For practical purposes, hepatitis C virus should be regarded as being at least as, if not more, resilient than the hepatitis B virus.
Hepatitis means 'inflammation of the liver'. It can be caused by:
Drugs notably alcohol
Inflammation of, and damage to the liver, caused by a hepatitis virus, may develop without symptoms over many years.
Where liver disease causes significant liver damage, symptoms may include:
Jaundice (yellow skin usually most evident in the whites of the eyes)
Nausea and lack of appetite
Raised level of liver enzymes, which can be measured by a simple liver function blood test (LFT).
The type of viral hepatitis causing a particular episode of illness can only be established by blood tests.
Six main types of viral hepatitis have been identified. Hepatitis B and C, which cause most problems for injecting drug users, are now discussed.
Hepatitis B is primarily a blood-borne virus, but it is present in all the body fluids of an infected person and so is also spread sexually. The main methods of spread of hepatitis B are parenteral (blood to blood) and sexual.
It is a much more easily transmissible infection than HIV, requiring a minuscule 0.00004 ml to be infective109. It can survive for at least four months in the environment.
Blood tests for viral infections usually identify antibodies that have been produced by the body in response to exposure to the virus. The time between contracting hepatitis B and producing antibodies (sometimes referred to as the window period) can vary between four weeks and six months.
As a safe vaccination for hepatitis B exists, it is an almost entirely preventable infection.
The current UK strategy is one of only vaccinating 'high-risk groups' against hepatitis B infection. Current rates of infection amongst injecting drug users in the UK are high. A policy of vaccinating the general population has been recommended by the Viral Hepatitis Prevention Board who have stated that they believe:
"that the most effective way to protect this group is through universal vaccination, before they start to use drugs." 110
Vaccination uptake by attenders at drug services is usually quite low. Those not attending exchanges will very seldom have access to vaccination. Hepatitis B vaccination should be available easily through syringe and needle exchanges and drug services but often in the UK it is not. However, even if availability of vaccination is increased, it will remain very difficult to reach meaningful numbers of injecting drug users for vaccination.
Hepatitis C is extremely prevalent amongst injecting drug users, with studies showing 6090% prevalence in some areas of the UK111. The general response to hepatitis C in the UK to date has been patchy and inconsistent.
There is no vaccination available to prevent hepatitis C infection.
Most people who have hepatitis C have no obvious symptoms and may be unaware that they are infected.
If people do have symptoms, they are often non-specific, including:
Chronic or extreme tiredness
Anxiety and depression
Although jaundice and other obvious symptoms are rare in the first ten years of infection among people with hepatitis C, liver damage may well be occurring.
Hepatitis C is almost universally transmitted by blood or blood products. The highest risk group for new infections of hepatitis C is now injecting drug users.
Before 1991 when donor screening was introduced, transmission of hepatitis C through blood transfusion was widespread, accounting for around 90% of post-transfusion hepatitis infections.
Haemophiliacs treated with factor concentrates to assist blood clotting, before 1991, were at high risk of contracting hepatitis C and there is now a large population of hepatitis C positive haemophiliacs.
The risk of sexual transmission of hepatitis C through vaginal sex appears to be very low, although any sexual activities in which there is a greater chance of blood exchange, such as anal sex or during menstruation, will increase the risk.
Vertical (mother to baby) transmission of hepatitis has been recorded, but appears to be unusual. Babies are often born with hepatitis C antibodies from the mother. As these usually disappear within the first 12 months, it has been suggested that babies should not be tested for their hepatitis C status until they are one year old112. The risk of mother to baby transmission is increased if the mother is HIV positive.
The risk of infection following needlestick injury is thought to be between 2.7% and 10%.
It is thought that injecting drug users who do not share needles and syringes still often place themselves at high risk of contracting hepatitis C by repeated exposure to 'low-risk' events such as the sharing of injecting paraphernalia (e.g. spoons, water, filters).
Progress of the disease
The majority of those who have been infected will give a positive antibody test after eight weeks, although it may take up to six months for some people to develop antibodies.
The most reliable test is a PCR (polymerase chain reaction) test, which checks for the circulating virus.
Chronic infection (lasting longer than six months) is thought likely to occur in at least 80% of cases113.
Much of what is known about the progress of the disease comes from studies of people who were infected through blood transfusion. Some evidence suggests that those infected with hepatitis C through injecting may have more benign outcomes than those infected through blood transfusion.
Alcohol use (especially if excessive) is associated with a greater likelihood of progression to serious liver complications.
Over a time period of 15 to 40 years about 50% of the people infected with the virus will develop symptoms of liver disease. About 50% of those people (i.e. 25% of the infected population) will develop serious, long-term liver disease.
About 10% of those who become ill (i.e. 5% of the infected population) will develop cirrhosis of the liver. Cirrhosis is the process by which damaged liver tissue dies and the liver becomes incapable of fulfilling its many functions. It is usually a terminal disease.
About 5% of those who become ill (i.e. 2.5% of the infected population) will develop life-threatening cancer of the liver.
Conventional medical treatment of hepatitis C is limited at the moment to alfa interferon which has a success rate (clearing the virus to undetectable levels) of about 20%.
The vast majority of doctors insist that a drug user is no longer injecting before they are started on a course of interferon. It is usually administered by subcutaneous self injection three times a week. Interferon often produces significant side effects which cause some people to discontinue treatment.
Clinical trials appear to suggest that using interferon in conjunction with ribavirin significantly improves the success rate of treatment.
There are many alternative treatments available for hepatitis C, although none has been conclusively shown to be of benefit.
'Task Force' recommendations on hepatitis
A UK government sponsored independent review of drug services in England in 199627 made the following recommendations:
Injectors should have easy access to hepatitis B vaccinations through drug services, GUM clinics and GPs
Purchasers should review their local arrangements for providing hepatitis B vaccinations and monitor their progress towards universal vaccinations for drug service clients
Consideration should be given to how best encourage those who could benefit from treatment for hepatitis B and C to come forward.
An excellent source of free, up-to-date and accurate information about hepatitis is:
The British Liver Trust
Information line tel. 01473 276328.