Hepatitis C Virus - HCV

  • Diagnosis
  • Algorithms
  • Screening
  • Monitoring
  • Background
  • Lab Tests
  • References
  • Related Topics
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Indications for Testing

  • New onset of jaundice, anorexia, or dark urine
  • Known exposure to hepatitis
  • Suspicion of chronic hepatitis (elevated liver enzymes)

Laboratory Testing

  • Testing recommendations for chronic hepatitis C (CDC)
  • Initial testing – rule out hepatitis A virus (HAV) or hepatitis B virus (HBV) for acute presentation
    • Perform testing for HAV antibody IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody or for elevated liver enzymes in asymptomatic patient, test for HCV antibody
      • Positive HCV – perform quantitative HCV RNA PCR test
        • Documents baseline level of viremia for acute disease
        • Quantitative PCR test negative – infected but recovered, or false-positive screen
          • Inform patient that s/he does not have active infection 
        • Quantitative PCR test positive – currently infected (acute versus chronic designation depends on initial presentation)
      • Coinfection with HBV – predicts poorer prognosis
  • Consider further testing for positive HCV test
    • HIV testing – coinfection associated with poorer prognosis 
    • HCV genotyping – guides selection of most appropriate antiviral regimen
      • Subtyping for 1a, 1b, and 6 may be useful
        • If genotype 1 cannot be subtyped, it should be treated as genotype 1a
    • Interleukin 28 B (IL28B) gene for patients with HCV genotype 1
      • Predicts response to peginterferon (PEG-IFNα) and ribavirin (RBV) therapy for chronic genotype 1 HCV
    • HCV genotype 1a
      • Q80K polymorphism (NS3) testing
      • Recommendations for testing for NS5A and other mutations are emerging
    • Liver biopsy
      • Patients with HCV genotype 1 – tend to have more advanced disease
        • More advanced disease is associated with lower response to therapy

Prognosis

  • Viral load (as measured by quantitative PCR) predicts likelihood of treatment response
    • Lower viral load at therapy initiation is associated with improved therapeutic response

Differential Diagnosis

  • American Association for the Study of Liver Diseases (AASLD), 2014; CDC, 2012;  Infectious Diseases Society of America (IDSA), 2014;  and U.S. Preventive Services Task Force (USPSTF), 2013 – recommend screening at least once for all individuals born between 1945-1965
    • All others with risk factors for HCV infection (refer to Background section) – one-time testing should be performed
  • WHO, 2014; American Gastroenterological Association, 2013; and European Association for the Study of the Liver (EASL), 2014 – recommend screening for those at high risk (eg, IV drug users, immigrants from endemic areas)
    • Initial screening for HCV antibodies by CIA, EIA, ELISA
    • Follow-up testing required for positive result
  • Pregnant females – routine HCV screening is not recommended
  • Injection drug users and HIV-seropositive men who have unprotected sex with men – annual HCV testing (IDSA, 2014)
  • HCV RNA PCR quantitative test – monitor effectiveness of treatment and perform when treatment is complete
    • Monthly until week 12 of treatment
    • Negative result confirms successful treatment

Hepatitis C is a virally mediated disease of the liver with a propensity to cause chronic infection, leading to cirrhosis and an increased risk of hepatocellular carcinoma.

Epidemiology

  • Prevalence – ~3.8 million of U.S. population is infected  
    • >50% of new cases are caused by IV drug use; previous U.S. cases were attributed to transfusion of blood products
    • ~25,000 laboratory-confirmed cases of chronic hepatitis C (National Notifiable Diseases Surveillance System, 2010)
  • Age – peaks in 30s-40s
  • Sex – M:F, equal

Organism

  • Single-stranded RNA virus; member of Flaviviridae family (genus Hepacivirus)
  • Multiple genotypes with multiple subtypes (1a, 1b, 1c, etc.)
    • Genotype is an important predictor of virological response to HCV treatment
      • Type 1 is predominant genotype in U.S. and more difficult to treat
      • Types 2 and 3 are less aggressive and easier to treat

