View source for User:Fconaway/sandbox

{{User sandbox}}
<!-- EDIT BELOW THIS LINE -->
{{Infobox disease
|  Name           = Hepatitis C
|  Image          = HCV EM picture 2.png
|  Caption        = [[Electron micrograph]] of [[hepatitis C virus]] purified from cell culture (scale = 50&nbsp;[[nanometers]])
|  DiseasesDB     = 5783
|  ICD10          = {{ICD10|B|17|1|b|15}}, {{ICD10|B|18|2|b|15}}
|  ICD9           = {{ICD9|070.70}},{{ICD9|070.4}}, {{ICD9|070.5}}
|  OMIM           = 609532
|  MedlinePlus    = 000284
|  eMedicineSubj  = med
|  eMedicineTopic = 993
|  eMedicine_mult = {{EMedicine2|ped|979}}
|  MeshID         = D006526
}}
'''Hepatitis C''' is an [[infectious disease]] affecting primarily the [[liver]], caused by the [[hepatitis C virus]] (HCV).<ref name=Sherris>{{cite book | title = Sherris Medical Microbiology | edition = 4th | publisher = McGraw Hill | year = 2004 | pages=551&ndash;2 | isbn = 0838585299 | editor = Ryan KJ, Ray CG (editors) }}</ref> The infection is often [[asymptomatic]], but chronic infection can lead to scarring of the liver and ultimately to [[cirrhosis]], which is generally apparent after many years. In some cases, those with cirrhosis will go on to develop [[liver failure]], [[hepatocellular carcinoma|liver cancer]] or life-threatening [[esophageal varices|esophageal]] and [[gastric varices]].<ref name=Sherris/>

HCV is spread primarily by blood-to-blood contact associated with [[intravenous drug use]], poorly sterilized medical equipment and [[blood transfusions|transfusions]]. An estimated 150&ndash;200&nbsp;million people worldwide are infected with {{nowrap|hepatitis C}}.<ref name=Gravitz2011>{{cite journal |title= A smouldering public-health crisis |author=Gravitz L.|journal=Nature|year= 2011 |volume=474|issue=7350 |page=S2&ndash;4 |doi= 10.1038/474S2a|pmid=21666731 |pages= S2&ndash;4 |s2cid=205065732}}</ref><ref name=WHO2011/><ref name=Mohd2013/> The existence of {{nowrap|hepatitis C}} (originally "non-[[Hepatitis A|A]] non-[[Hepatitis B|B]] hepatitis") was postulated in the 1970s and proven in 1989.<ref name="pmid19781804">{{cite journal |author=Houghton M |title=The long and winding road leading to the identification of the hepatitis C virus |journal=Journal of Hepatology |volume=51 |issue=5 |pages=939&ndash;48 |year=2009 |date=November 2009 |pmid=19781804 |doi=10.1016/j.jhep.2009.08.004 |url=http://www.journal-of-hepatology.eu/article/S0168-8278%2809%2900535-2/fulltext}}</ref> {{nowrap|Hepatitis C}} infects only  humans and [[chimpanzees]].<ref>{{cite book|last=Shors|first=Teri|title=Understanding viruses|publisher=Jones & Bartlett Learning|location=Burlington, MA|isbn=9780763785536|pages=535|url=https://books.google.com/books?id=Uk8xP5LRHr4C&pg=PA535|edition=2nd|date=2011-11-08}}</ref>

The virus persists in the liver in about 85% of those infected. This persistent infection can be treated with medication: the standard therapy is a combination of [[peginterferon]] and [[ribavirin]], with either [[boceprevir]] or [[telaprevir]] added in some cases. Overall, 50&ndash;80% of people treated are cured. Those who develop cirrhosis or liver cancer may require a [[liver transplant]]. {{nowrap|Hepatitis C}} is the leading reason for liver transplantation, though the virus usually recurs after transplantation.<ref name=NEJM2011/> No [[vaccine]] against {{nowrap|hepatitis C}} is available.
{{TOC limit|3}}

==Signs and symptoms==

===Acute infection===
{{nowrap|Hepatitis C}} infection causes acute symptoms in 15% of cases.<ref>{{cite journal|title=Acute hepatitis C|journal=Lancet|date=2008-07-26|volume=372|issue=9635|pages=321&ndash;32|pmid=18657711|doi=10.1016/S0140-6736(08)61116-2|s2cid=46648044|last1=Maheshwari|first1=Anurag|last2=Ray|first2=Stuart|last3=Thuluvath|first3=Paul J.}}</ref> Symptoms are generally mild and vague, including a decreased appetite, fatigue, [[nausea]], muscle or joint pains, and weight loss<ref name=AFP2010>{{cite journal|last=Wilkins|first=T|coauthors=Malcolm JK; Raina D; Schade RR |title=Hepatitis C: diagnosis and treatment|journal=American Family Physician|date=2010-06-01|volume=81|issue=11|pages=1351&ndash;7|pmid=20521755|url=http://www.aafp.org/afp/2010/0601/p1351.pdf }}</ref> and rarely does [[acute liver failure]] result.<ref name=EMB10>{{cite journal|last=Bailey|first=Caitlin|title=Hepatic Failure: An Evidence-Based Approach In The Emergency Department|journal=Emergency Medicine Practice|year=2010|date=Nov 2010|volume=12|issue=4|url=http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=219}}</ref> Most cases of acute infection are not associated with [[jaundice]].<ref name=Book2011p4>{{cite book|title=Chronic Hepatitis C Virus Advances in Treatment, Promise for the Future |year=2011|publisher=Springer Verlag|isbn=9781461411918|page=4|url=https://books.google.com/books?id=6G7mff5DnBQC&pg=PA4}}</ref> The infection resolves spontaneously in 10-50% of cases, which occurs more frequently in individuals who are young and female.<ref name=Book2011p4/>

===Chronic infection===
About 80% of those exposed to the virus develop a chronic infection.<ref name=Lancet2011/> This is defined as the presence of detectable viral replication for at least six months. Most experience minimal or no symptoms during the initial few decades of the infection,<ref name=Book2011/> although chronic {{nowrap|hepatitis C}} can be associated with fatigue.<ref name=ID2010/> Chronic infection after several years may cause [[cirrhosis]] or [[liver cancer]].<ref name=NEJM2011>{{cite journal|last=Rosen|first=HR|title=Clinical practice. Chronic hepatitis C infection|journal=The New England Journal of Medicine|date=2011-06-23|volume=364|issue=25|pages=2429&ndash;38|pmid=21696309|doi=10.1056/NEJMcp1006613}}</ref> The liver enzymes are normal in 7-53%.<ref name=Nicot2011/>

[[Steatohepatitis|Fatty changes to the liver]] occur in about half of those infected and are usually present before cirrhosis develops.<ref name=El-Zayadi2008/><ref>{{cite journal|title=Definition and natural history of metabolic steatosis: histology and cellular aspects|journal=Diabetes & Metabolism|date=2008 Dec|volume=34|issue=6 Pt 2|pages=638&ndash;42|pmid=19195624|doi=10.1016/S1262-3636(08)74598-1|last1=Paradis|first1=V.|last2=Bedossa|first2=P.}}</ref> Usually (80% of the time) this change affects less than a third of the liver.<ref name=El-Zayadi2008>{{cite journal|last=El-Zayadi|first=AR|title=Hepatic steatosis: a benign disease or a silent killer|journal=World Journal of Gastroenterology : WJG|date=2008 Jul 14|volume=14|issue=26|pages=4120&ndash;6|pmid=18636654|doi=10.3748/wjg.14.4120|pmc=2725370}}</ref> Worldwide hepatitis C is the cause of 27% of cirrhosis cases and 25% of hepatocellular carcinoma.<ref name=World2007>{{cite journal|last=Alter|first=MJ|title=Epidemiology of hepatitis C virus infection|journal=World Journal of Gastroenterology : WJG|date=2007-05-07|volume=13|issue=17|pages=2436&ndash;41|doi=10.3748/wjg.v13.i17.2436|pmid=17552026 |pmc=4146761| url = http://www.wjgnet.com/downpdf.asp?url=/1007-9327/13/2436 | format = PDF }}</ref> About 10&ndash;30% of those infected develop cirrhosis over 30&nbsp;years.<ref name=NEJM2011/><ref name=AFP2010/> Cirrhosis is more common in those also infected with [[hepatitis B]], [[schistosoma]], or HIV, in [[alcoholic]]s and in those of male gender.<ref name=AFP2010/> In those with hepatitis C, excess alcohol increases the risk of developing cirrhosis 100-fold.<ref>{{cite journal|title=Alcoholic liver disease and hepatitis C: a frequently underestimated combination|journal=World Journal of Gastroenterology : WJG|date=2009-07-28|volume=15|issue=28|pages=3462&ndash;71|pmid=19630099|doi=10.3748/wjg.15.3462|pmc=2715970 | url = http://www.wjgnet.com/downpdf.asp?url=/1007-9327/15/3462 | format = PDF |last1=Mueller|first1=S.|last2=Millonig|first2=G.|last3=Seitz|first3=H. K.}}</ref> Those who develop cirrhosis have a 20-fold greater risk of [[hepatocellular carcinoma]]. This transformation occurs at a rate of 1&ndash;3% per year.<ref name=NEJM2011/><ref name=AFP2010/>

