This article has been written to coincide with World Hepatitis Day [July 28th] with the aim of raising awareness of the Hepatitis C virus [HCV, Ｃ型肝炎] that has chronically infected 2-3% [130–170 million people] of the world’s population and claims more than 350,000 people to HCV-related liver diseases each year [WHO 2011]. In 1990, HCV was still undiscovered and even though there have been some advancements over the past two decades, the reality is that HCV remains something of an enigma. Previously known as ‘Non-B Hepatitis’ and of unknown etiology, our understanding has progressed to the point where we can tailor treatment according to genotypes and yet in spite this, a vaccine continues to elude us.
Placing my ‘academic hat’ to one side for a moment, this article has particular resonance as I have close friends in Hong Kong who are living with the Hepatitis C virus. Much of what is described here in a rather factual manner is lived out everyday by people across Hong Kong and around the world. Words often fail to capture the chasms of despair and glimpses of hope that somebody living with HCV and their family experiences. It is hoped that this article contributes to the efforts of the wider community in raising awareness of the Hepatitis C virus in Hong Kong.
Simply put, hepatitis means ‘inflammation of the liver’ and there are a number of causes of hepatitis. This includes excessive intake of alcohol as well as several viruses. Hepatitis C is a blood-borne virus [BBV] and is one of the viral types of hepatitis [hepatitis A, B, C, D and E] that infects the cells of the liver and causes hepatitis.
It’s all in the RNA: Understanding the HCV Virus
To understand the characteristics that differentiate HCV from other viruses and enable it to withstand defense responses from the immune system as well as eluding efforts to develop a vaccine against it, then the virus’s genetic profile is central to this. HCV is an enveloped RNA flavivirus as opposed to the less robust DNA viruses [such as chickenpox & herpes]. RNA viruses have ribonucleic acid as the genetic material and in the case of HCV, the virus is comprised of unstable molecules that are capable of reacting with itself under the correct conditions (Everett Koop Institute 2001).
RNA viruses such as HCV, SARS and influenza are able to mutate more effectively than DNA viruses. These characteristics are key to understanding why Hepatitis C continues to pose such a public health threat. The HCV storage characteristics has implications in terms of the virus life cycle and when combined with the ability to mutate and in effect outwit an immune system that is usually able to withstand viral infections by learning to recognise an infecting virus and create anti-bodies, then you have a formidable virus and threat to public health. This ability to mutate also provides one explanation as to why a vaccine for HCV has been so difficult to produce.
The below CGI animation illustrates the life cycle of the Hepatitis C virus:
Video: Life Cycle of the Hepatitis C virus [CGI Animation]
HCV is not only prevalent in Hong Kong but has been found in every part of the world where it has been sought [Purcell, 1994; WHO, 1997]. The Hepatitis C virus has eleven major genotypes. These refer to the genetic make up of the virus and have implications for subsequent treatment options that will be discussed later. There is a debate about the need to distinguish genotypes 7-11 from genotype 6 due to the fact that HCV genotypes 7, 8, and 9 have only been identified in Vietnamese patients [Tokita et al, 1994] and genotypes 10 and 11 is only found in Indonesia [Tokita et al, 1996].
Table 1: Hepatitis C virus prevalence among adults and genotype distribution [ Liver International 2011]
HCV genotypes have clusters of global distribution and types 1a and 1b are the most common, accounting for about 60% of global infections. They predominate in Northern, Southern & Eastern Europe, North America and Japan respectively. HCV genotype 2 also has a global distribution, but is less common than genotype 1. Genotype 3 is also seen in various regions throughout the world, but is more common in South Asia and Australia. Genotype 4 is found in the Middle East and Africa, especially in Egypt which has the highest rate of HCV infection in the world. Genotype 5 accounts for 50% of the genotypes found in South Africa and is rarely seen outside Africa. Genotypes 6-11 are distributed around the Asian region [Houghton, 1996; Mondelli, 1999; WHO, 1997] with Genotype 6 being found in Hong Kong, Macau and surrounding South China region. China alone has more HCV infections than all of Europe or the Americas [Negro & Alberti, 2011]. While most countries had prevalence rates from 1 to 2%, several countries have relatively high HCV prevalence rates. These include Egypt (15%), Pakistan (4.7%) and Taiwan (4.4%) [Negro & Alberti, 2011].
