2f BRAIN FOG
This is the mental
fuzziness and forgetfulness that some people experience. It’s not the same as
encephalopathy, and seems to occur in all stages of the illness. Some people have
found taking CoEnzyme Q10, also known as CoQ10, to be helpful (2 30mg capsules per
day). Another listmember recommends taking Gingko Biloba.
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II.2.2g ITCHING
The build-up of bilirubin
in the skin may cause itching.
Itching can be treated with
antihistamines, or cholestyramine (which binds bile in the intestines).
Actigall and Questran are two drugs reported to help with this problem.
Recently many of our members have taken to using “bag
balm,” an antibacterial ointment used on cow’s udders. It is apparently
effective and harmless. It can be
obtained from any equestrian or farm supply store, and sometimes in the better
pharmacies.
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II.2.2h VISION PROBLEMS
Some hepatitis patients complain of blurring vision,
and dry eyes. This can be especially true while undergoing interferon
treatment. Interferon treatment can and does trigger retinal complications in
some people, such as hemorrhages, as well as vitreous detachments, cotton wool
spots, cataracts and even strokes (infarcts). Be sure to get your eyes tested
before beginning treatment. There are products to counteract dry eyes. If you
are on treatment, use sunglasses outdoors
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II.2.2i DIZZINESS
Some people have found that wearing “Sea Bands” helps
with their dizziness. Sea Bands are elastic bands that can be bought, usually
in sporting goods stores, which press against pressure points in the wrist.
They were designed for use in seasickness.
Hepatitis C is becoming increasingly associated with a
host of autoimmune disorders. Some of these disorders affect the inner
ear. The inner ear regulates
balance. Symptoms of autoimmune inner
ear disease are dizziness, ringing in the ears (tinnitus) and hearing loss.
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II.2.2j DRY MOUTH
There are some products (mouthwash,
toothpaste, etc.) by the name of Biotene, which are designed to help with the
problem of a dry mouth and gum problems resulting from medication use. Several
listmembers have reported great relief by using these products. The pharmacies
often don’t carry the products, but can order them.
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