Liver cirrhosis may lead to [[portal hypertension]], [[ascites]] (accumulation of fluid in the abdomen), [[coagulopathy|easy bruising or bleeding]], varices (enlarged veins, especially in the stomach and esophagus), [[jaundice]], and a syndrome of cognitive impairment known as [[hepatic encephalopathy]].<ref name=Tah2009/> Ascites occurs at some stage in more than half of those who have a chronic infection.<ref name=Zaltron2012>{{cite journal|title=Chronic HCV infection: epidemiological and clinical relevance|journal=BMC Infectious Diseases|year=2012|volume=12 Suppl 2|pages=S2|pmid=23173556|doi=10.1186/1471-2334-12-S2-S2|pmc=3495628|last1=Zaltron|first1=S.|last2=Spinetti|first2=A.|last3=Biasi|first3=L.|last4=Baiguera|first4=C.|last5=Castelli|first5=F.|issue=Suppl 2}}</ref> Late relapses after apparent cure have been reported, but these can be difficult to distinguish from reinfection.<ref name=Nicot2011/>

=== Extrahepatic complications===
The most common problem due to {{nowrap|hepatitis C}} but not involving the liver is mixed [[cryoglobulinemia]] (usually the type II form) - an [[vasculitis|inflammation of small and medium-sized blood vessels]].<ref name="NEJM2013">{{cite journal| title =Review Article: Therapy for Hepatitis C Virus&ndash;Related Cryoglobulinemic Vasculitis| journal =N Engl J Med | date =September 12, 2013| volume =369| issue =11| pages =1035&ndash;1045| url =http://www.nejm.org/doi/full/10.1056/NEJMra1208642| doi =10.1056/NEJMra1208642| pmid =24024840| last1 =Dammacco | first1 =F. | last2 =Sansonno | first2 =D. }}</ref><ref>{{cite journal | last1 = Iannuzzella | first1 = F | last2 = Vaglio | first2 = A | last3 = Garini | first3 = G |title=Management of hepatitis C virus-related mixed cryoglobulinemia |journal=Am. J. Med. |volume=123 |issue=5 |pages=400&ndash;8 |year=2010 |date=May 2010 |pmid=20399313 |doi=10.1016/j.amjmed.2009.09.038 |url=}}</ref> {{nowrap|Hepatitis C}} is also associated with [[SjÃ¶gren's syndrome]] (an autoimmune disorder); [[thrombocytopenia]]; [[lichen planus]]; [[porphyria cutanea tarda]]; [[necrolytic acral erythema]]; insulin resistance; [[diabetes mellitus]]; diabetic nephropathy; autoimmune [[thyroiditis]] and B-cell [[lymphoproliferative disorder]]s.<ref name=Extrahepatic>{{cite journal | last1 = Zignego | first1 = AL | last2 = Ferri | first2 = C | last3 = Pileri | first3 = SA | last4 = Caini | first4 = P | last5 = Bianchi | first5 = FB |title=Extrahepatic manifestations of Hepatitis C Virus infection: a general overview and guidelines for a clinical approach |journal=Digestive and Liver Disease |volume=39 |issue=1 |pages=2&ndash;17 |year=2007 |date=January 2007 |pmid=16884964 |doi=10.1016/j.dld.2006.06.008 | display-authors=3 | author6 = Italian Association of the Study of Liver Commission on Extrahepatic Manifestations of HCV infection }}</ref><ref name=Ko2012>{{cite journal|title=Morphologic features of extrahepatic manifestations of hepatitis C virus infection|journal=Clinical & Developmental Immunology|year=2012|volume=2012|pages=740138|pmid=22919404|doi=10.1155/2012/740138|pmc=3420144|doi-access=free|last1=Ko |first1=Huaibin M. |last2=Hernandez-Prera |first2=Juan C. |last3=Zhu |first3=Hongfa |last4=Dikman |first4=Steven H. |last5=Sidhu |first5=Harleen K. |last6=Ward |first6=Stephen C. |last7=Thung |first7=Swan N. }}</ref> Thrombocytopenia is estimated to occur in 0.16% to 45.4% of people with chronic {{nowrap|hepatitis C}}.<ref>{{cite journal|title=Prevalence of thrombocytopenia among patients with chronic hepatitis C: a systematic review|journal=Journal of Viral Hepatitis|year=2011 |date = January 2011|volume=18|issue=1|pages=1&ndash;7|pmid=20796208|doi=10.1111/j.1365-2893.2010.01366.x|s2cid=21412295|last1=Louie |first1=K. S. |last2=Micallef |first2=J. M. |last3=Pimenta |first3=J. M. |last4=Forssen |first4=U. M. }}</ref>  20-30% of people infected have [[rheumatoid factor]] - a type of antibody.<ref name=Dammacco2000>{{cite journal|title=The lymphoid system in hepatitis C virus infection: autoimmunity, mixed cryoglobulinemia, and Overt B-cell malignancy|journal=Seminars in Liver Disease|year=2000|volume=20|issue=2|pages=143&ndash;57|pmid=10946420|doi=10.1055/s-2000-9613|last1=Dammacco|first1=Franco|last2=Sansonno|first2=Domenico|last3=Piccoli|first3=Claudia|last4=Racanelli|first4=Vito|last5=d'Amore|first5=Francesca Paola|last6=Lauletta|first6=Gianfranco}}</ref> Possible associations include [[prurigo nodularis|Hyde's prurigo nodularis]]<ref>{{cite journal|title=Prurigo nodularis: a review|journal=The Australasian Journal of Dermatology|year=2005 |date = November 2005|volume=46|issue=4|pages=211&ndash;18; quiz 219&ndash;20|pmid=16197418|doi=10.1111/j.1440-0960.2005.00187.x|s2cid=30087432|last1=Lee |first1=Michael R. |last2=Shumack |first2=Stephen }}</ref> and [[membranoproliferative glomerulonephritis]].<ref name=ID2010/>  [[Cardiomyopathy]] with associated arrhythmias has also been reported.<ref name=Matsumori2006>{{cite book|last=Matsumori|first=A|title=Chronic Viral and Inflammatory Cardiomyopathy|chapter=Role of hepatitis C virus in cardiomyopathies|year=2006|issue=55|pages=99&ndash;120|pmid=16329660|doi=10.1007/3-540-30822-9_7|series=Ernst Schering Research Foundation Workshop|isbn=978-3-540-23971-0|volume=55}}</ref> A variety of central nervous system disorders have been reported.<ref name=Monaco2012>{{cite journal|title=HCV-related nervous system disorders|journal=Clinical & Developmental Immunology|year=2012|volume=2012|pages=236148|pmid=22899946|doi=10.1155/2012/236148|pmc=3414089|doi-access=free|last1=Monaco|first1=Salvatore|last2=Ferrari|first2=Sergio|last3=Gajofatto|first3=Alberto|last4=Zanusso|first4=Gianluigi|last5=Mariotto|first5=Sara}}</ref> Chronic infection seems to be associated with an increased risk of [[pancreatic cancer]].<ref name=Xu2013>{{cite journal|title=Hepatitis B or C viral infection and risk of pancreatic cancer: A meta-analysis of observational studies|journal=World Journal of Gastroenterology : WJG|date=2013 Jul 14|volume=19|issue=26|pages=4234&ndash;41|pmid=23864789|doi=10.3748/wjg.v19.i26.4234|pmc=3710428|last1=Xu |first1=Jian-Hua |last2=Fu |first2=J. J. |last3=Wang |first3=X. L. |last4=Zhu |first4=J. Y. |last5=Ye |first5=X. H. |last6=Chen |first6=S. D. }}</ref>

===Occult infection===
Persons who have been infected with hepatitis C may appear to clear the virus but remain infected.<ref name=Sugden2012>{{cite journal|title=Occult infection with hepatitis C virus: friend or foe?|journal=Immunology and Cell Biology|date=2012 Sep|volume=90|issue=8|pages=763&ndash;73|pmid=22546735|doi=10.1038/icb.2012.20|s2cid=23845868|last1=Sugden |first1=Peter B. |last2=Cameron |first2=Barbara |last3=Bull |first3=Rowena |last4=White |first4=Peter A. |last5=Lloyd |first5=Andrew R. }}</ref> The virus is not detectable with conventional testing but can be found with ultra-sensitive tests.<ref name="CarreÃ±o2006">{{cite journal|last=CarreÃ±o|first=V|title=Occult hepatitis C virus infection: a new form of hepatitis C|journal=World Journal of Gastroenterology : WJG|date=2006 Nov 21|volume=12|issue=43|pages=6922&ndash;5|doi=10.3748/wjg.v12.i43.2000|pmid=17109511|pmc=4087333}}</ref> The original method of detection was by demonstrating the viral [[genome]] within liver biopsies, but newer methods include an antibody test for the virus' core protein and the detection of the viral genome after first concentrating the viral particles by [[ultracentrifugation]].<ref name="CarreÃ±oGarcÃa2011">{{cite journal|title=[Occult hepatitis C virus infection]|journal=Enfermedades Infecciosas y Microbiologia Clinica|date=2011 Mar|volume=29 Suppl 3|pages=14&ndash;9|pmid=21458706|doi=10.1016/S0213-005X(11)70022-2|last1=Carreño García|first1=V.|last2=Nebreda|first2=J. B.|last3=Aguilar|first3=I. C.|last4=Quiroga Estévez|first4=J. A.}}</ref> A form of infection with persistently moderately elevated serum liver enzymes but without antibodies to hepatitis C has also been reported.<ref name=Pham2010>{{cite journal|title=Occult hepatitis C virus infection: what does it mean?|journal=Liver International : Official Journal of the International Association for the Study of the Liver|date=2010 Apr|volume=30|issue=4|pages=502&ndash;11|pmid=20070513|doi=10.1111/j.1478-3231.2009.02193.x|s2cid=205651069|last1=Pham |first1=Tram N. Q. |last2=Coffin |first2=Carla S. |last3=Michalak |first3=Tomasz I. }}</ref> This form is known as cryptogenic occult infection.