As a blood-borne virus, risk of HCV transmission increases due to the following behaviours:
Injecting Drug Use
The major risk factor for HCV infection is through risky injecting drug behaviour [Clarke & Kulasegaram, 2006; EASL, 1999; Cook et al, 2001; Hagan et al, 2004; Valenciano et al, 2001]. The high prevalence of HCV among Injecting Drug Users [IDUs] demonstrates a high efficiency of transfer within this population group [WHO, 2011]. HCV has a higher efficiency of transmission via blood contact than HIV, and risk behaviour such as sharing of contaminated needles and other drug paraphernalia significantly increases the chance of infection. Most cases in Hong Kong occur through the sharing of syringes and paraphernalia by IDUs [Mak et al, 2009]. Some practical harm reduction advice for an injecting drug user to follow that can minimise the risk of HCV transmission is:
Avoid sharing the following equipment/paraphernalia during preparation and injecting:
- syringes [make sure a sterile syringe is used for each injection].
- spoons [HCV can potentially be transmitted via spoons. Use your own spoon and do not let others use it].
- filters [these are potential breeding grounds for infections. This is particularly the case in Hong Kong with humid environments].
- water [use your own water that has ideally been filtered]
- cup or other vessel used for holding water that is used for any part of the injecting process
It is important that nobody else has access to your injecting equipment or paraphernalia. This is important if you are living with other drug users or store your equipment in a place that other people may have access to. Before injecting, try and remember to wash the injection site with soap and water to minimise the risk of bacterial infection such as abscesses, cellulitis and septicemia.
Tattoos, Acupuncture & Body piercing
The equipment and supplies used for acupuncture, piercing or tattooing can be infected with HCV. Research has shown that tattoos performed by non-professionals and/or in prison settings heighten the risk in the transmission HCV [Babudieri et al, 2005; Haley & Fischer, 2003; Nishioka & Gyorkos, 2001]. In Hong Kong there is no legislation or licensing for tattoo artists and so it is imperative that a customer is assured that standard procedures are adhered to before having tattoo work done. Following are some practical guidelines that tattoo artists should follow:
- The tattooist should always wash their hands and wear gloves before applying a tattoo.
- The furniture in the area where tattooing takes place should have water-proof material between the customer and the furniture surface that is then changed between sessions.
- The tattoo parlour should ensure that all work areas are clean and sterilised.
- The tattooist should ensure that inks are poured into individual cups before use then discarded after the session.
- The customer should insist that tattooing needles are opened in front of them and disposed of after use. Customers should try and use a tattoo artist that has an autoclave steriliser.
It is advisable to have acupuncture carried out by a licensed Chinese Medicine Practitioner. In Hong Kong, this means that the acupuncturist has passed the Licensing Examination conducted by the Chinese Medicine Practitioners Board of the Chinese Medicine Council. A registered practitioner should display their certificate within the clinic as this is required by the Code of Practice. A directory of registered practitioners in Hong Kong can be found on the Chinese Medicine Council of Hong Kong website
High-risk sexual activity
Sexual transmission of Hepatitis C is relatively low risk but the transmission rate is increased in instances of multiple sexual partners, anal sex, traumatic sex, sex during menstruation, or sex without suitable vaginal lubrication [McQuillan et al, 1999].
Implements such as straws that are used for sniffing drugs such as ice [冰 - methamphetamine hydrochloride], ketamine [K仔] and cocaine [可卡因] are potential instruments for the transmission of HCV. This is due to the straw potentially damaging the lining inside the nose and as a result small amounts of blood can be deposited on the straw. If another person uses this straw for sniffing drugs then there is a potential risk that HCV can be transmitted. Aaron et al  investigated whether there was any clinical and virological evidence to support this notion that HCV can be transmitted onto implements used for sniffing cocaine . The findings of this study that comprised of 38 intranasal drug users with chronic, active HCV infection included a high prevalence of blood (74%) in the nasal secretions of HCV-positive long-term drug sniffers and confirmed that HCV RNA was present in nasal secretions. This study demonstrated that both blood and HCV particles can be transferred onto sniffing implements (straws) during intranasal drug use.
Blood transfusions prior to 1991
Before 1991, cases of HCV in Hong Kong developed after blood transfusions. This included recipients of blood, blood products and organs. In 1991, a screening test for HCV was developed, significantly reducing the chances of acquiring the virus through transfusions.
