Hepatitis C is a single-stranded RNA virus that often results in progressive inflammatory disease of the liver. In its fact sheet on hepatitis C (Fact Sheet No. 164), the World Health Organization estimates that more than 200 million people worldwide have been infected with the virus, and 170 million have chronic disease. Of this number, three to four million Americans have chronic disease, with the majority being baby boomers born between 1946 and 1964.
In 1989 hepatitis C was first identified as a separate entity; before that time it was diagnosed only as non-A, non-B hepatitis. It is a blood-borne disease transmitted through blood and blood products, and most common after transfusions, use of contaminated syringes, organ transplant, or sexual activity with an infected person.
Screening of blood and organ donations has decreased transmission; however, even today up to three quarters of people with hepatitis C may not know they have the disease. The diagnosis is often made accidentally, by finding abnormal liver enzymes on a routine blood draw and subsequently testing for the virus.
Most people infected with hepatitis C do not show symptoms until the findings are advanced. As mentioned, most are either informed that the infection exists during routine blood testing or when donating blood. Jaundice, or liver damage, typically occurs late in the process. In those cases, complications of chronic liver disease including cirrhosis, bleeding and hepatocellular carcinoma (liver cancer) may be pre-terminal events.
Initial testing for hepatitis C looks for antibodies in the antigenic regions of the virus. A test for anti-HCV antibodies usually is positive four weeks after exposure to hepatitis C, and a high titre or viral load is confirmed with a count of more than two million viral copies per milliliter. A recombinant immunoblot assay (RIBA) test confirms that the results are indeed not false positive ones.
Other liver function tests are often raised at the same time—those are the ones that usually trigger the advanced testing for the disease. Later on, when the disease becomes chronic, liver function tests actually drop toward the normal range but do not correlate well with the stage of the disease.
Testing once the presence of hepatitis C is confirmed usually involves checking the viral load (amount of virus in the system) and a liver biopsy to determine how much the liver has been affected by the virus.
Staging on a liver biopsy goes from zero to four, with four being the most advanced and read out by a pathologist. CT scans and abdominal ultrasounds are useful screens and provide information on the extent of liver damage as well. Mortality from hepatitis C is from liver failure, liver cancer and end-stage liver damage (cirrhosis).
Thankfully, newer treatments have delayed the onset of severe problems with hepatitis C and have been able to control the disease for much longer periods of time than previously. Depending on the specific genotype of the virus, treatments such as ribavirin and interferon have had excellent responses.
While the term “cure” is used at times, it really means that at the time of testing, hepatitis C virus particles have decreased to an undetectable level. Thus, what this truly indicates is a remission in the disease, a normalization of liver function tests, and a clearance of RNA virus from the bloodstream.
Without treatment, hepatitis C does not often abate on its own; chronic infection develops and up to 20 percent of cases will progress to cirrhosis or liver cancer.
Many cases of hepatitis C may not be treated if an individual does not have symptoms, has favorable liver function testing, and has had the disease for more than 15 years. These individuals are followed carefully and treated if or when clinical problems or relapse occurs. The treatment generally requires several medications administered concurrently; it is difficult to adhere to in many cases, and contraindicated in certain disease states or concurrent medical conditions.
While previously considered to be an uninsurable disease, rated insurance is now available for many with hepatitis C virus. Those with symptoms or active disease may be declined, but those whose viral titres are low to absent, have a biopsy that shows minimal disease, and who have normal liver function tests are looked upon most favorably. The longer the disease has been observed without complication, the more favorable the outlook.
New medications are being developed that result in longer and longer periods of remission, and although no vaccine is available against hepatitis C at present, much current research is being aimed at that goal.
Robert Goldstone, MD, FACE, FLMI
Goldstone, board certified internist and endocrinologist, is vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1990. Goldstone can be reached by telephone at 949-420-8390. Email: firstname.lastname@example.org.