Several clinical pictures have been associated with this type of infection.<ref name="CarreÃ±o2012">{{cite journal|title=New perspectives in occult hepatitis C virus infection|journal=World Journal of Gastroenterology : WJG|date=2012 Jun 21|volume=18|issue=23|pages=2887&ndash;94|pmid=22736911|doi=10.3748/wjg.v18.i23.2887|pmc=3380315|last1=Carreño|first1=Vicente|last2=Bartolomé|first2=J.|last3=Castillo|first3=I.|last4=Quiroga|first4=J. A.}}</ref> It may be found in people with anti-hepatitis-C antibodies but with normal serum levels of liver enzymes; in antibody-negative people with ongoing elevated liver enzymes of unknown cause; in healthy populations without evidence of liver disease; and in groups at risk for HCV infection including those on haemodialysis or family members of people with occult HCV. The clinical relevance of this form of infection is under investigation.<ref name="CarreÃ±o2008">{{cite journal|title=Occult hepatitis B virus and hepatitis C virus infections|journal=Reviews in Medical Virology|date=2008 May-Jun|volume=18|issue=3|pages=139&ndash;57|pmid=18265423|doi=10.1002/rmv.569|s2cid=12331754|last1=Carreño|first1=Vicente|last2=Bartolomé|first2=Javier|last3=Castillo|first3=Inmaculada|last4=Quiroga|first4=Juan Antonio}}</ref> The consequences of occult infection appear to be less severe than with chronic infection but can vary from minimal to hepatocellular carcinoma.<ref name="CarreÃ±oGarcÃa2011"/>

The rate of occult infection in those apparently cured is controversial but appears to be low.<ref name=Nicot2011>{{cite book|last=Nicot|first=F|title=Occult hepatitis C virus infection: Where are we now?|year=2004|isbn=978-953-307-883-0|page=Chapter 19. Liver biopsy in modern medicine}}</ref> 40% of those with hepatitis but with both negative hepatitis C serology and the absence of detectable viral genome in the serum have hepatitis C virus in the liver on biopsy.<ref name=Scott2007>{{cite journal|title=Molecular diagnostics of hepatitis C virus infection: a systematic review|journal=JAMA: The Journal of the American Medical Association|date=2007 Feb 21|volume=297|issue=7|pages=724&ndash;32|pmid=17312292|doi=10.1001/jama.297.7.724|last1=Scott |first1=J. D. |last2=Gretch |first2=D. R. }}</ref> How commonly this occurs in children is unknown.<ref name=Robinson2008>{{cite journal|last=Robinson|first=JL|title=Vertical transmission of the hepatitis C virus: Current knowledge and issues|journal=Paediatr Child Health|date=July 4, 2008|volume=13|issue=6|pages=529&ndash;534|doi=10.1093/pch/13.6.529|pmid=19436425|pmc=2532905}}</ref>

==Virology==
{{main|Hepatitis C virus}}

The [[hepatitis C virus]] (HCV) is a small, enveloped, single-stranded, positive-sense [[RNA virus]].<ref name=NEJM2011/> It is a member of the ''[[Hepacivirus]]'' genus in the family ''[[Flaviviridae]]''.<ref name=ID2010>{{cite book | last1 = Ray | first1 = Stuart C. | last2 = Thomas | first2 = David L. |editor1-first = Gerald L. | editor1-last = Mandell | editor2-first = John E. | editor2-last = Bennett | editor3-last = Dolin | editor3-first = Raphael |title=Mandell, Douglas, and Bennett's principles and practice of infectious diseases|year=2009|publisher=Churchill Livingstone |location=Philadelphia, PA|isbn=978-0443068393|chapter=Chapter 154: Hepatitis C |edition=7th}}</ref> There are seven major genotypes of HCV, which are known as genotypes one to seven.<ref name=Nakano2011>{{cite journal | last1 = Nakano | first1 = T | last2 = Lau | first2 = GM | last3 = Lau | first3 = GM | last4 = Sugiyama | first4 = M | last5 = Mizokami | first5 = M |title=An updated analysis of hepatitis C virus genotypes and subtypes based on the complete coding region |journal=Liver Int. |year=2011 |date=December 2011 |pmid=22142261 |doi=10.1111/j.1478-3231.2011.02684.x |volume=32 |issue=2 |pages=339&ndash;45 | s2cid = 23271017 | display-authors=3 }}</ref> The genotypes are divided into several subtypes with the number of subtypes depending on the genotype. In the United States, about 70% of cases are caused by genotype 1, 20% by genotype 2 and about 1% by each of the other genotypes.<ref name=AFP2010/> Genotype 1 is also the most common in South America and Europe.<ref name=NEJM2011/>

The half life of the virus particles in the serum is around 3 hours and may be as short as 45 minutes.<ref name=Lerat2004/><ref>{{cite book|last=Pockros|first=Paul|title=Novel and Combination Therapies for Hepatitis C Virus, An Issue of Clinics in Liver Disease|year=2011|isbn=9781455771981|page=47|url=https://books.google.com/books?id=Gm6aXv8A8cUC&pg=PT47}}</ref> In an infected person, about 10<sup>12</sup> virus particles are produced each day.<ref name=Lerat2004>{{cite journal|title=Hepatitis C virus (HCV) occult infection or occult HCV RNA detection?|journal=The Journal of Infectious Diseases|date=2004 Jan 1|volume=189|issue=1|pages=3&ndash;6|pmid=14702146|doi=10.1086/380203|last1=Lerat|first1=Hervé|last2=Hollinger|first2=F. Blaine|s2cid=28523691}}</ref> In addition to replicating in the liver the virus can multiply in lymphocytes.<ref name=Zignego2012>{{cite journal|title=Hepatitis C virus infection in the immunocompromised host: a complex scenario with variable clinical impact|journal=Journal of Translational Medicine|date=2012 Aug 3|volume=10|pages=158|pmid=22863056|doi=10.1186/1479-5876-10-158|pmc=3441205|last1=Zignego |first1=Anna Linda |last2=Giannini |first2=Carlo |last3=Gragnani |first3=Laura |last4=Piluso |first4=Alessia |last5=Fognani |first5=Elisa }}</ref>

==Transmission==
[[File:Hepatitis C infection by source (CDC) - en.svg|thumb|250px|Hepatitis C infection in the United States by source]]
The primary route of transmission in the [[developed world]] is [[intravenous drug use]] (IDU), while in the [[developing world]] the main methods are [[blood transfusions]] and unsafe medical procedures.<ref name=Mah2010>{{cite journal|title=Management of acute hepatitis C|journal=Clinics in Liver Disease|year=2010 |date = February 2010|volume=14|issue=1|pages=169&ndash;76; x|pmid=20123448|doi=10.1016/j.cld.2009.11.007|last1=Maheshwari|first1=Anurag|last2=Thuluvath|first2=Paul J.}}</ref> The cause of transmission remains unknown in 20% of cases;<ref name=Pon2011>{{cite journal|last=PondÃ©|first=RA |title=Hidden hazards of HCV transmission|journal=Medical Microbiology and Immunology|year=2011 |date = February 2011|volume=200|issue=1|pages=7&ndash;11|pmid=20461405|doi=10.1007/s00430-010-0159-9 |s2cid=664199 | url = https://dx.doi.org/10.1007/s00430-010-0159-9 }}</ref> however, many of these are believed to be accounted for by IDU.<ref name=Book2011p4/>

===Intravenous drug use===
IDU is a major risk factor for {{nowrap|hepatitis C}} in many parts of the world.<ref name=China2008>{{cite journal|title=Epidemiology of HCV infection among injection drug users in China: systematic review and meta-analysis|journal=Public Health|year=2008 |date = October 2008|volume=122|issue=10|pages=990&ndash;1003|pmid=18486955|doi=10.1016/j.puhe.2008.01.014|last1=Xia |first1=X. |last2=Luo |first2=J. |last3=Bai |first3=J. |last4=Yu |first4=R. }}</ref> Of 77 countries reviewed, 25 (including the United States) were found to have prevalences of {{nowrap|hepatitis C}} in the intravenous drug user population of between 60% and 80%.<ref name=Lancet2011>{{cite journal|title=Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews|journal=Lancet|date=2011-08-13|volume=378|issue=9791|pages=571&ndash;83|pmid=21802134|doi=10.1016/S0140-6736(11)61097-0|pmc=3285467|last1=Nelson |first1=Paul K. |last2=Mathers |first2=Bradley M. |last3=Cowie |first3=Benjamin |last4=Hagan |first4=Holly |last5=Des Jarlais |first5=Don |last6=Horyniak |first6=Danielle |last7=Degenhardt |first7=Louisa }}</ref><ref name=China2008/>  Twelve countries had rates greater than 80%.<ref name=Lancet2011/> It is believed that ten million intravenous drug users are infected with {{nowrap|hepatitis C}}; China (1.6&nbsp;million), the United States (1.5&nbsp;million), and Russia (1.3&nbsp;million) have the highest absolute totals.<ref name=Lancet2011/> Occurrence of {{nowrap|hepatitis C}} among prison inmates in the United States is 10 to 20 times that of the occurrence observed in the general population; this has been attributed to high-risk behavior in prisons such as IDU and tattooing with nonsterile equipment.<ref name=Jail2010>{{cite journal|last=Imperial|first=JC|title=Chronic hepatitis C in the state prison system: insights into the problems and possible solutions|journal=Expert Review of Gastroenterology & Hepatology|year=2010 |date = June 2010|volume=4|issue=3|pages=355&ndash;64|pmid=20528122|doi=10.1586/egh.10.26|s2cid=7931472}}</ref><ref>{{cite journal|title=Correlates of hepatitis C virus seropositivity in prison inmates: a meta-analysis|journal=Journal of Epidemiology and Community Health|year=2008 |date = April 2008|volume=62|issue=4|pages=305&ndash;13|pmid=18339822|doi=10.1136/jech.2006.051599|s2cid=206989111|last1=Vescio |first1=M. F. |last2=Longo |first2=B. |last3=Babudieri |first3=S. |last4=Starnini |first4=G. |last5=Carbonara |first5=S. |last6=Rezza |first6=G. |last7=Monarca |first7=R. }}</ref>

