Background to HCV
Although Hepatitis C is a relative newcomer as infections go, it has quickly become a worldwide problem. This section discusses who might be a risk and why a guideline on management is needed.
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The need for a guideline
The hepatitis C virus (HCV) was first identified in 19891 and HCV infection has become a major health problem worldwide. Approximately 0.8% of the Scottish population are thought to be chronically infected with HCV (around 37,500 individuals). The prevalence of infection varies between population groups ranging from 50% in injecting drug users (IDU) to less than 0.04% among new blood donors.1
Up to 80% of patients infected with HCV become chronically infected and most of these patients will show evidence of chronic hepatitis.2
Hepatitis C is usually slowly progressive over a period of many years. Five to fifteen percent of patients with chronic hepatitis may progress to liver cirrhosis over 20 years.3 Four to nine per cent of patients with cirrhosis will develop liver failure, and two to five per cent of patients with cirrhosis will develop primary hepatocellular carcinoma.
In the UK the two major routes of transmission of HCV have been sharing of drug injecting equipment by IDU and transfusion of infected blood or blood products. Virus inactivation treatment of blood products began in 1987 and from 1991 blood has been screened for hepatitis C, eliminating blood products as a source of HCV infection.
HCV infection can be effectively treated with combination drug therapy (pegylated alfa interferon and ribavirin) with sustained viral response rates in 50-80% of patients. Although there are existing guidelines around the selection of patients for treatment4-7 there are no national guidelines for screening, testing, diagnosis, service configuration, care during treatment nor post-treatment follow up in adults or children. Presently, wide variation exists across Scotland in the delivery of services to individuals infected with HCV.
Remit of the guideline
The guideline provides evidence - based recommendations covering all stages of the patient care pathway; screening, testing, diagnosis, referral, treatment, care and follow up of infants, children and adults with, or exposed to, HCV infection. The remit encompasses prevention of secondary transmission of the virus but specifically excludes primary prevention of HCV infection. Primary prevention of hepatitis C infection is an important public health concern but is a difficult topic for an evidence - based guideline to cover. The principles and evidence for the prevention of all blood borne viruses are generic and reviewing all of this evidence would have been beyond the capacity of any guideline development group, whilst reviewing the HCV evidence alone would have produced a distorted view.
This guideline will be of interest to all health professionals in primary and secondary care involved in the management of people with hepatitis C infection.
Statement of intent
This guideline is not intended to be construed or to serve as a standard of care. Standards of care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge and technology advance and patterns of care evolve. Adherence to guideline recommendations will not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care aimed at the same results. The ultimate judgement must be made by the appropriate healthcare professional(s) responsible for clinical decisions regarding a particular clinical procedure or treatment plan. This judgement should only be arrived at following discussion of the options with the patient, covering the diagnostic and treatment choices available. It is advised, however, that significant departures from the national guideline or any local guidelines derived from it should be fully documented in the patient’s case notes at the time the relevant decision is taken.
Review and updating
This guideline was issued in 2006 and will be considered for review in three years. Any updates to the guideline in the interim period will be noted on the SIGN website: www.sign.ac.uk.