Health Care Professionals
Doctors, nurses, and laboratory personnel have a higher prevalence of HCV than the general population. Exposure to blood products, poor safety precautions and accidental needle stick injuries can potentially increase the risk of acquiring the disease.
It is important to note that HCV is not spread by food or water, sneezing, hugging, coughing and any other normal social contact.
Symptoms of HCV
HCV is known as the ‘silent virus’ mainly due to the asymptomatic nature of the virus. Symptoms are often only apparent during the chronic stage of infection. Most persons (80%) who develop acute HCV have no symptoms [Mast et al, 1999] and symptoms may not appear until after a period of ten years or even longer. However, if left untreated, HCV can lead to cirrhosis [scarring] and liver cancer. Some individuals may have symptoms during the early acute phase HCV infection. These symptoms have been described as being ‘flu-like’ and develop between five to twelve weeks after exposure to the virus [WHO, 2011]. These include:
- Loss of appetite
- Pain over the liver (right side of the abdomen)
- Stools are pale in colour (clay coloured)
- Urine is dark in colour (Often described as looking like tea)
Testing for HCV
A blood test for HCV can detect the presence of anti-HCV antibodies which confirms infection of HCV. A standard EIA test [enzyme immunoassays] is undertaken to achieve this. A Hepatitis C RNA assay can also be undertaken to measure the viral load. It is important to note that anti-HCV antibodies are not generally detectable immediately after infection. This is due to the fact that anti-HCV antibodies develop in acute infection which can take between 2 and 8 weeks after evidence of liver injury. A liver biopsy can be undertaken to assess to what extent the liver has been damaged.
For Hong Kong residents, a test for HCV can be carried out by a doctor or arranged to be undertaken through the confidential service provided by the Social Hygiene Services that are managed by the Department of Health. These clinics provide medical check-up, treatment and counselling on HCV and STIs. Test results are usually available within 7 working days. Prior appointment and doctor’s referral are not required and more information is available at the end of this article.
Prevalence of HCV in Hong Kong
HCV has been a notifiable infection in the Hong Kong region of China since 1996 and it has been estimated that 0.5% of the population in Hong Kong are carriers of the virus. HCV cases are tracked through the Surveillance and Epidemiology Branch of the Centre for Health Protection [Mak et al, 2009]. Most cases in Hong Kong occur through the sharing of syringes and paraphenalia by IDUs. Zhou et al  conducted a study in Hong Kong that sampled 1055 IDUs and non-IDUs between 1998–2004. The non-IDU population showed a genotype 1b prevalence of 63.6%. Genotypes 2a and 3 had prevalence rates of 3.1 and 3.9%, respectively, and genotype 6a was found in 23.6% of participants. The IDU population showed statistically different genotype distributions, where genotype 6a was seen in 58.5% and 1b in 33.0%.
As discussed, HCV genotype influences treatment decisions due to predicted response to anti-viral treatment. Genotype 1 is generally associated with a poor response to interferon alone, whereas genotypes 2 and 3 are associated with more favourable responses [Mondelli, 1999]. The current ‘gold standard’ of therapy: pegylated interferon-α in combination with ribavirin, improves response for all genotypes [National Institutes of Health, 2002]. Therapy in Hong Kong usually involves this combination. Interferon alpha is usually administered by subcutaneous or intramuscular injection. Tsang et al  undertook a retrospective study to compare the therapeutic responses of the pegylated interferon and ribavirin regimen in patients infected with genotype 6 and genotype 1. This study found that the sustained virological response (SVR) to treatment in patients with genotype 6 was also significantly superior to that of patients with genotype 1 (75.7% vs 57.1%, P = 0.02).
A number of new therapies are currently being developed for chronic HCV. These include direct-acting antiviral drugs (DAA), which target specific HCV enzymes. A review conducted in 2010, reported that two of these compounds were already into phase 3 development in the USA and EU [Pockros, 2010]. A reported possibility of DAA drugs being used in future HCV treatment is the potential for interferon-free regimens [Watch video report of developments in DAA drugs].