===Healthcare exposure===
[[Blood transfusion]], transfusion of blood products, or [[organ transplants]] without HCV screening carry significant risks of infection.<ref name=AFP2010/> The United States instituted universal screening in 1992<ref name=Rosen2011/> and Canada instituted universal screening in 1990.<ref>{{cite book|author = Day RA; Paul P; Williams B; ''et al.'' |title=Brunner & Suddarth's textbook of Canadian medical-surgical nursing|year=2009|date=November 2009|publisher=Lippincott Williams & Wilkins|location=Philadelphia, PA|isbn=9780781799898|page=1237|url=https://books.google.com/books?id=SB_-CRXvZPYC&pg=PA1237|edition=Canadian 2nd}}</ref> This decreased the risk from one in 200 units<ref name=Rosen2011>{{cite book|title=Rosen's emergency medicine: concepts and clinical practice 7th edition |last=Marx |first=John |authorlink=|year=2010|publisher=Mosby/Elsevier |location=Philadelphia, PA |isbn=9780323054720 |page=1154 |url=}}</ref> to between one in 10,000 to one in 10,000,000 per unit of blood.<ref name=Book2011p4/><ref name=Pon2011/> This low risk remains as there is a period of about 11&ndash;70&nbsp;days between the potential [[blood donor]]'s acquiring {{nowrap|hepatitis C}} and the blood's testing positive depending on the method.<ref name=Pon2011/> Some countries do not screen for {{nowrap|hepatitis C}} due to the cost.<ref name=World2007/>

Those who have experienced a [[needle stick injury]] from someone who was HCV positive have about a 1.8% chance of subsequently contracting the disease themselves.<ref name=AFP2010/> The risk is greater if the needle in question is hollow and the puncture wound is deep.<ref name=World2007/> There is a risk from mucosal exposures to blood; but this risk is low, and there is no risk if blood exposure occurs on intact skin.<ref name=World2007/>

Hospital equipment has also been documented as a method of transmission of {{nowrap|hepatitis C}}, including reuse of needles and syringes; multiple-use medication vials; infusion bags; and improperly sterilized surgical equipment, among others.<ref name=World2007/> Limitations in the implementation and enforcement of stringent standard precautions in public and private medical and dental facilities are known to be the primary cause of the spread of HCV in [[Egypt]], the country with highest rate of infection in the world.<ref>{{cite web|url=http://www1.albawaba.com/en/news/highest-rates-hepatitis-c-virus-transmission-found-egypt |title=Highest Rates of Hepatitis C Virus Transmission Found in Egypt |publisher=Al Bawaaba |date=2010-08-09 |accessdate=2010-08-27}}</ref>

===Sexual intercourse===
Whether {{nowrap|hepatitis C}} can be transmitted through sexual activity is controversial.<ref name=Sex2010>{{cite journal|author=Tohme RA, Holmberg SD |title=Is sexual contact a major mode of hepatitis C virus transmission? |journal=Hepatology |volume= 52|issue= 4|pages= 1497&ndash;505|year=2010 |date=June 2010|pmid=20635398 |doi=10.1002/hep.23808 |s2cid=5592006 | url = http://onlinelibrary.wiley.com/doi/10.1002/hep.23808/pdf }}</ref> While there is an association between high-risk sexual activity and {{nowrap|hepatitis C}}, it is not known whether transmission of the disease is due to drug use that has not been admitted to or sex (as risk factors).<ref name=AFP2010/> The majority of evidence supports there being no risk for [[monogamous]] [[heterosexual]] couples.<ref name=Sex2010/> Sexual practices that involve higher levels of trauma to the anogenital mucosa, such as [[anal penetration|anal penetrative sex]], or that occur when there is a concurrent [[sexually transmitted infection]], including [[HIV]] or [[genital ulcer]]ation, do present a risk.<ref name=Sex2010/> The United States government recommends [[condom]] use to prevent {{nowrap|hepatitis C}} transmission in only those with multiple partners.<ref>{{cite web|title=Hepatitis C Group Education Class|url=http://www.hepatitis.va.gov/products/HCV-education-class-script.asp|publisher=United States Department of Veteran Affairs}}</ref>

===Body modification===
[[Tattooing]] is associated with two to threefold increased risk of {{nowrap|hepatitis C}}.<ref name=Tato2010>{{cite journal|title=Tattooing and the risk of transmission of hepatitis C: a systematic review and meta-analysis|journal=International Journal of Infectious Diseases : IJID : Official Publication of the International Society for Infectious Diseases|year=2010 |date = November 2010|volume=14|issue=11|pages=e928&ndash;40|pmid=20678951|url=http://natap.org/2010/HCV/tatoohcv.pdf|doi=10.1016/j.ijid.2010.03.019|last1=Jafari|first1=Siavash|last2=Copes|first2=Ray|last3=Baharlou|first3=Souzan|last4=Etminan|first4=Mahyar|last5=Buxton|first5=Jane}}</ref> This can be due to either improperly sterilized equipment or contamination of the dyes being used.<ref name=Tato2010/> [[Tattoos]] or [[Body piercing|piercings]] performed either before the mid-1980s, "underground," or nonprofessionally are of particular concern, since sterile techniques in such settings may be lacking. The risk also appears to be greater for larger tattoos.<ref name=Tato2010/> It is estimated that nearly half of prison inmates share unsterilized tattooing equipment.<ref name=Tato2010/> It is rare for tattoos in a licensed facility to be directly associated with HCV infection.<ref>{{cite web|title=Hepatitis C|url=http://www.cdc.gov/hepatitis/HCV/PDFs/HepCGeneralFactSheet.pdf|publisher=Centers for Disease Control and Prevention (CDC) |accessdate=2 January 2012}}</ref>

===Shared personal items===
Personal-care items such as razors, toothbrushes, and manicuring or pedicuring equipment can be contaminated with blood. Sharing such items can potentially lead to exposure to HCV.<ref name="pmid16907842">{{cite journal |author=Lock G |title=Hepatitis C &ndash; contamination of toothbrushes: myth or reality? |journal=J. Viral Hepat. |volume=13 |issue=9 |pages=571&ndash;3 |year=2006 |date=September 2006 |pmid=16907842 |doi=10.1111/j.1365-2893.2006.00735.x |url= |author-separator=, |author2=Dirscherl M |author3=Obermeier F |display-authors=3 |last4=Gelbmann |first4=CM |last5=Hellerbrand |first5=C |last6=Knoll |first6=A |last7=Scholmerich |first7=J |last8=Jilg |first8=W |s2cid=24264376 }}</ref><ref name=CDC12/> Appropriate caution should be taken regarding any medical condition that results in [[bleeding]], such as cuts and sores.<ref name=CDC12/> HCV is not spread through casual contact, such as hugging, kissing, or sharing eating or cooking utensils.<ref name=CDC12>{{cite web |url= http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm |title=Hepatitis C FAQs for Health Professionals |publisher = Centers for Disease Control and Prevention (CDC) |accessdate=2 January 2012}}</ref> Neither is it transmitted through food or water.<ref>{{cite journal |author=Wong T, Lee SS |title=Hepatitis C: a review for primary care physicians |journal=CMAJ |volume=174 |issue=5 |pages=649&ndash;59 |year=2006 |date=February 2006 |pmid=16505462 |pmc=1389829 |doi=10.1503/cmaj.1030034 |url=}}</ref>

===Vertical transmission===
[[Vertical transmission]] of {{nowrap|hepatitis C}} from an infected mother to her child occurs in less than 10% of pregnancies.<ref name=Preg10>{{cite journal|title=Caring for pregnant women and newborns with hepatitis B or C|journal=American Family Physician|date=2010-11-15|volume=82|issue=10|pages=1225&ndash;9|pmid=21121533 | url = http://www.aafp.org/afp/2010/1115/p1225.pdf |last1=Lam |first1=N. C. |last2=Gotsch |first2=P. B. |last3=Langan |first3=R. C. }}</ref> There are no measures that alter this risk.<ref name=Preg10/> It is not clear when during pregnancy transmission occurs, but it may occur both during gestation and at delivery.<ref name=Pon2011/> A long labor is associated with a greater risk of transmission.<ref name=World2007/> There is no evidence that [[breast-feeding]] spreads HCV; however, to be cautious, an infected mother is advised to avoid breastfeeding if her nipples are cracked and bleeding,<ref>{{cite book |author=Mast EE |title=Protecting Infants through Human Milk |chapter=Mother-to-infant hepatitis C virus transmission and breastfeeding |volume=554 |pages=211&ndash;6|year=2004 |pmid=15384578 |doi=10.1007/978-1-4757-4242-8_18 |series=Advances in Experimental Medicine and Biology |isbn=978-1-4419-3461-1}}</ref> or her viral loads are high.<ref name=Pon2011/>

==Diagnosis==
[[Image:Hepatitis C serology.png|thumb|Serologic profile of Hepatitis C infection]]
There are a number of diagnostic tests for {{nowrap|hepatitis C}}, including HCV [[antibody]] [[ELISA|enzyme immunoassay]] or ELISA, [[Western blot|recombinant immunoblot assay]], and quantitative HCV [[RNA]] [[polymerase chain reaction]] (PCR).<ref name=AFP2010/> HCV [[RNA]] can be detected by PCR typically one to two weeks after infection, while antibodies can take substantially longer to form and thus be detected.<ref name=Tah2009/>

