Hepatitis C - Full Management Guide

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

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