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Announcer: The information provided in this video is not intended as a substitute for professional medical advice. If you have any questions or concerns about your health, you should contact your health care provider.

Segment 1: Introducing Dr. Jacobson

Jacobson: Greetings and welcome to the All about Hepatitis C Web site. I'm Dr. Ira Jacobson, Professor of Clinical Medicine and a physician at the New York-Weill Cornell Medical Center in New York City. I'm here to help explain a portion of the important information on this Web site. Through a series of short video segments, we will explore the characteristics of hepatitis C infection, examine those activities that increase a person's risk of contracting the virus, and discuss current strategies for managing the infection. We will also provide a list of questions to ask your physician, highlighting some important steps to follow should you find out that you are positive for hepatitis C. If you or someone you know is infected with HCV, we hope that this Web site will be a valuable source of information to help answer the everyday questions you might have about this disease.

Segment 2: What is hepatitis C?

Jacobson: As you can tell by its name, the hepatitis C virus, also called HCV, is one of about a half-dozen viruses that specifically infects the liver. Some hepatitis infections, such as those caused by the hepatitis A virus, are short-lived infections that usually cause a lot of specific symptoms, such as nausea, vomiting, jaundice-a yellowing of the skin-and an overall feeling of illness, called malaise. Hepatitis C on the other hand, is primarily a long-term infection, and the initial infection with hepatitis C often causes no symptoms at all. In fact, the infection may go unnoticed for years until symptoms appear, or more commonly, when routine blood tests reveal abnormal liver enzyme levels. Because liver disease caused by HCV can progress very slowly, complications of advanced liver damage may not appear until a person has been infected for 20 or 30 years, or even longer.

Hepatitis C is also a fairly common disease. In the United States, about 4 million people are infected with the virus, with about 35,000 new infections occurring each year. About 8 in 10 people infected with HCV develop a chronic infection.

Segment 3: What effect does hepatitis C infection have on my liver?

Jacobson: In about 15% of patients who are infected with hepatitis C, the infection resolves within the first 6 months, without any lasting effect. These patients are said to have an acute infection. However, the majority of patients infected with HCV--75 to 85%--develop a chronic infection. The term "chronic" is used to describe an infection that lasts longer than 6 months. Once chronic infection is in place, the virus is rarely cleared from the body in the absence of treatment.

The natural history of chronic HCV infection can vary dramatically between individuals. Some develop only a minor inflammation of the liver, and never have serious complications. On the other end of the spectrum, some patients have a very severe reaction to the virus, and develop severe liver disease in as little as 5 years. Most, however, fall in between these two extremes.

The first step in the liver's reaction to infection is inflammation, just like what happens when a cut on your finger becomes infected. As infection and inflammation continue, healthy liver cells are injured or destroyed, which stimulates the development of scar tissue. This process of scarring is known as fibrosis. Cirrhosis develops once a large portion of the working liver cells is replaced by scar tissue.

With cirrhosis, the liver cells are separated into tight groups called nodules, which are surrounded by cords of scar tissue. Blood flow through the liver is disturbed by this process, and the liver also cannot function as efficiently. When the liver continues to perform its functions adequately despite cirrhosis, it is called compensated cirrhosis. When the liver can no longer do its job efficiently, resulting in such complications as toxin or fluid buildup, or internal bleeding, it is called decompensated cirrhosis.

Cirrhosis produced by hepatitis C is presently the leading cause of liver cancer, and is the leading indication for liver transplantation in the United States.

Segment 4: Risk factors

Jacobson: A number of risk factors for contracting hepatitis C infection have been identified. The use of illicit injection drugs, such as heroin, and sharing needles with other users is the strongest risk factor. Sharing straws to inhale cocaine has also been implicated.

Having had a blood transfusion prior to 1992 is another risk factor for infection. However, since blood tests for HCV were developed in that year, all potential donors testing positive for HCV have been excluded from donation, and the chances of getting HCV from a blood transfusion are now extremely low. Likewise, hemophiliacs and all other persons who were treated with clotting factors manufactured before 1987 are at risk for harboring hepatitis C.

Other risk factors include having many sex partners or a history of sexually transmitted disease, or STDs, such as chlamydia, syphilis, or gonorrhea. Occupational exposure to blood and blood products, and mother-to-child transmission have also been implicated. (Ref.2, pg.975)

To find out your risk of becoming infected, return to the Home Page and click on "Quick List" in the upper left corner of the page. Then, click on "take the risk test." (Risk Factors) There you will find a short questionnaire that will help you estimate your chances of becoming infected with HCV.

Segment 5: How do I get tested?

Jacobson: Individuals with the risk factors for contracting HCV--described in the "About Hepatitis C" portion of this Web site--may wish to be tested for infection. Several blood tests are available for this purpose, and your doctor may order just one or a combination of these tests. The first test usually done is the EIA, or enzyme immunoassay. The EIA tests for antibodies that your body manufactures in response to HCV infection. Many people refer to this test as the HCV antibody test.

If the EIA is positive, then a RIBA, or recombinant immunoblot assay, may be done to confirm the EIA. However, an assay called PCR is used by most specialists, and has largely replaced the RIBA. This assay looks directly for hepatitis viral genetic material in your blood, and can assess your chance of responding to treatment by estimating the number of virus particles in your blood.

An additional test called a viral genotype is obtained to determine the strain of the virus that is present. Three major genotypes exist in the United States, and are called genotypes 1, 2, and 3. Genotype 1 is the most common, and unfortunately the most difficult to treat. In addition, infection with genotype 1 may require a longer period of treatment in order to achieve satisfactory results.