Chronic {{nowrap|hepatitis C}} is defined as infection with the {{nowrap|hepatitis C}} virus persisting for more than six months based on the presence of its RNA.<ref name=Book2011>{{cite book|title=Chronic Hepatitis C Virus Advances in Treatment, Promise for the Future |year=2011|publisher=Springer Verlag|isbn=9781461411918|pages=103&ndash;104|url=https://books.google.com/books?id=6G7mff5DnBQC&pg=PA104}}</ref> Chronic infections are typically asymptomatic during the first few decades,<ref name=Book2011/> and thus are most commonly discovered following the investigation of [[Liver function tests|elevated liver enzyme levels]] or during a routine screening of high-risk individuals. Testing is not able to distinguish between acute and chronic infections.<ref name=World2007/> Diagnosis in the infant is difficult as maternal antibodies may persist for up to 18 months.<ref name=Robinson2008/>

===Serology===
{{nowrap|Hepatitis C}} testing typically begins with [[serology|blood testing]] to detect the presence of antibodies to the HCV, using an enzyme immunoassay.<ref name=AFP2010/> If this test is positive, a confirmatory test is then performed to verify the immunoassay and to determine the [[viral load]].<ref name=AFP2010/> A recombinant immunoblot assay is used to verify the immunoassay and the viral load is determined by a HCV RNA polymerase chain reaction.<ref name=AFP2010/> If there are no RNA and the immunoblot is positive, it means that the person tested had a previous infection but cleared it either with treatment or spontaneously; if the immunoblot is negative, it means that the immunoassay was wrong.<ref name=AFP2010/> It takes about 6&ndash;8 weeks following infection before the immunoassay will test positive.<ref name=ID2010/> A number of tests are available as [[point of care testing]] which means that results are available within 30&nbsp;minutes.<ref>{{cite journal|last=Shivkumar|first=S|coauthors=Peeling, R; Jafari, Y; Joseph, L; Pant Pai, N|title=Accuracy of Rapid and Point-of-Care Screening Tests for Hepatitis C: A Systematic Review and Meta-analysis|journal=Annals of Internal Medicine|date=2012 Oct 16|volume=157|issue=8|pages=558&ndash;66|pmid=23070489|doi=10.7326/0003-4819-157-8-201210160-00006|s2cid=5650682}}</ref>

Liver enzymes are variable during the initial part of the infection<ref name=Book2011/> and on average begin to rise at seven weeks after infection.<ref name=ID2010/> The elevation of liver enzymes does not closely follow disease severity.<ref name=ID2010/>

===Biopsy===
[[Liver biopsy|Liver biopsies]] are used to determine the degree of liver damage present; however, there are risks from the procedure.<ref name=NEJM2011/> The typical changes seen are [[lymphocyte]]s within the parenchyma, [[lymphoid follicles]] in [[portal triad]], and changes to the bile ducts.<ref name=NEJM2011/> There are a number of blood tests available that try to determine the degree of [[hepatic fibrosis]] and alleviate the need for biopsy.<ref name=NEJM2011/>

===Screening===
It is believed that only 5&ndash;50% of those infected in the United States and Canada are aware of their status.<ref name=Tato2010/> Testing is recommended in those at high risk, which includes injection drug users, those who have received blood transfusions before 1992,<ref>{{cite journal|title=Screening for Hepatitis C Virus Infection in Adults: U.S. Preventive Services Task Force Recommendation Statement|journal=Annals of Internal Medicine|date=2013 Jun 25|pmid=23798026|doi=10.7326/0003-4819-159-5-201309030-00672|volume=159|issue=5|pages=349&ndash;57|s2cid=8563203|last1=Moyer |first1=Virginia A. |author2=U.S. Preventive Services Task Force }}</ref> and those with tattoos.<ref name=Tato2010/> Screening is also recommended in those with elevated liver enzymes, as this is frequently the only sign of chronic hepatitis.<ref>{{cite journal|last=Senadhi|first=V|title=A paradigm shift in the outpatient approach to liver function tests|journal=Southern Medical Journal|year=2011 |date = July 2011|volume=104|issue=7|pages=521&ndash;5|pmid=21886053|doi=10.1097/SMJ.0b013e31821e8ff5|s2cid=26462106}}</ref> Routine screening is not currently recommended in the United States.<ref name=AFP2010 /> In 2012, the U.S. [[Centers for Disease Control and Prevention]] (CDC) added a recommendation for a single screening test for those born between 1945 and 1965.<ref>{{cite journal |author= Smith BD, Morgan RL, Beckett GA, ''et al.''|title=Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965 |journal=MMWR Recomm Rep |volume=61 |issue=RR-4 |pages=1&ndash;32 |year=2012 |date=August 2012 |pmid=22895429 |doi= |url=}}</ref>

==Prevention==
{{See also|Hepatitis C vaccine}}
{{As of|2011}}, no [[vaccine]] protects against contracting {{nowrap|hepatitis C}}. However, there are a number under development and some have shown encouraging results.<ref>{{cite journal|title=Vaccination for hepatitis C virus: closing in on an evasive target|journal=Expert Review of Vaccines|date=2011 May|volume=10|issue=5|pages=659&ndash;72|pmid=21604986|doi=10.1586/erv.11.55|pmc=3112461 |last1=Halliday|first1=John|last2=Klenerman|first2=Paul|last3=Barnes|first3=Eleanor}}</ref> A combination of [[harm reduction]] strategies, such as the [[needle exchange programs|provision of new needles and syringes]] and treatment of [[substance abuse|substance use]], decrease the risk of {{nowrap|hepatitis C}} in intravenous drug users by about 75%.<ref>{{cite journal|title=A systematic review and meta-analysis of interventions to prevent hepatitis C virus infection in people who inject drugs|journal=The Journal of Infectious Diseases|date=2011-07-01|volume=204|issue=1|pages=74&ndash;83|pmid=21628661|doi=10.1093/infdis/jir196|pmc=3105033 | url = http://jid.oxfordjournals.org/content/204/1/74.full|last1=Hagan|first1=H.|last2=Pouget|first2=E. R.|last3=Des Jarlais|first3=D. C.}}</ref> The screening of blood donors is important at a national level, as is adhering to [[universal precautions]] within healthcare facilities.<ref name=ID2010/> In countries where there is an insufficient supply of sterile [[syringes]], medications should be given orally rather than via injection (when possible).<ref name=World2007/>

==Treatment==
HCV induces chronic infection in 50&ndash;80% of infected persons. Approximately 40&ndash;80% of these clear with treatment.<ref>{{cite journal|title=Progress in the development of preventive and therapeutic vaccines for hepatitis C virus|journal=Journal of Hepatology|year=2011 |date = June 2011|volume=54|issue=6|pages=1273&ndash;85|pmid=21236312|doi=10.1016/j.jhep.2010.09.040 | url = http://download.journals.elsevierhealth.com/pdfs/journals/0168-8278/PIIS0168827811000183.pdf |last1=Torresi|first1=Joseph|last2=Johnson|first2=Doug|last3=Wedemeyer|first3=Heiner}}</ref><ref>{{cite journal|title=An overview of emerging therapies for the treatment of chronic hepatitis C|journal=Clinics in Liver Disease|year=2011 |date = August 2011|volume=15|issue=3|pages=515&ndash;36|pmid=21867934|doi=10.1016/j.cld.2011.05.002|last1=Ilyas |first1=Jawad A. |last2=Vierling |first2=John M. }}</ref> In rare cases, infection can clear without treatment.<ref name=Book2011p4/> Those with chronic {{nowrap|hepatitis C}} are advised to avoid [[alcohol]] and medications toxic to the liver,<ref name=AFP2010/> and to be [[vaccinated]] for [[hepatitis A]] and [[hepatitis B]].<ref name=AFP2010/> [[Ultrasound]] surveillance for [[hepatocellular carcinoma]] is recommended in those with accompanying cirrhosis.<ref name=AFP2010/>

===Medications===
In general, treatment is recommended for those with proven HCV infection liver abnormalities;<ref name=AFP2010/> {{as of|2010}}, treatments consist of a combination of [[pegylated interferon|pegylated interferon alpha]] and the antiviral drug [[ribavirin]] for a period of 24 or 48 weeks, depending on HCV [[genotype]].<ref name=AFP2010/> This results cure rates of between 70&ndash;80% for genotype 2 and 3, and 45 to 70% for other genotypes.<ref name=NEJM2013>{{cite journal|title=Current and future therapies for hepatitis C virus infection|journal=The New England Journal of Medicine|date=2013 May 16|volume=368|issue=20|pages=1907&ndash;17|pmid=23675659|doi=10.1056/NEJMra1213651|pmc=3893124|last1=Liang |first1=T. Jake |last2=Ghany |first2=Marc G. }}</ref> When combined with ribavirin, [[pegylated interferon-alpha-2a]] may be superior to [[pegylated interferon-alpha-2b]], though the evidence is not strong.<ref name="pmid20187106">{{cite journal | author = Awad T, Thorlund K, Hauser G, Stimac D, Mabrouk M, Gluud C | title = Peginterferon alpha-2a is associated with higher sustained virological response than peginterferon alfa-2b in chronic hepatitis C: systematic review of randomized trials | journal = Hepatology | volume = 51 | issue = 4 | pages = 1176&ndash;84 | year = 2010 | date = April 2010 | pmid = 20187106 | doi = 10.1002/hep.23504 | s2cid = 19437977 | url = http://onlinelibrary.wiley.com/doi/10.1002/hep.23504/pdf }}</ref> Another agent, [[sofosbuvir]], when combined with ribavirin, shows improved response rates in the 95% range for genotype 2.<ref name=NEJM2013/> This benefit is somewhat offset by a greater rate of adverse effects.<ref name=NEJM2013/>