Genetics

Risk Factors (from IDSA Practice Guidelines, 2014)

  • Risk behaviors
    • Injection drug use (current or ever, including those who injected once)
    • Intranasal illicit drug use
  • Risk exposures
    • Long-term hemodialysis (ever)
    • Unregulated tattoo parlors
    • Healthcare, emergency medical, and public safety workers after needle stick, sharps, or mucosal exposure to HCV-infected blood
    • Babies born to HCV-infected mothers
    • Prior recipients of transfusions or organ transplants, including individuals who
      • Were notified that they received blood from a donor who later tested positive for HCV infection
      • Received a transfusion of blood or blood components, or underwent an organ transplant before July 1992
      • Received clotting factor concentrates produced before 1987
      • Previous incarceration
      • HIV infection
  • Other medical conditions
    • Unexplained chronic liver disease and chronic hepatitis, including elevated alanine aminotransferase levels
      • Recently associated with previous oral prescription narcotic use in young Caucasian individuals

Clinical Presentation

  • HCV is typically asymptomatic as acute infection
    • Infection may be initially identified when patient has positive anti-HCV in a blood donor screen or has high alanine aminotransferase (10-20 times the upper limit of normal) in blood chemistry testing for flu-like symptoms
  • Chronic disease occurs in ~10-20% of patients
    • Cirrhosis (20%) and hepatocellular carcinoma (1-5%)
  • Chronic asymptomatic hepatitis may manifest with other systemic symptoms
    • Mixed cryoglobulinemia – systemic vasculitis involving skin, kidneys, nervous system
    • Sjögren syndrome – anti-SSA and SSB antibodies are usually absent or are present in low levels
    • Lichen planus – violaceous papules on any skin site; oral most common
    • Porphyria cutanea tarda
    • Non-Hodgkin lymphoma – B-cell type most common
  • Pregnant females
    • Not transmitted to infant via breast-feeding 
    • Pregnancy not contraindicated
Tests generally appear in the order most useful for common clinical situations. Click on number for test-specific information in the ARUP Laboratory Test Directory.

Hepatitis Panel, Acute with Reflex to HBsAg Confirmation 0020457
Method: Qualitative Chemiluminescent Immunoassay

Recommended Use 

Order to evaluate viral etiology in patients with acute hepatitis

Not recommended for screening asymptomatic patients

Panel includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody

Reflex pattern – if results for HBsAg are repeatedly reactive with an index value between 1.00 and 50.00, then HBsAg confirmation will be added

Hepatitis B Virus Surface Antigen with Reflex to Confirmation 0020089
Method: Qualitative Chemiluminescent Immunoassay 

Recommended Use 

Initial testing for suspected chronic HBV infection

Can be ordered as part of the acute hepatitis panel which includes HAV IgM, HBV core antibody IgM, HBV surface antigen, and HCV antibody

Reflex pattern – if results for HBsAg screen are repeatedly reactive with an index value between 1.00 and 50.00, then HBsAg confirmation will be added

Hepatitis C Virus Antibody by CIA with Reflex to HCV by Quantitative PCR 2010784
Method: Qualitative Chemiluminescent Immunoassay/Quantitative Polymerase Chain Reaction

Recommended Use 

Preferred reflex test for screening and confirming HCV in at-risk individuals

Reflex pattern – if positive, reflexes to quantitative HCV PCR to confirm HCV infection

Hepatitis C Virus (HCV) by Quantitative PCR with Reflex to HCV Genotype by Sequencing 2002685
Method: Quantitative Polymerase Chain Reaction/Sequencing

Recommended Use 

Preferred reflex test to confirm active HCV infection following positive HCV screen

Reflex to genotype aids in prognosis and treatment selection; order only after positive HCV screen

