Positive Serology
CONFIRMING THE INFECTION
Patients with a positive hepatitis C serology should be tested for HCV RNA to confirm active infection.
A positive hepatitis C serology with a negative HCV RNA test most likely represents a prior infection that spontaneously cleared, or a previous successful treatment. No further management is recommended in this case.
CHRONIC INFECTION
If the patient has a positive viral load, HCV genotyping is then usually required in preparation for treatment (recommendations for genotyping might vary depending on the local guidelines). Some Canadian laboratories will automatically perform genotyping on HCV PCR positive specimens.
Chronic hepatitis C is defined by the persistence of HCV RNA in the blood for >6 months. However, patients with one positive HCV RNA result should still be managed as probable chronic hepatitis C patients from the beginning.
The new direct-acting antiviral (DAA) regimens, with cure rates close to 100%, have drastically changed the treatment of hepatitis C patients. This is why hepatitis C patients should be referred to a Hepatologist as soon as possible.
Once a current hepatitis C infection (HCV RNA+) is confirmed, the following steps should be followed by the patient’s family physician while waiting for the Hepatologist consultation:
Hepatitis C is a nationally notifiable disease in Canada. Unless reporting is done automatically by the laboratory, the ordering physician should directly notify the local public health agency in charge. An adequate public health investigation should then be performed to notify and offer testing to potential contacts.
Disclose the diagnosis to the patient in a culturally-sensitive manner, using an interpreter if required. Explain the various modes of hepatitis C transmission (and how to avoid transmitting the virus - no needle sharing, condoms, no blood donation, etc.). They should understand the potential consequences of the infection (hepatocellular carcinoma, cirrhosis) as well as the concept of chronic infection. Explain that there is a cure for hepatitis C and that this will be prescribed by a specialist. The importance of adhering to the full treatment regimen (usually 3 months) should be stated.
Inquire about any potential history of symptomatic hepatitis in the past. Ask about any family history of hepatitis C, hepatocellular carcinoma or any other liver disease. Injection drug use is the most common cause of hepatitis C transmission, and thus patients should be asked about this. In addition, alcohol intake as well as sexual history should be addressed. Contrarily to the regular Canadian population, blood transfusions and nosocomial transmission (contaminated needles) are common modes of hepatitis C transmission in the refugee population and refugee patients should be questioned about this. Ask about any potential symptom of cirrhosis on history (jaundice, abdominal distension, history of upper GI bleeding, constitutional symptoms - anorexia, weight loss, fatigue).
Look for any potential sign of liver disease/cirrhosis - jaundice, spider angiomata, gynecomastia, ascites, hepatosplenomegaly, caput medusae, palmar erythema, asterixis, etc.
Sexual contacts as well as children (if the patient is a woman) should be screened for hepatitis C.
Once the hepatitis A and B serologies have been ordered, chronic hepatitis C patients should be referred for specific immunizations - pneumococcal and hepatitis A/B (if non-immune).
The following baseline tests should be ordered after a confirmed hepatitis C diagnosis: CBC, INR, creatinine, urea, electrolytes, ALT, AST, GGT, albumin, total bilirubin, anti-Hep A IgG, HBsAg, anti-HBs, anti-HBc, HIV serology
An initial abdominal ultrasound is recommended to screen for hepatocellular carcinoma and look for signs of cirrhosis.
All chronic hepatitis C patients should be seen by a Hepatologist to plan for treatment with DAAs*. |
* Although they are very expensive, DAAs have been covered for our refugee and refugee claimant patients in the past (this is usually taken care of by the Hepatologist). Coverage may however vary depending on the province. The Hepatologist might send instructions to the family doctor regarding follow-up during and after treatment. All patients will require a qualitative HCV RNA test 12 weeks after the end of treatment to ensure a sustained virologic response (i.e. cure).
>> Refer to the guidelines from the Canadian Association for the Study of the Liver (Shah et al., 2018) for more information on the management of hepatitis C.