Combining either [[boceprevir]] or [[telaprevir]] with ribavirin and peginterferon alfa improves antiviral response for hepatitis C genotype 1.<ref name="pmid21828346">{{cite journal | author = Foote BS, Spooner LM, Belliveau PP | title = Boceprevir: a protease inhibitor for the treatment of chronic hepatitis C | journal = Annals of Pharmacotherapy | volume = 45 | issue = 9 | pages = 1085&ndash;93 | year = 2011 | date = September 2011 | pmid = 21828346 | doi = 10.1345/aph.1P744 | s2cid = 39593200 }}</ref><ref name="pmid21558488">{{cite journal | author = Smith LS, Nelson M, Naik S, Woten J | title = Telaprevir: an NS3/4A protease inhibitor for the treatment of chronic hepatitis C | journal = Annals of Pharmacotherapy | volume = 45 | issue = 5 | pages = 639&ndash;48 | year = 2011 | date = May 2011 | pmid = 21558488 | doi = 10.1345/aph.1P430 | s2cid = 2886659 }}</ref><ref name="pmid21898493">{{cite journal | author = Ghany MG, Nelson DR, Strader DB, Thomas DL, Seeff LB | title = An update on treatment of genotype 1 chronic hepatitis C virus infection: 2011 practice guideline by the American Association for the Study of Liver Diseases | journal = Hepatology | volume = 54 | issue = 4 | pages = 1433&ndash;44 | year = 2011 | date = October 2011 | pmid = 21898493 | pmc = 3229841 | doi = 10.1002/hep.24641 }}</ref> Adverse effects with treatment are common, with half of people getting [[Influenza-like illness|flu like symptoms]] and a third experiencing emotional problems.<ref name=AFP2010/> Treatment during the first six months is more effective than once {{nowrap|hepatitis C}} has become chronic.<ref name=Tah2009/> If someone develops a new infection and it has not cleared after eight to twelve weeks, 24 weeks of pegylated interferon is recommended.<ref name=Tah2009/> In people with [[thalassemia]], ribavirin appears to be useful but increases the need for transfusions.<ref>{{cite journal |author=Alavian SM, Tabatabaei SV |title=Treatment of chronic hepatitis C in polytransfused thalassaemic patients: a meta-analysis |journal=J. Viral Hepat. |volume=17 |issue=4 |pages=236&ndash;44 |year=2010 |date=April 2010 |pmid=19638104|doi=10.1111/j.1365-2893.2009.01170.x |s2cid=20271240 }}</ref>

===Surgery===
Cirrhosis due to hepatitis C is a common reason for [[liver transplant]]ion<ref name=Tah2009>{{cite journal|title=Acute hepatitis C: prevention and treatment|journal=Expert Review of Anti-infective Therapy|year=2009 |date = April 2009|volume=7|issue=3|pages=351&ndash;61|pmid=19344247|doi=10.1586/eri.09.8|s2cid=25574917|last1=Ozaras|first1=Resat|last2=Tahan|first2=Veysel}}</ref> though the virus usually (80&ndash;90% of cases) recurs afterwards.<ref name=NEJM2011/><ref>{{cite book|last=Sanders|first=Mick|title=Mosby's Paramedic Textbook|year=2011|publisher=Jones & Bartlett Publishers|isbn=9780323072755|page=839|url=https://books.google.com/books?id=PJyhIH8N8qgC&pg=PA839}}</ref> Infection of the graft leads to 10&ndash;30% of people developing cirrhosis within five years.<ref name=Ciria2013>{{cite journal |author=Ciria R, Pleguezuelo M, Khorsandi SE, ''et al.'' |title=Strategies to reduce hepatitis C virus recurrence after liver transplantation |journal=World J Hepatol |volume=5 |issue=5 |pages=237&ndash;50 |year=2013 |date=May 2013 |pmid=23717735 |pmc=3664282 |doi=10.4254/wjh.v5.i5.237 |url=}}</ref> Treatment with pegylated interferon and ribavirin post transplant decreases the risk of recurrence to 70%.<ref name=Coilly2013>{{cite journal |author=Coilly A, Roche B, Samuel D |title=Current management and perspectives for HCV recurrence after liver transplantation |journal=Liver Int. |volume=33 Suppl 1 |issue= |pages=56&ndash;62 |year=2013 |date=February 2013 |pmid=23286847 |doi=10.1111/liv.12062 |s2cid=23601091 |url=}}</ref>

===Alternative medicine===
Several [[alternative medicine|alternative therapies]] are claimed by their proponents to be helpful for {{nowrap|hepatitis C}} including [[Silybum marianum|milk thistle]], [[ginseng]], and [[colloidal silver]].<ref name=NCCAM>[http://nccam.nih.gov/health/providers/digest/hepatitisC-science.htm Hepatitis C and CAM: What the Science Says]. [[National Center for Complementary and Alternative Medicine]] (NCCAM). March 2011. (Retrieved 7 March 2011)</ref> However, no alternative therapy has been shown to improve outcomes in {{nowrap|hepatitis C}}, and no evidence exists that alternative therapies have any effect on the virus at all.<ref name=NCCAM/><ref>{{cite journal|title=Medicinal herbs for hepatitis C virus infection: a Cochrane hepatobiliary systematic review of randomized trials|journal=The American Journal of Gastroenterology|year=2003 |date= March 2003|volume=98|issue=3|pages=538&ndash;44|pmid=12650784|last1=Liu|first1=J.|last2=Manheimer|first2=E.|last3=Tsutani|first3=K.|last4=Gluud|first4=C.|doi=10.1111/j.1572-0241.2003.07298.x|s2cid=20014583}}</ref><ref>{{cite journal|last1 = Rambaldi|first1 = A|last2 = Jacobs|first2 = BP|last3 = Gluud|first3 = C|coauthors=([http://ctu.rh.dk/chbg Hepato-Biliary Group]|editor1-first = Andrea|editor1-last = Rambaldi|date = 2007-10-17|title=Milk thistle for alcoholic and/or hepatitis B or C virus liver diseases|periodical = [[Cochrane Library|Cochrane Database of Systematic Reviews]]|volume = 2007|issue=4|at=[http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD003620/frame.html CD003620]&nbsp;(2nd&nbsp;rev.)|doi=10.1002/14651858.CD003620.pub2|pmid=17943794|pmc = 8724782}}</ref>

==Prognosis==
[[Image:Hepatitis C world map - DALY - WHO2004.svg|thumb|[[Disability-adjusted life year]] for hepatitis C in 2004 per 100,000&nbsp;inhabitants
{{Col-begin}}
{{Col-break}}
{{legend|#b3b3b3|no data}}
{{legend|#ffff65|<10}}
{{legend|#fff200|10&ndash;15}}
{{legend|#ffdc00|15&ndash;20}}
{{legend|#ffc600|20&ndash;25}}
{{legend|#ffb000|25&ndash;30}}
{{legend|#ff9a00|30&ndash;35}}
{{Col-break}}
{{legend|#ff8400|35&ndash;40}}
{{legend|#ff6e00|40&ndash;45}}
{{legend|#ff5800|45&ndash;50}}
{{legend|#ff4200|50&ndash;75}}
{{legend|#ff2c00|75&ndash;100}}
{{legend|#cb0000|>100}}
{{col-end}}]]
The responses to treatment is measured by [[sustained viral response]] and vary by [[Epidemiology of Hepatitis C virus|HCV C genotype]]. A sustained response occurs in about 40-50% in people with HCV genotype 1 given 48 weeks of treatment.<ref name=NEJM2011/> A sustained response is seen in 70-80% of people with HCV genotypes 2 and 3 with 24 weeks of treatment.<ref name=NEJM2011/> A sustained response occurs about 65% in those with genotype 4 after 48 weeks of treatment. The evidence for treatment in genotype 6 disease is sparse and what evidence there is supports 48 weeks of treatment at the same doses used for genotype 1 disease.<ref>{{cite journal |author=Fung J |title=Chronic hepatitis C virus genotype 6 infection: response to pegylated interferon and ribavirin |journal=The Journal of Infectious Diseases |volume=198 |issue=6|pages=808&ndash;12 |year=2008 |date=September 2008 |pmid=18657036 |doi=10.1086/591252 |author-separator=, |author2=Lai CL |author3=Hung I |display-authors=3 |last4=Young |first4=John |last5=Cheng |first5=Charles |last6=Wong |first6=Danny |last7=Yuen |first7=Man&ndash;Fung |s2cid=22715733 | url = http://jid.oxfordjournals.org/content/198/6/808.full}}</ref> Successful treatment decreases the future risk of hepatocellular carcinoma by 75%.<ref>{{cite journal |author=Morgan RL, Baack B, Smith BD, Yartel A, Pitasi M, Falck-Ytter Y |title=Eradication of Hepatitis C Virus Infection and the Development of Hepatocellular Carcinoma: A Meta-analysis of Observational Studies |journal=Annals of Internal Medicine |volume=158 |issue=5 Pt 1 |pages=329&ndash;37 |year=2013 |date=March 2013 |pmid=23460056 |doi=10.7326/0003-4819-158-5-201303050-00005 |s2cid=15553488 |url=}}</ref>

