Dr Alan Gilman, a GP in Stockport, shares his experience of identifying hepatitis C, sometimes dubbed the ‘silent disease’
Hepatitis C (HCV) is largely asymptomatic and can remain so for years or even decades. As a result the likelihood of an infected patient coming to me with symptoms that might indicate the need for testing is rare. It is estimated that 200,000 people have chronic HCV in England, with approximately half of these being undiagnosed. As GPs we see patients for a number of reasons and are therefore ideally placed to determine if they are at risk from HCV and offer testing.
In most HCV cases the likely transmission route is sharing injecting drug paraphernalia. This could be from regular use, or from sharing needles only once or twice many years ago, with the patient experiencing no symptoms since. In my practice in Stockport, we realised early on that intravenous drug use was a major problem and we routinely test for blood-borne viruses.
In 1997, I carried out research in my area into HCV prevalence in drug users. Out of 400 individuals with a history of drug use, 70% had HCV antibodies present in their system.
Identifying a patient who has a history of drug abuse can prove difficult. I often ask my patients where relevant if they have ever used drugs alongside routine screening questions on smoking and alcohol. Patients often feel more comfortable sharing this kind of information with a GP that they have a relationship with, rather than other healthcare professionals that they might be in contact with for a shorter time.
We will offer an HCV test to anyone who:
• has unexplained abnormal liver function tests (e.g. elevated ALT), or unexplained jaundice
• has ever injected drugs in the past (including anabolic steroids) using shared equipment, however long ago, even if this was only once or twice
• has had a blood transfusion in the UK before September 1991 or received any blood products before 1986
• has received medical or dental treatment abroad (including blood transfusions), in countries where hepatitis C is common and where infection control may be poor
• is the child of a mother with HCV
• is a regular sexual partner of someone with HCV
• has been accidentally exposed to blood where there is a risk of transmission of HCV
• has had tattoos, piercings, acupuncture or electrolysis where infection control procedures are poor
• has shared razors or toothbrushes of someone with HCV.
After offering patients an HCV test, I prepare them for it to be positive (as here it often is) and discuss their options with treatment and recovery rates. About 25% of those who acquire HCV infection will clear it naturally, but for those that develop chronic infection I will recommend that they are referred to a specialist for assessment and treatment.
Success is not 100% guaranteed – on average treatment with pegylated interferon alpha and ribavirin is successful in treating up to 55% of patients with moderate to severe chronic hepatitis C. Success rates vary depending on the genotype, being up to about 45% in those infected with genotype 1, but rising to about 80% in those infected with genotypes 2 and 3.
With effective treatment now available, it is all the more important to be on the look out for patients who may have been at risk of hepatitis C so that they can be diagnosed and treated as early as possible.
Dr Alan Gilman is a GP in Stockport and sits on the GP representative board of the Stockport Alcohol & Drugs Directorate.
For further information, please go to www.nhs.uk/hepc/hcp .
Dr Alan Gilman Download a Hepatitis C diagnosis flowchart
To download a copy of ‘Hepatitis C: Quick reference guide for primary care’ please click here.