Treatment Side Effects:
Side effects are common and can be problematic for some patients who find some of the more chronic side effects unbearable and choose to stop treatment. HCV treatment side effects can include:
- Constitutional flu-like illness fever [tend to occur within 6-8 hours of starting treatment]
- arthralgia [joint pain]
- myalgia fatigue [chronic fatigue syndrome]
- leukopenia [low white blood cell count. Decrease in disease-fighting cells]
- thrombocytopenia [disorder in which there is an abnormally low amount of platelets that help blood to clot]
- Weight loss
- hypothyroidism [a deficiency of thyroid hormone due to insufficient production by thyroid gland]
Teenager Jazzy was born with Hepatitis C. The below video diary is a moving account of her experience undergoing treatment.
Video: Jazzy’s Story
This article originally included a wider discussion of harm reduction policy in Hong Kong and the potential role of needle exchange [針頭交換] within the range of harm reduction [減少毒品傷害] interventions. However, it became apparent that this could potentially detract from raising awareness of Hepatitis C. By discussing the nature of HCV, transmission risks and ways in which these risks can be minimised, it is hoped that readers will be more informed.
A follow up article will be available later this year that will discuss Hong Kong’s harm reduction policy and interventions. A discussion of whether the Hong Kong government should include Syringe Exchange Programmes [SEPs, 針頭交換] within the available range of harm reduction interventions will be included. The primary purpose of SEPs are to prevent the spread of blood-borne viruses and help reduce the incidence of infection and other harms associated with the use of damaged, non-sterile or shared syringes (Beirness, Jesseman et al. 2008). However, despite its aggressive harm reduction strategy in the form of methadone maintenance treatment that has been in place since 1972 (Ch’ien & Cheung, 1999), Hong Kong does not permit the operation of SEPs that involve the provision of sterile injecting equipment and the mechanism to collect and appropriately dispose of used syringes. Providing a Syringe Exchange Programme would mean that an agency could currently be prosecuted in Hong Kong. Syringes are currently purchased without prescription from pharmacies. The only SEP to be sanctioned in Hong Kong was provided by Médecins Sans Frontières in Pillar Point Vietnamese refugee camp during a trial which was brought to a close in 1997. Since then, no other SEP has been sanctioned or repeated by the Hong Kong government (Nemayechi & Taveaux, 1996).
It would be interesting to hear reader’s views on whether Syringe Exchange Programmes should be allowed in Hong Kong as this will be discussed at length in the next article.
“Should the Hong Kong government allow Syringe Exchange Programmes [針頭交換] to operate as part of a harm reduction strategy [減少毒品傷害策略] to minimise the transmission [感染] of blood-borne viruses [血源性傳播病毒] such as Hepatitis C?”
Upcoming Article: ‘Needle Exchange: The Missing Link in Hong Kong’s Harm Reduction Interventions?’
‘Hepatitis C: Hong Kong 2011′ by Lloyd Belcher is licensed under a Creative Commons Attribution-Non Commercial-Share Alike 3.0 Unported License. Permissions beyond the scope of this license must be obtained from the author.
Videos about Hepatitis C:
WHO Hepatitis Awareness [Mandarin] 世卫组织共同纪念世界肝炎日 Hepatitis awareness video in Mandarin Chinese [produced by the World Health Organisation]
Hepatitis C Made Simple An animated video by the John Hopkins University that contains facts about Hepatitis C with a particular focus on the USA.
How Small Is The Hepatitis C Virus? This animation highlights the importance of avoiding transmission of blood-borne viruses such as Hepatitis C.
Hepatitis C: ‘What Not To Share’ A Hepatitis C awareness video with Pete Doherty higlighting the importance of ‘what not to share’
HIV and Hepatitis C Survival in Used Syringes This video provides an insight into experiments that were conducted at Yale University to find out how long HIV and Hepatitis C can survive in used syringes.
Developments in DAA drugs for HCV Treatment A report on developments in HCV treatment with progress in direct-acting antiviral [DAA] drugs that target specific HCV enzymes [Medical Edge 2011].
Aaron, S., McMahon, J., Milano, D., Torres, L., Clatts, M., Tortu, S., Mildvan, D. and Simm, M. (2008) Intranasal Transmission of Hepatitis C Virus: Virological and Clinical Evidence Clinical Infectious Diseases 47(7): 931-934 doi:10.1086/591699.
Babudieri, S., Longo, B., Sarmati, L., Starnini, G., Dori, L., Suligoi, B., Carbonara, S., Monarca, R., Quercia, G., Florenzano, G., Novati, S., Sardu, A., Iovinella, V., Casti, A., Romano, A., Uccella, I., Maida, I., Brunetti, B., Mura, M., Andreoni, M., Rezza, G.  Correlates of HIV, HBV, and HCV infections in a prison inmate population: results from a multicentre study in Italy. Journal of Medical Virology, 76(3):311-317.