==Epidemiology==
[[Image:HCV prevalence 1999.png|thumb|left|Prevalence of hepatitis C worldwide in 1999]]
{{main|Epidemiology of Hepatitis C virus}}
It is estimated that 150&ndash;200&nbsp;million people, or ~3% of the world's population, are living with chronic {{nowrap|hepatitis C}}.<ref name=Gravitz2011/><ref name=WHO2011/><ref name=Mohd2013/> About 3&ndash;4&nbsp;million people are infected per year, and more than 350,000 people die yearly from hepatitis C-related diseases.<ref name=WHO2011/> During 2010 it is estimated that 16,000 people died from acute infections while 196,000 deaths occurred from liver cancer secondary to the infection.<ref name=Loz2012>{{cite journal|last1=Lozano|first1=R|title=Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010|journal=Lancet|date=2012 Dec 15|volume=380|issue=9859|pages=2095&ndash;128|pmid=23245604|doi=10.1016/S0140-6736(12)61728-0|first2=Mohsen|first3=Kyle|first4=Stephen|first5=Kenji|first6=Victor|first7=Jerry|first8=Timothy|first9=Rakesh|first10=Stephanie Y|first11=Mohammad A|first12=Miriam|first13=H Ross|first14=Laurie M|first15=Kathryn G|first16=Charles|first17=Larry M|first18=Suzanne|first19=David H|first20=Michelle L|first21=Emelia J|first22=Derrick|first23=Kavi|first24=Boris|first25=Aref Bin|first26=Gretchen|first27=Fiona|first28=Ian|first29=Soufiane|first30=Chiara|hdl=10292/13775|s2cid=1541253|url=http://www.cobiss.si/scripts/cobiss?command=DISPLAY&base=cobib&rid=1537267652&fmt=11}}</ref> Rates have increased substantially in the 20th century due to a combination of intravenous drug abuse and reused but poorly sterilized medical equipment.<ref name="World2007"/>

Rates are high (>3.5% population infected) in Central and East Asia, North Africa and the Middle East, they are intermediate (1.5%-3.5%) in South and Southeast Asia, sub-Saharan Africa, Andean, Central and Southern Latin America, Caribbean, Oceania, Australasia and Central, Eastern and Western Europe; and they are low (<1.5%) in Asia Pacific, Tropical Latin America and North America.<ref name=Mohd2013>{{cite journal|title=Global epidemiology of hepatitis C virus infection: new estimates of age-specific antibody to HCV seroprevalence|journal=Hepatology (Baltimore, Md.)|date=2013 Apr|volume=57|issue=4|pages=1333&ndash;42|pmid=23172780|doi=10.1002/hep.26141|s2cid=16265266|last1=Mohd Hanafiah|first1=Khayriyyah|last2=Groeger|first2=Justina|last3=Flaxman|first3=Abraham D.|last4=Wiersma|first4=Steven T.}}</ref>

Among those chronically infected, the risk of [[cirrhosis]] after 20 years varies between studies but has been estimated at ~10%-15% for men and ~1-5% for women. The reason for this difference is not known. Once cirrhosis is established, the rate of developing [[hepatocellular carcinoma]] is ~1%-4% per year.<ref name=Yu2009>{{cite journal | title = Treatment of chronic hepatitis C in Asia: when East meets West | journal = J. Gastroenterol. Hepatol. | volume = 24 | issue = 3 | pages = 336&ndash;45 | year = 2009 | date = March 2009 | pmid = 19335784 | doi = 10.1111/j.1440-1746.2009.05789.x | s2cid = 27333980 | url = http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1746.2009.05789.x/pdf | last1 = Yu | first1 = Ming-Lung | last2 = Chuang | first2 = Wan-Long }}</ref> Rates of new infections have decreased in the Western world since the 1990s due to improved screening of blood before transfusion.<ref name=Tah2009/>

In the United States, about 2% of people have {{nowrap|hepatitis C}},<ref name=AFP2010/> with the number of new cases per year stabilized at 17,000 since 2007.<ref>{{cite web|last=Published data for 1982-2010|title=Viral Hepatitis Statistics & Surveillance|url=http://www.cdc.gov/hepatitis/Statistics/index.htm|work=Viral Hepatitis on the CDC web site|publisher=Centers for Disease Control and Prevention, Atlanta, GA|accessdate=28 July 2013}}</ref> The number of deaths from hepatitis C has increased to 15,800 in 2008<ref>{{cite web|last=Table 4.5|title=Number and rate of deaths with hepatitis C listed as a cause of death, by demographic characteristic and year &ndash; United States, 2004-2008|url=http://www.cdc.gov/hepatitis/Statistics/2010Surveillance/Table4.5.htm|work=Viral Hepatitis on the CDC web site|publisher=Centers for Disease Control and Prevention, Atlanta, GA|accessdate=28 July 2013}}</ref> and by 2007 had overtaken HIV/AIDS as a cause of death in the USA.<ref>{{cite news|title=Hepatitis Death Rate Creeps past AIDS|url=http://www.nytimes.com/2012/02/28/health/research/hepatitis-c-deaths-creep-past-aids-study-finds.html?_r=0|accessdate=28 July 2013|newspaper=New York Times|date=27 February 2012}}</ref> This mortality rate is expected to increase, as those infected by transfusion before HCV testing become apparent.<ref name=Cola2004>{{cite book |editor1-last=Colacino |editor1-first=J. M. |editor2-last=Heinz |editor2-first=B. A. |last1=Blatt |first1=L. M. |last2=Tong |first2=M. |title=Hepatitis prevention and treatment |year=2004 |publisher=BirkhÃ¤user |location=Basel |isbn=9783764359560 |page=32 |url=https://books.google.com/books?id=KwSWN_QtVLUC&pg=PA32}}</ref> In Europe the percentage of people with chronic infections has been estimated to be between 0.13 and 3.26%.<ref>{{cite journal |author=Blachier M, Leleu H, Peck-Radosavljevic M, Valla DC, Roudot-Thoraval F |title=The burden of liver disease in Europe: a review of available epidemiological data |journal=J. Hepatol. |volume=58 |issue=3 |pages=593&ndash;608 |year=2013 |date=March 2013 |pmid=23419824 |doi=10.1016/j.jhep.2012.12.005 |url=}}</ref>

The total number of people with this infection is higher in some countries in [[Africa]] and [[Asia]].<ref>{{cite book|first=Scott |last=Holmberg |editor1-first=Gary W. |editor1-last=Brunette |editor2-first=Phyllis E. |editor2-last=Kozarsky |editor3-first=Alan J. |editor3-last=Magill |editor4-first=David R. |editor4-last=Shlim |editor5-first=Amanda D. |editor5-last=Whatley |title=CDC Health Information for International Travel 2012 |date=12 May 2011 |publisher=Oxford University Press |location=New York|isbn=9780199769018|page=231|url=http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/hepatitis-c.htm }}</ref> Countries with particularly high rates of infection include Egypt (22%), Pakistan (4.8%) and China (3.2%).<ref name=WHO2011>{{cite web | title=Hepatitis C |publisher=World Health Organization (WHO) |url=http://www.who.int/mediacentre/factsheets/fs164/en/index.html | year=2011 | date = June 2011 |accessdate=2011-07-13}}</ref> It is believed that the high prevalence in Egypt is linked to a now-discontinued mass-treatment campaign for [[schistosomiasis]], using improperly sterilized glass syringes.<ref name=World2007/>

==History==
In the mid-1970s, [[Harvey J. Alter]], Chief of the Infectious Disease Section in the Department of Transfusion Medicine at the [[National Institutes of Health]], and his research team demonstrated how most post-[[blood transfusion|transfusion]] hepatitis cases were not due to [[hepatitis A]] or [[Hepatitis B|B]] viruses. Despite this discovery, international research efforts to identify the virus, initially called ''non-A, non-B hepatitis'' (NANBH), failed for the next decade. In 1987, Michael Houghton, Qui-Lim Choo, and George Kuo at [[Chiron Corporation]], collaborating with Dr. D.W. Bradley at the [[Centers for Disease Control and Prevention]], used a novel [[molecular cloning]] approach to identify the unknown organism and develop a diagnostic test.<ref name = Boyer>{{cite book | isbn = 9780792387602 | last = Boyer | first = JL | title = Liver cirrhosis and its development: proceedings of the Falk Symposium 115 | pages = [http://books.google.ca/books?id=n5P696E7T0wC&pg=PA344#v=onepage&q&f=false 344] | publisher = [[Springer Science+Business Media|Springer]] | year = 2001 }}</ref> In 1988, the virus was confirmed by Alter by verifying its presence in a panel of NANBH specimens. In April 1989, the discovery of HCV was published in two articles in the journal ''Science''.<ref name="choo">{{cite journal |author=Choo QL, Kuo G, Weiner AJ, Overby LR, Bradley DW, Houghton M |title=Isolation of a cDNA clone derived from a blood-borne non-A, non-B viral hepatitis genome |journal=Science |volume=244 |issue=4902 |pages=359&ndash;62 |year=1989 |date=April 1989 |pmid=2523562 |doi=10.1126/science.2523562}}</ref><ref name="kuo">{{cite journal |author=Kuo G |title=An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis |journal=Science |volume=244 |issue=4902 |pages=362&ndash;4 |year=1989 |date=April 1989 |pmid=2496467 |doi=10.1126/science.2496467 |author-separator=, |author2=Choo QL |author3=Alter HJ |display-authors=3 |last4=Gitnick |first4=G. |last5=Redeker |first5=A. |last6=Purcell |first6=R. |last7=Miyamura |first7=T |last8=Dienstag |first8=J. |last9=Alter |first9=M. |first10=C. |first11=al.}}</ref> The discovery led to significant improvements in diagnosis and improved antiviral treatment.<ref name = Boyer/> In 2000, Drs. Alter and Houghton were honored with the [[Lasker Award|Lasker Award for Clinical Medical Research]] for "pioneering work leading to the discovery of the virus that causes hepatitis C and the development of screening methods that reduced the risk of blood transfusion-associated hepatitis in the U.S. from 30% in 1970 to virtually zero in 2000."<ref>[http://web.archive.org/web/20080225184627/http://www.laskerfoundation.org/awards/library/2000clinical.shtml2000 Winners Albert Lasker Award for Clinical Medical Research], The Lasker Foundation. Retrieved 20 February 2008.</ref>

