Hepatitis C - Guía Completa de Manejo
Overview
Hepatitis C virus (HCV) is screened as part of the routine initial refugee assessment. A positive HCV serology requires confirmation with an HCV RNA test to distinguish past resolved infection from current active infection. Direct-acting antiviral (DAA) regimens now achieve cure rates close to 100% with 8-12 weeks of oral treatment.
Interpreting the Serology
Anticuerpo HCV | ARN HCV | Interpretación | Acción |
Negativo | No solicitado | Sin exposición previa | No se requiere ninguna acción |
Positivo | Negativo | Infección pasada resuelta O falso positivo | Confirmar con repetición de ARN en 6 meses si persiste la sospecha |
Positivo | Positivo | Infección activa de HCV | Continuar con el manejo completo a continuación |
Indeterminado |
| Poco claro | Solicitar ARN HCV para aclarar |
Confirming Active Infection - Baseline Investigations
Order the following alongside the HCV RNA:
* CBC, INR, creatinine
* ALT, AST, GGT, bilirubin, albumin, total protein
* IgG, IgA, IgM
* ANA, anti-SMA, AMA, alpha-1 antitrypsin (to rule out other liver disease)
* Ferritin
* HBsAg, anti-HBs, anti-HBc (hepatitis B co-infection)
* HIV serology
* Anti-hepatitis A IgG (to assess vaccination need)
Step 1 - Report the Infection
Hepatitis C is a notifiable disease in Alberta. Contact AHS Communicable Disease Unit:
* Phone: 403-955-6750
* Fax: 403-955-6755
Step 2 - Post-Diagnosis Counselling
Disclose the diagnosis in a culturally sensitive manner. Discuss:
* Modes of transmission: sharing needles or drug equipment (most common), blood transfusions before 1992, tattooing with unsterilized equipment, sexual contact (lower risk)
* The concept of a curable infection: effective treatment is available and the goal is cure
* Potential complications if untreated: cirrhosis, liver failure, hepatocellular carcinoma
* Alcohol: advise complete abstinence or significant reduction, as alcohol accelerates liver fibrosis
Step 3 - Screen Contacts
The following contacts should be offered HCV testing:
* Sexual partners (especially if the patient has other STIs or reports traumatic sexual contact)
* Children born to the patient if she has been HCV RNA positive during a pregnancy
* Household members who may have shared needles, razors, or other sharp items
Step 4 - Vaccination
Refer for vaccination if non-immune:
* Hepatitis A (if anti-HAV IgG negative)
* Hepatitis B (if anti-HBs below 10 IU/L)
* Pneumococcal vaccine
Step 5 - Abdominal Imaging
Order an abdominal ultrasound to:
* Screen for hepatocellular carcinoma (HCC)
* Assess for signs of cirrhosis (nodular liver, splenomegaly, ascites)
* Identify incidental findings
Step 6 - Referral for Treatment
All patients with confirmed active HCV infection should be referred for curative DAA therapy. In Calgary:
* Hepatitis C Clinic at CUPS: Fax 403-221-8785 (recommended for patients with complex social situations)
* Calgary Division of Gastroenterology and Hepatology Central Access and Triage: Fax 403-944-6540
Treatment is covered under the IFHP for eligible refugee patients.
While Awaiting Referral
* Repeat ALT every 6 months
* Repeat abdominal ultrasound every 6 months if cirrhosis is suspected
* Reinforce alcohol abstinence
* Avoid hepatotoxic medications including acetaminophen in high doses and NSAIDs in patients with advanced fibrosis
References
* CASL HCV Guidelines 2018: cmaj.ca/content/190/22/E677