Hepatitis C

Overview

Hepatitis C virus (HCV) causes both acute and chronic infection. Acute HCV infections are usually asymptomatic and most do not lead to a life-threatening disease. Around 30% (15–45%) of infected persons spontaneously clear the virus within 6 months of infection without any treatment.

The remaining 70% (55–85%) of persons will develop chronic HCV infection. Of those with chronic HCV infection, the risk of cirrhosis ranges from 15% to 30% within 20 years.

Geographical distribution

HCV occurs in all WHO regions. The highest burden of disease is in the Eastern Mediterranean Region and European Region, with 12 million people chronically infected in each region. In the South-East Asia Region and the Western Pacific Region, an estimated 10 million people in each region are chronically infected. Nine million people are chronically infected in the African Region and 5 million the Region of the Americas.

Transmission

The hepatitis C virus is a bloodborne virus. It is most commonly transmitted through:

• the reuse or inadequate sterilization of medical equipment, especially syringes and needles in healthcare settings;
• the transfusion of unscreened blood and blood products; and
• injecting drug use through the sharing of injection equipment.

HCV can be passed from an infected mother to her baby and via sexual practices that lead to exposure to blood (for example, people with multiple sexual partners and among men who have sex with men); however, these modes of transmission are less common.

Hepatitis C is not spread through breast milk, food, water or casual contact such as hugging, kissing and sharing food or drinks with an infected person.

Symptoms

The incubation period for hepatitis C ranges from 2 weeks to 6 months. Following initial infection, approximately 80% of people do not exhibit any symptoms. Those who are acutely symptomatic may exhibit fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, dark urine, pale faeces, joint pain and jaundice (yellowing of skin and the whites of the eyes).

Testing and diagnosis

Because new HCV infections are usually asymptomatic, few people are diagnosed when the infection is recent. In those people who go on to develop chronic HCV infection, the infection is often undiagnosed because it remains asymptomatic until decades after infection when symptoms develop secondary to serious liver damage.

HCV infection is diagnosed in 2 steps:

1. Testing for anti-HCV antibodies with a serological test identifies people who have been infected with the virus.
2. If the test is positive for anti-HCV antibodies, a nucleic acid test for HCV ribonucleic acid (RNA) is needed to confirm chronic infection and the need for treatment. This test is important because about 30% of people infected with HCV spontaneously clear the infection by a strong immune response without the need for treatment. Although no longer infected, they will still test positive for anti-HCV antibodies. This nucleic acid for HCV RNA can either be done in a lab or using a simple point-of-care machine in the clinic.

After a person has been diagnosed with chronic HCV infection, an assessment should be conducted to determine the degree of liver damage (fibrosis and cirrhosis). This can be done by liver biopsy or through a variety of non-invasive tests. The degree of liver damage is used to guide treatment decisions and management of the disease.

Early diagnosis can prevent health problems that may result from infection and prevent transmission of the virus. WHO recommends testing people who may be at increased risk of infection.

In settings with high HCV antibody seroprevalence in the general population (defined as >2% or >5% HCV antibody seroprevalence), WHO recommends that all adults have access to and be offered HCV testing with linkage to prevention, care and treatment services.

About 2.3 million people (6.2%) of the estimated 37.7 million living with HIV globally have serological evidence of past or present HCV infection. Chronic liver disease represents a major cause of morbidity and mortality among persons living with HIV globally.

Treatment

A new infection with HCV does not always require treatment, as the immune response in some people will clear the infection. However, when HCV infection becomes chronic, treatment is necessary. The goal of hepatitis C treatment is to cure the disease.

WHO recommends therapy with pan-genotypic direct-acting antivirals (DAAs) for all adults, adolescents and children down to 3 years of age with chronic hepatitis C infection. DAAs can cure most persons with HCV infection, and treatment duration is short (usually 12 to 24 weeks), depending on the absence or presence of cirrhosis. In 2022, WHO included new recommendations for treatment of adolescents and children using the same pangenotypic treatments used for adults.  

Pan-genotypic DAAs remain expensive in many high- and upper-middle-income countries. However, prices have dropped dramatically in many countries (primarily low-income and lower-middle-income countries) due to the introduction of generic versions of these medicines. The most widely used and low-cost pangenotypic DAA regimen is sofosbuvir and daclatasvir. In many low and middle income countries the curative treatment course is avaiable for less than $50.

Access to HCV treatment is improving but remains too limited. Of the 58 million persons living with HCV infection globally in 2019, an estimated 21% (15.2 million) knew their diagnosis, and of those diagnosed with chronic HCV infection, around 62% (9.4 million) persons had been treated with DAAs by the end of 2019.

Service Delivery

Until recently, delivery of hepatitis C testing and treatment in many countries relied on specialist-led (usually by a hepatologist or gastroenterologist) care models in hospital settings to administer complex treatment. With the short-course oral, curative pangenotypic HCV DAA treatment regimens with few if any side-effects means that minimal expertise and monitoring are now required. WHO now recommends that testing, care and treatment for persons with chronic hepatitis C infection can be provided by trained non-specialist doctors and nurses.

Testing, care and treatment can also now be provided safely in primary care, harm reduction services and prisons which is more accessible and convenient for patients.

Prevention

There is no effective vaccine against hepatitis C so prevention depends on reducing the risk of exposure to the virus in health care settings and in higher risk populations. This includes people who inject drugs and men who have sex with men, particularly those infected with HIV or those who are taking pre-exposure prophylaxis against HIV.

Primary prevention interventions recommended by WHO include:

• safe and appropriate use of health care injections;
• safe handling and disposal of sharps and waste;
• provision of comprehensive harm-reduction services to people who inject drugs;
• testing of donated blood for HBV and HCV (as well as HIV and syphilis);
• training of health personnel; and
• prevention of exposure to blood during sex.

WHO response

In May 2016, the World Health Assembly adopted the first Global health sector strategy on viral hepatitis, 2016–2020. The strategy highlighted the critical role of universal health coverage and sets targets that align with those of the Sustainable Development Goals. The strategy proposed the elimination of viral hepatitis as a public health threat by 2030 (defined as a 90% reduction in new chronic infections and a 65% reduction in mortality, compared with the 2015 baseline), and included a roadmap towards elimination by implementing key prevention, diagnosis, treatment and community interventions strategies. In May 2022 the 75th World Health Assembly noted a new set of integrated global health sector strategies on HIV, viral hepatitis and sexually transmitted infections for the period of 2022–2030. Based on these previous and now new strategies, a broad range of Member States have developed comprehensive national hepatitis programmes and elimination strategies guided by the global health sector strategy.

WHO is working in the following areas to support countries in moving towards achieving the global hepatitis goals under the Sustainable Development Agenda 2030:

• raising awareness, promoting partnerships and mobilizing resources
• formulating evidence-based policy and data for action
• increase health equities within the hepatitis response
• preventing transmission
• scaling up screening, care and treatment services.

WHO organizes the annual World Hepatitis Day campaign (as 1 of its 9 flagship annual health campaigns) to increase awareness and understanding of viral hepatitis. For World Hepatitis Day 2022, WHO focuses on the theme “Bringing hepatitis care closer to you” and calls for simplified service delivery of viral hepatitis services, bringing care closer to communities.