Chiron filed for several patents on the virus and its diagnosis.<ref name="houghton">{{cite patent | country = EP | number = 0318216 | status = patent | title = NANBV diagnostics | gdate = 1989-05-31 | invent1 = Houghton, M | invent2 = Choo, Q-L | invent3 = Kuo, G | assign1 = Chiron }}</ref> A competing patent application by the CDC was dropped in 1990 after Chiron paid $1.9&nbsp;million to the CDC and $337,500 to Bradley. In 1994, Bradley sued Chiron, seeking to invalidate the patent, have himself included as a coinventor, and receive damages and royalty income. He dropped the suit in 1998 after losing before an appeals court.<ref>{{cite web|last=Wilken|first=Judge|title=United States Court of Appeals for the Federal Circuit|url=http://www.ll.georgetown.edu/federal/judicial/fed/opinions/96opinions/96-1536.html|publisher=United States Court of Appeals for the Federal Circuit|accessdate=11 January 2012}}</ref>

==Society and culture==
{{see also|List of people with hepatitis C}}
[[World Hepatitis Day]], held on July 28, is coordinated by the World Hepatitis Alliance.<ref>{{cite journal|last=Eurosurveillance editorial|first=team|title=World Hepatitis Day 2011|journal=[[Eurosurveillance]]|date=2011-07-28|volume=16|issue=30|pmid=21813077 | url = http://www.eurosurveillance.org/images/dynamic/EE/V16N30/art19926.pdf }}</ref> The economic costs of hepatitis C are significant both to the individual and to society. In the United States the average lifetime cost of the disease was estimated at 33,407&nbsp;USD in 2003<ref name=Cost2006>{{cite journal|last=Wong|first=JB|title=Hepatitis C: cost of illness and considerations for the economic evaluation of antiviral therapies |journal=PharmacoEconomics |year=2006 |volume=24 |issue=7 |pages=661&ndash;72 |pmid=16802842|doi=10.2165/00019053-200624070-00005|s2cid=6713508}}</ref> with the cost of a liver transplant {{as of|2011|lc=y}} costing approximately 200,000&nbsp;USD.<ref name=Cost2011/> In Canada the cost of a course of antiviral treatment is as high as 30,000&nbsp;CAD in 2003,<ref>{{cite web|title=Hepatitis C Prevention, Support and Research ProgramHealth Canada|url=http://www.phac-aspc.gc.ca/hepc/pubs/psrpmideval-ppsrevalinter/i_problem-eng.php|publisher=Public Health Agency of Canada|accessdate=10 January 2012|date=Nov 2003|year=2003}}</ref> while the United States costs are between 9,200 and 17,600 in 1998 USD.<ref name=Cost2006/> In many areas of the world, people are unable to afford treatment with antivirals as they either lack insurance coverage or the insurance they have will not pay for antivirals.<ref>{{cite book|last=Zuckerman|first=edited by Howard Thomas, Stanley Lemon, Arie|title=Viral Hepatitis |year=2008|publisher=John Wiley & Sons|location=Oxford|isbn=9781405143882|pages=532|url=https://books.google.com/books?id=nT2dauLXoYAC&pg=PA532|edition=3rd}}</ref>

==Research==
{{As of|2011}}, there are about one hundred medications in development for hepatitis C.<ref name=Cost2011>{{cite journal|last1 = El Khoury | first1 = AC | last2 = Klimack | first2 = WK | last3 = Wallace | first3 = C | last4 = Razavi | first4 = H |title=Economic burden of hepatitis C-associated diseases in the United States|journal=Journal of Viral Hepatitis|date=1 December 2011|doi=10.1111/j.1365-2893.2011.01563.x|volume=19|issue=3|pages=153&ndash;60|pmid=22329369| s2cid = 27409621 }}</ref> These include vaccines to treat hepatitis, [[immunomodulators]], and [[cyclophilin]] inhibitors, among others.<ref>{{cite journal|title=Hepatitis C therapy: other players in the game|journal=Clinics in Liver Disease|year=2011 |date = August 2011|volume=15|issue=3|pages=641&ndash;56|pmid=21867942|doi=10.1016/j.cld.2011.05.008|last1=Ahn|first1=Joseph|last2=Flamm|first2=Steven L.}}</ref> These potential new treatments have come about due to a better understanding of the hepatitis C virus.<ref>{{cite journal|title=New HCV therapies on the horizon|journal=Clinical Microbiology and Infection : The Official Publication of the European Society of Clinical Microbiology and Infectious Diseases|year=2011 |date = February 2011|volume=17|issue=2|pages=122&ndash;34|pmid=21087349|doi=10.1111/j.1469-0691.2010.03430.x | url = http://onlinelibrary.wiley.com/doi/10.1111/j.1469-0691.2010.03430.x/pdf |last1=Vermehren|first1=J.|last2=Sarrazin|first2=C.|s2cid=32983889}}</ref>

==Special populations==
===Children and pregnancy===
{{Main|HCV in children and pregnancy}}
Compared with adults, infection in children is much less well understood. Worldwide the prevalence of hepatitis C virus infection in pregnant women and children has been estimated to 1-8% and 0.05-5% respectively.<ref name=Arshad2011>{{cite journal|author=Arshad M, El-Kamary SS, Jhaveri R |year=2011 |title=Hepatitis C virus infection during pregnancy and the newborn period--are they opportunities for treatment? |journal=J Viral Hepat |volume=18|issue=4|pages=229&ndash;236 |doi=10.1111/j.1365-2893.2010.01413.x|pmid=21392169 |s2cid=35515919 }}</ref> The vertical transmission rate has been estimated to be 3-5% and there is a high rate of spontaneous clearance (25-50%) in the children. Higher rates have been reported for both vertical transmission (18%, 6-36% and 41%).<ref name=Hunt1997>{{cite journal|author=Hunt CM, Carson KL, Sharara AI |year=1997|title=Hepatitis C in pregnancy |journal=Obstet Gynecol |volume=89 |issue=5 Pt 2 |pages=883&ndash;890|doi=10.1016/S0029-7844(97)81434-2|pmid=9166361 |s2cid=23182340}}</ref><ref name=Thomas1998>{{cite journal |author=Thomas SL, Newell ML, Peckham CS, Ades AE, Hall AJ |year=1998 |title=A review of hepatitis C virus (HCV) vertical transmission: risks of transmission to infants born to mothers with and without HCV viraemia or human immunodeficiency virus infection |journal=Int J Epidemiol |volume=27 |issue=1 |pages=108&ndash;117 |doi=10.1093/ije/27.1.108 |pmid=9563703 }}</ref> and prevalence in children (15%).<ref name=Fischler2007>{{cite journal |author=Fischler B |year=2007 |title=Hepatitis C virus infection |journal=Semin Fetal Neonatal Med |volume=12 |issue=3 |pages=168&ndash;173 |doi=10.1016/j.siny.2007.01.008 |pmid=17320495 }}</ref>

In developed countries transmission around the time of birth is now the leading cause of HCV infection. In the absence of virus in the mother's blood transmission seems to be rare.<ref name="Thomas1998" /> Factors associated with an increased rate of infection include membrane rupture of longer than 6 hours before delivery and procedures exposing the infant to maternal blood.<ref name=Indolfi2009>{{cite journal |author=Indolfi G, Resti M |year=2009 |title=Perinatal transmission of hepatitis C virus infection |journal=J Med Virol |volume=81 |issue=5 |pages=836&ndash;843 |doi=10.1002/jmv.21437 |pmid=19319981|s2cid=21207996 }}</ref> Cesarean sections are not recommended. Breast feeding is considered safe if the nipples are not damaged. Infection around the time of birth in one child does not increase the risk in a subsequent pregnancy. All genotypes appear to have the same risk of transmission.

HCV infection is frequently found in children who have previously been presumed to have non-A, non-B hepatitis and cryptogenic liver disease.<ref name=GonzÃ¡lez-Peralta1997>{{cite journal |author=GonzÃ¡lez-Peralta RP  |year=1997 |title=Hepatitis C virus infection in pediatric patients |journal=Clin Liver Dis  |volume=1 |issue=3 |pages=691&ndash;705 |doi=10.1016/S1089-3261(05)70329-9 |pmid=15560066 }}</ref> The presentation in childhood may be asymptomatic or with elevated liver function tests.<ref name=Suskind2004>{{cite journal |author=Suskind DL, Rosenthal P  |title=Chronic viral hepatitis |journal=Adolesc Med Clin  |volume=15 |issue=1|pages=145&ndash;58, x&ndash;xi |doi=10.1016/j.admecli.2003.11.001 |year=2004 |pmid=15272262 }}</ref> While infection is commonly asymptomatic both cirrhosis with liver failure and hepatocellular carcinoma may occur in childhood.

===Immunosuppressed===
The prevalence of hepatitis C in immunosuppressed hosts is higher than the normal population particularly in those with  [[human immunodeficiency virus]] infection, recipients of [[organ transplant]]s and those with [[hypogammaglobulinemia]].<ref name=Einav2002>{{cite journal |author=Einav S, Koziel MJ  |year=2002 |title=Immunopathogenesis of hepatitis C virus in the immunosuppressed host |journal=Transpl Infect Dis |volume=4 |issue=2 |pages=85&ndash;92 |doi=10.1034/j.1399-3062.2002.t01-2-02001.x |pmid=12220245 |s2cid=27843061 }}</ref> Infection in these hosts is associated with an unusually rapid progression to cirrhosis.

==References==
{{Reflist|colwidth=30em}}

==External links==

{{Viral diseases}}
{{gastroenterology}}
{{Good article}}

[[:Category:Hepatitis C|C]]
[[:Category:Healthcare-associated infections]]