Finally, if HCV infection is confirmed, then your doctor may wish you to have a liver biopsy. In this procedure, which is performed under a local anesthetic, a needle is quickly inserted into the liver, and a sample of the liver tissue is removed. This tissue is then examined under the microscope to estimate the amount of damage that has been done to the liver by the infection.

Segment 6: Next steps

Jacobson: In many cases, antibody testing is first suggested because levels of a specific liver enzyme in the blood, called ALT or alanine aminotransferase, are increased. ALT is a good indicator of liver inflammation in many people. For this reason, your doctor may measure your ALT level several times during the first 6 to 12 months after your infection is diagnosed. It is important to know that it is possible to have a normal ALT level and still have hepatitis C with inflammation. In fact, many patients with chronic HCV show a periodic rise and fall in ALT levels. If the liver enzyme level remains normal, your doctor may check it less frequently, such as once a year.

You can do several things to protect your liver. Minimize the intake of alcoholic beverages. Don't start any new medicines or use over-the-counter, herbal, and other medicines without clearing them through your doctor first. Also, get vaccinated for hepatitis A and B to prevent getting these other forms of hepatitis that can complicate your condition. If cirrhosis is present, periodic imaging of the liver by ultrasound or other techniques is important to detect early liver cancer.

Finally, you and your physician should discuss treatment for your HCV infection.

Segment 7: The importance of treatment

Jacobson: Treatments for hepatitis C have been improving since they were first introduced in the 1980s. The first treatment regimen used was interferon alfa alone. Therapy has been continually improved, to the point that in clinical trials of approved products, combination treatment with pegylated interferon and ribavirin has produced sustained responses in more than half of the patients treated.

Announcer: As is shown on this chart, (bring up 12% bar for interferon monotherapy) interferon alfa alone was the first treatment used in patients with hepatitis C infection, producing a sustained viral response rate of 12 percent. (fade out 12% bar) In a clinical study using pegylated interferon alfa-2b combined with ribavirin (fade in 52% bar) produced sustained viral responses in 52 percent of patients.

Announcer: Definition: Sustained viral response (SVR) means the inability to detect genetic material from the hepatitis C virus for at least 24 weeks after hepatitis C therapy is completed. A very sensitive gene-based blood test, called a PCR (polymerase chain reaction), is used for this purpose.

Segment 8: What is interferon therapy?

Jacobson: Interferon is a protein produced naturally by our bodies and works in a variety of ways. It helps to activate the body's immune system, increasing the possibility that the virus will be recognized as foreign and attacked. It likely also has a direct effect against the virus itself.

When a person has HCV, additional interferon in the form of a prescription may be necessary in combination with daily ribavirin pills. Studies suggest that interferon therapy may cause a modest reduction of liver inflammation.

Interferon is injected subcutaneously, which literally means under the skin. The initial formulations were administered three times each week, but the new, pegylated forms of the drug are administered just once each week.

Segment 9: What is pegylation?

Jacobson:I've already mentioned pegylated interferon as the latest improvement in therapy for hepatitis C. Let me explain briefly what pegylation is.

Pegylation is a process that attaches a substance called polyethylene glycol--PEG for short--to a protein. PEG has long been used in everyday products, such as foods and cosmetics. When attached to an interferon molecule, PEG allows the interferon to stay in the body longer, which can extend its treatment effects.

PEG molecules vary in size, and may be linear or branched. Let's look at the smaller of the two available molecules. This molecule stays at effective treatment levels within the body for about 10 to 12 days after injection. This allows for injections to be given just once per week, which is far less frequently than the 3-day-per-week regimen of standard interferon, and translates into significantly fewer injections over the course of treatment. In addition to allowing fewer injections, pegylation also provides more consistent levels of interferon within the body during that period. Dosing is also different with pegylated interferon alfa-2b. Although standard interferon was dosed in a single amount for all patients, studies found that response rates were highest in patients who weighed the least. By dosing the pegylated interferon alfa-2b according to a patient's weight, these variations have been avoided, producing more consistent sustained HCV response rates across all weight classes.

So, by attaching a molecule of PEG to the protein, the duration of action and therefore the effectiveness of the interferon is improved.

Segment 10: Questions for your doctor

Jacobson:Hepatitis C infection is a serious matter. For this reason, it is in your own best interest that you learn to ask your doctor appropriate questions about HCV, and educate yourself about the disease and its treatment. There are a number of questions you might want to ask your physician, such as:

What is my virus level and genotype?
Should I be vaccinated against hepatitis A and B?
Do I need a liver biopsy?
Do I need to be treated?
Do I have any other conditions that will complicate therapy?
Do I have sufficient liver scarring to be at risk for liver cancer? If so, how should I be monitored?
Is peginterferon/ribavirin treatment right for me?
Do you recommend that I be treated with a weight-based or fixed dose of pegylated interferon?
How long will my treatment last?
How often do I need to be seen?
What tests do I need to take? Will these tests be repeated? How often?
What side effects can I expect? Whom do I contact in your office about any side effects I am having? Should I contact you directly?
What changes should I make in my everyday life?
What other medications can I take and which should I avoid?

The more questions that you ask, the more you will learn about hepatitis C, and the better prepared you'll be to fight this disease. Additional questions can be found in the Frequently Asked Questions section under the portion of this Web site designated as "Living with Hepatitis C."

The information provided on this site is not intended to be a substitute for professional medical advice. Please consult your health care provider directly with any question you may have regarding your health, condition, or treatment. Your health care provider should be your primary source of information regarding your medical condition and treatment.