Beirness, D. & Jesseman, R.  Harm Reduction: What’s in a Name? Ottawa, Canadian Centre on Substance Abuse.
Burrows, D.  Advocacy and Coverage of Needle Exchange Programs: Results of a Comparative Study of Harm Reduction Programs in Brazil, Bangladesh, Belarus, Ukraine, Russian Federation, and China, 22 CADERNOS DE SAÚDE PÚBLICA 871, 872
Ch’ien, J.N. & Cheung Y.W.  Previous Participation in Outpatient Methadone Program and Residential Treatment Outcome: A Research Note from Hong Kong. Substance Use & Misuse. 34(1): 103-118.
Clarke, A. & Kulasegaram, R.  Hepatitis C transmission – where are we now? International Journal of STD & AIDS 2006, 17(2):74-80.
Cook, P., McVeigh, J., Syed, Q., Mutton, K., Bellis, M.  Predictors of hepatitis B and C infection in injecting drug users both in and out of drug treatment. Addiction 2001, 96(12):1787-1797.
EASL International Consensus Conference on Hepatitis C. Consensus Statement. Journal of Hepatology, 1999, 31:3-8.
Hagan, H., Thiede, H. & Des Jarlais, D . Hepatitis C virus infection among injection drug users: survival analysis of time to seroconversion. Epidemiology 2004, 15(5):543-549.
Haley, R. & Fischer, R  The tattooing paradox: are studies of acute hepatitis adequate to identify routes of transmission of subclinical hepatitis C infection? Archives of Internal Medicine 2003, 163(9):1095-1098.
Houghton, M.  Hepatitis C viruses. In: Fields BN, Knipe DM, Howley PM, eds. Fields Virology, 3rd ed. Philadelphia, Lippincott – Raven, 1996:1035-1058.
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Mak, I., Tse, S., Ho, C., Tse, I., Wong, K.  Surveillance of Viral Hepatitis in Hong Kong – 2008, Update 2008 edn. Hong Kong: Viral Hepatitis Preventive Service, Department of Health.
Mast, E., Alter, M. & Margolis, H  Strategies to prevent and control hepatitis B and C virus infections: a global perspective. Vaccine, 1999, 17:1730-1733.
Mondelli, M. & Silini, E.  Clinical significance of hepatitis C virus genotypes. Journal of Hepatology, 1999, 31:65-70.
National Institutes of Health  Consensus Development Conference Statement: Management of Hepatitis C: 2002, June 10–12. 2002.
Negro, F. & Alberti, A. (2011), The global health burden of hepatitis C virus infection. Liver International, 31: 1–3. doi: 10.1111/j.1478-3231.2011.02537.
Nemayechi, G. & Taveaux, T.  Harm reduction program for Vietnamese drug users in Pillar Point Refugee Camp. Hong Kong: Medecins Sans Frontieres.
Nishioka, S. & Gyorkos, T.  Tattoos as Risk Factors for Transfusion-Transmitted Diseases. International Journal of Infectious Disease 2001, 5:27-34.
McQuillan, G., Gao, F., Moyer, L., Kaslow, R & Margolis, H.  The prevalence of hepatitis C virus in the United States. N Engl J Med 1999; 341: 556–62.
Mondelli, M. & Silini, E. Clinical significance of hepatitis C virus genotypes. Journal of Hepatology, 1999, 31:65-70.
Pockros, P.  Review: New direct-acting antivirals in the development for hepatitis C virus infection Therapeutic Advances in Gastroenterology May 2010 3: 191-202
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Tsang, O., Zee, J., Chan, J., Li, R., Kan, Y., Li, F., Lo, F., Chow, D., Cheung, K., Chan, K., Yeung, Y., Ng, F., Li, M., Kwan, K. & Lai, T.  Chronic Hepatitis C Genotype 6 Responds Better to Pegylated Interferon and Ribavirin combination Therapy than Genotype 1 Journal of Gastroenterol Hepatol. 2010 Apr;25(4):766-71.
Valenciano, M., Emmanuelli, J. & Lert, F.  Unsafe injecting practices among attendees of syringe exchange programmes in France. Addiction 2001, 96(4):597-606.
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