Reflex pattern – if PCR result is ≥3.6 log IU/mL, then HCV genotype by sequencing will be added

Limitations 

If virus is not detected, result will be reported as <1.2 log IU/mL; if virus is detected but number of copies not accurately quantified, result will be reported as not quantified

Hepatitis C Virus by Quantitative PCR 0098268
Method: Quantitative Polymerase Chain Reaction

Recommended Use 

Preferred single test to confirm HCV infection following positive HCV antibody screen

Order only after positive HCV screen

Monitor therapy

Limitations 

If virus is not detected, result will be reported as <1.2 log IU/mL; if virus is detected but number of copies not accurately quantified, result will be reported as not quantified 

Hepatitis C Virus Genotype by Sequencing 0055593
Method: Polymerase Chain Reaction/Sequencing

Recommended Use 

Preferred genotyping test for prognosis and treatment selection

Do not order prior to molecular confirmation of positive HCV screen

Assay does not differentiate between type 1a and type 1b

Limitations 

Due to high conservation of the 5' un-translated region of the HCV genome, this test has limitations in differentiating subtype 1a from 1b; therefore, these subtypes will be reported as "1a or 1b"

In rare instances, type 6 virus may be misclassified as type 1

Test may be unsuccessful if HCV RNA viral load is <log 3.6 or 4,000 IU/mL

Hepatitis C Virus (HCV) by Quantitative PCR with Reflex to HCV High-Resolution Genotype by Sequencing 2010793
Method: Quantitative Polymerase Chain Reaction/Sequencing

Recommended Use 

Confirm active HCV infection following positive HCV screen when a higher level of subtype resolution is required

Reflex pattern – if PCR is ≥5.0 log IU/mL, then HCV high-resolution genotype by sequencing will be added

Limitations 

If virus is not detected, result will be reported as <1.2 log IU/mL; if virus is detected but number of copies not accurately quantified, result will be reported as not quantified

Hepatitis C Virus (HCV) Genotype with Reflex to HCV High-Resolution Genotype by Sequencing 2009255
Method: Polymerase Chain Reaction/Sequencing

Recommended Use 

Reflex genotyping panel for prognosis and treatment selection when a higher level of subtype resolution is required

Do not order prior to molecular confirmation of positive HCV screen

Differentiate between type 1a and type 1b

Reflex pattern – if initial result is 1a or 1b, a mixed genotype containing Type 1 or Type 6, then genotyping will be added

Limitations 

Test may be unsuccessful if HCV RNA viral load is <log 5.0 or 100,000 IU/mL

Interleukin 28 B (IL28B)-Associated Variants, 2 SNPs 2004680
Method: Polymerase Chain Reaction/Single Nucleotide Extension

Recommended Use 

Predict response to peginterferon (PEG-IFNα)/ribavirin (RBV) therapy for chronic hepatitis C virus genotype 1 (HCV-1) infection

Clinical sensitivity/specificity – unknown

Limitations 

SNPs other than those targeted will not be detected

Usefulness of IL28B-associated SNPs for predicting therapy response for HCV genotypes other than HCV-1 is unknown; lack of favorable genetic factors should not be used to deny therapy

Mutations in genes and nongenetic factors that may affect response to HCV therapy are not detected

Diagnostic errors can occur due to rare sequence variations

Guidelines

European Association for Study of Liver. EASL Clinical Practice Guidelines: management of hepatitis C virus infection. J Hepatol. 2014; 60(2): 392-420. PubMed

Full Report: HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. American Association for the Study of Liver Diseases; Infectious Diseases Society of America. [Revised Oct 2016; Accessed: Dec 2016]

Ghany MG, Nelson DR, Strader DB, Thomas DL, Seeff LB, American Association for Study of Liver Diseases. 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. Hepatology. 2011; 54(4): 1433-44. PubMed

Guidelines for the Screening, Care and Treatment of Persons with Hepatitis C Infection. World Health Organization. Geneva, Switzerland [Accessed: Nov 2015]

HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. AASLD/IDSA HCV Guidance Panel. [Updated/Changes Apr 2017; Accessed: Apr 2017]

Moyer VA, U.S. Preventive Services Task Force. Screening for hepatitis C virus infection in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013; 159(5): 349-57. PubMed

Smith B, Morgan R, Beckett G, et al. Recommendations for the Identification of Chronic Hepatitis C Virus Infection Among Persons Born During 1945–1965. Centers for Disease Control and Prevention. Atlanta, GA [Last updated Aug 2012; Accessed: Jan 2017]

General References

Ahlenstiel G, Booth DR, George J. IL28B in hepatitis C virus infection: translating pharmacogenomics into clinical practice. J Gastroenterol. 2010; 45(9): 903-10. PubMed

Albeldawi M, Ruiz-Rodriguez E, Carey WD. Hepatitis C virus: Prevention, screening, and interpretation of assays. Cleve Clin J Med. 2010; 77(9): 616-26. PubMed

Balagopal A, Thomas DL, Thio CL. IL28B and the control of hepatitis C virus infection. Gastroenterology. 2010; 139(6): 1865-76. PubMed

Chakravarty R. Diagnosis and monitoring of chronic viral hepatitis: serologic and molecular markers. Front Biosci (Schol Ed). 2011; 3: 156-67. PubMed

Chan J. Hepatitis C. Dis Mon. 2014; 60(5): 201-12. PubMed

Chevaliez S, Hézode C. IL28B polymorphisms and chronic hepatitis C. Gastroenterol Clin Biol. 2010; 34(11): 587-9. PubMed

Cobb B, Heilek G, Vilchez RA. Molecular diagnostics in the management of chronic hepatitis C: key considerations in the era of new antiviral therapies. BMC Infect Dis. 2014; 14 Suppl 5: S8. PubMed

Gullett JC, Nolte FS. Quantitative nucleic acid amplification methods for viral infections. Clin Chem. 2015; 61(1): 72-8. PubMed

Maheshwari A, Thuluvath PJ. Management of acute hepatitis C. Clin Liver Dis. 2010; 14(1): 169-76; x. PubMed

Morrison BJ, Labo N, Miley WJ, Whitby D. Serodiagnosis for tumor viruses. Semin Oncol. 2015; 42(2): 191-206. PubMed

Pearlman BL. The IL-28 genotype: how it will affect the care of patients with hepatitis C virus infection. Curr Gastroenterol Rep. 2011; 13(1): 78-86. PubMed

Sagnelli E, Santantonio T, Coppola N, Fasano M, Pisaturo M, Sagnelli C. Acute hepatitis C: clinical and laboratory diagnosis, course of the disease, treatment. Infection. 2014; 42(4): 601-10. PubMed

Viral Hepatitis - Hepatitis C Information - Testing Recommendations. Centers for Disease Control and Prevention. Atlanta, GA [Accessed: Dec 2016]

Webster DP, Klenerman P, Dusheiko GM. Hepatitis C. Lancet. 2015; 385(9973): 1124-35. PubMed

Wilkins T, Malcolm JK, Raina D, Schade RR. Hepatitis C: diagnosis and treatment. Am Fam Physician. 2010; 81(11): 1351-7. PubMed

References from the ARUP Institute for Clinical and Experimental Pathology®

Bossler A, Gunsolly C, Pyne MT, Rendo A, Rachel J, Mills R, Miller M, Sipley J, Hillyard D, Jenkins S, Essmyer C, Young S, Lewinski M, Rennert H. Performance of the COBAS® AmpliPrep/COBAS TaqMan® automated system for hepatitis C virus (HCV) quantification in a multi-center comparison. J Clin Virol. 2011; 50(2): 100-3. PubMed

Konnick EQ, Erali M, Ashwood ER, Hillyard DR. Performance characteristics of the COBAS Amplicor Hepatitis C Virus (HCV) Monitor, Version 2.0, International Unit assay and the National Genetics Institute HCV Superquant assay. J Clin Microbiol. 2002; 40(3): 768-73. PubMed

Konnick EQ, Williams SM, Ashwood ER, Hillyard DR. Evaluation of the COBAS Hepatitis C Virus (HCV) TaqMan analyte-specific reagent assay and comparison to the COBAS Amplicor HCV Monitor V2.0 and Versant HCV bDNA 3.0 assays. J Clin Microbiol. 2005; 43(5): 2133-40. PubMed

Liew M, Erali M, Page S, Hillyard D, Wittwer C. Hepatitis C genotyping by denaturing high-performance liquid chromatography. J Clin Microbiol. 2004; 42(1): 158-63. PubMed

Mallory MA, Lucic DX, Sears MT, Cloherty GA, Hillyard DR. Evaluation of the Abbott realtime HCV genotype II RUO (GT II) assay with reference to 5'UTR, core and NS5B sequencing. J Clin Virol. 2014; 60(1): 22-6. PubMed

Margraf RL, Erali M, Liew M, Wittwer CT. Genotyping hepatitis C virus by heteroduplex mobility analysis using temperature gradient capillary electrophoresis. J Clin Microbiol. 2004; 42(10): 4545-51. PubMed

Margraf RL, Page S, Erali M, Wittwer CT. Single-tube method for nucleic acid extraction, amplification, purification, and sequencing. Clin Chem. 2004; 50(10): 1755-61. PubMed

Melis R, Fauron C, McMillin G, Lyon E, Shirts B, Hubley LM, Slev PR. Simultaneous genotyping of rs12979860 and rs8099917 variants near the IL28B locus associated with HCV clearance and treatment response. J Mol Diagn. 2011; 13(4): 446-51. PubMed

Pyne MT, Hillyard DR. Evaluation of the Roche COBAS AmpliPrep/COBAS TaqMan HCV Test. Diagn Microbiol Infect Dis. 2013; 77(1): 25-30. PubMed

Pyne MT, Konnick EQ, Phansalkar A, Hillyard DR. Evaluation of the Abbott investigational use only RealTime hepatitis C virus (HCV) assay and comparison to the Roche TaqMan HCV analyte-specific reagent assay. J Clin Microbiol. 2009; 47(9): 2872-8. PubMed

Pyne MT, Mallory M, Hillyard DR. HCV RNA measurement in samples with diverse genotypes using versions 1 and 2 of the Roche COBAS® AmpliPrep/COBAS® TaqMan® HCV test J Clin Virol. 2015; 65: 54-7. PubMed

Slev P. Host genomics and HCV personalized medicine. Ann Clin Lab Sci. 2012; 42(4): 363-9. PubMed

Medical Reviewers

Hillyard, David R., MD, Medical Director, Molecular Infectious Diseases at ARUP Laboratories; Professor of Clinical Pathology, Adjunct Professor of Biology, University of Utah

Krautscheid, Patti, MS, LCGC, Genetic Counselor, Molecular Genetics and Special Genetics Laboratories at ARUP Laboratories

Lyon, Elaine, PhD, Medical Director, Genetics, and Co-Medical Director, Pharmacogenomics at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

McMillin, Gwendolyn A., PhD, DABCC (CC, TC), Medical Director of Toxicology and Pharmacogenomics at ARUP Laboratories; Professor of Clinical Pathology, University of Utah

Slev, Patricia R., PhD, Medical Director, Serological Hepatitis/Retrovirus, Immunology Core; Co-Medical Director, Microbial Immunology and Immunogenetics; Chief Medical Director, Immunology Division at ARUP Laboratories; Associate Professor of Clinical Pathology, University of Utah

Last Update: August 2017