Hepatitis C Questions and Answers for Health Professionals

Index of Questions

Overview and Statistics

What are the case definitions for reportable hepatitis C virus (HCV) infections?

  • The specific viral cause of illness cannot be determined based solely on signs, symptoms, history, or current risk factors, but must be verified by specific serologic testing. Case definitions have been developed by CDC, in collaboration with the Council of State and Territorial Epidemiologists, to provide uniform clinical and laboratory-testing criteria for the identification and reporting of nationally notifiable infectious diseases. The case definitions for acute and chronic hepatitis C are available at the following links:

    Additional guidance on viral hepatitis surveillance and case management is available.

How many new HCV infections occur annually in the United States?

In 2017, a total of 3,216 cases of acute hepatitis C were reported to CDC.  After adjusting for under-ascertainment and under-reporting, an estimated 44,700 acute hepatitis C cases occurred in 2017. More information on hepatitis C surveillance is available:  Surveillance for Viral Hepatitis—United States, 2017.

What is the prevalence of chronic HCV infection in the United States?

An estimated 2.4 million people in the United States are living with hepatitis C  virus infection (1).

Who is at risk for HCV infection?

The following people are at increased risk for HCV infection:

  • Current or former injection drug users, including those who injected only once many years ago
  • Recipients of clotting factor concentrates made before 1987, when less advanced methods for manufacturing those products were used
  • Recipients of blood transfusions or solid organ transplants prior to July 1992, before better testing of blood donors became available
  • Chronic hemodialysis patients
  • People with known exposures to HCV, such as
    • health care workers after needle sticks involving HCV-positive blood
    • recipients of blood or organs from a donor who tested HCV-positive
  • People with HIV infection
  • Children born to HCV-positive mothers

Is it possible for someone to become infected with HCV and then spontaneously clear the infection?

Yes. Approximately 15%–25% of people clear the virus from their bodies without treatment and do not develop chronic infection; the reasons for this are not well known. Predictors of spontaneous clearance include jaundice, elevated ALT level, hepatitis B virus surface antigen (HBsAg) positivity, female sex, younger age, HCV genotype 1, and host genetic polymorphisms, most notably those near the IL28B gene (2, 3).

How likely is HCV infection to become chronic?

HCV infection becomes chronic in approximately 75%–85% of cases (2, 3).

Why do most persons remain chronically infected with HCV?

A person infected with HCV mounts an immune response to the virus, but replication of the virus during infection can result in changes that evade the immune response. This may explain how the virus establishes and maintains chronic infection (3).

What are the chances of someone developing chronic HCV infection, cirrhosis, or liver cancer or dying because of hepatitis C?

Of every 100 people infected with HCV, approximately:

  • 75-85 will go on to develop chronic infection
  • 10-20 will go on to develop cirrhosis over a period of 20-30 years

Among patients with cirrhosis, there is:

  • 1-5% annual risk of hepatocellular carcinoma
  • 3-6% annual risk of hepatic decompensation, for which the risk of death in the following year is 15-20%

Rates of progression to cirrhosis are increased in the presence of a variety of factors: males > females, age >50 years, alcohol, nonalcoholic fatty liver disease, HBV or HIV coinfection, immunosuppressive therapy (24).

Can people become infected with a different strain of HCV after they have cleared the initial infection?

Yes. Prior infection with HCV does not protect against later infection with the same or different genotypes of the virus. This is because people infected with HCV typically have an ineffective immune response due to changes in the virus during infection. For the same reason, no effective pre- or post-exposure prophylaxis (i.e., immune globulin) is available.

Is hepatitis C a common cause for liver transplantation?

Yes. Chronic HCV infection is a common reason for liver transplants in the United States (5, 6).

How many deaths can be attributed to chronic HCV infection?

In 2017, 17,253 U.S. death certificates had HCV recorded as an underlying or contributing cause of death (7). However, this is a conservative estimate. Evidence derived from a cohort of patients with known HCV infection who received care at four large health care organizations in the United States found that only 19% of decedents had HCV infection listed on their death certificates. More than 70% of these decedents had evidence of moderate to severe underlying liver disease (according to the electronic health record, liver biopsy, or FIB-4 score) and the average age at death was 59 years (8).

Is there a hepatitis C vaccine?

No vaccine for hepatitis C is available. Research into the development of a vaccine is under way.


Transmission and Symptoms

How is HCV transmitted?

HCV is transmitted primarily through parenteral exposures to infectious blood or body fluids that contain blood. Possible exposures include

  • Injection drug use (currently the most common means of HCV transmission in the United States) (7)
  • Receipt of donated blood, blood products, and organs (once a common means of transmission but now rare in the United States since blood screening became available in 1992)
  • Needlestick injuries in health care settings
  • Birth to an HCV-infected mother

Although infrequent, HCV can also be spread through:

  • Sex with an HCV-infected person (an inefficient means of transmission, although HIV-infected men who have sex with men [MSM] have increased risk of sexual transmission)
  • Sharing personal items contaminated with infectious blood, such as razors or toothbrushes (also inefficient vectors of transmission)
  • Other health care procedures that involve invasive procedures, such as injections (usually recognized in the context of outbreaks)
  • Unregulated tattooing

What is the prevalence of HCV infection among injection drug users (IDUs)?

There are no nationwide seroprevalence surveys targeting PWID in the United States; estimates based on smaller surveys in regional and metropolitan areas vary considerably. A multi-state systematic review of global HCV infection prevalence among PWID published in 2017 provided a point estimate of 53.1% in the United States, with a range of 38.1% to 68.0% (9).

Is cocaine use associated with HCV transmission?

There are limited epidemiologic data to suggest an additional risk from non-injection (snorted or smoked) cocaine use, but this risk is difficult to differentiate from associated injection drug use and sex with HCV-infected partners.

What is the risk of acquiring HCV infection from transfused blood or blood products in the United States?

Now that more advanced screening tests for HCV are used in blood banks, the risk is considered to be less than 1 chance per 2 million units transfused. Before 1992, when blood screening for HCV became available, blood transfusion was a leading means of HCV transmission (10, 11)

Can HCV be spread during medical or dental procedures?

As long as Standard Precautions and other infection control practices are used consistently, medical and dental procedures performed in the United States generally do not pose a risk for the spread of HCV. However, HCV is spread in health care settings when injection equipment, such as syringes, is shared between patients or when injectable medications or intravenous solutions are mishandled and become contaminated with blood. Health care personnel should understand and adhere to Standard Precautions, which includes Injection Safety practices aimed at reducing bloodborne pathogen risks for patients and health care personnel. If health care-associated HCV infection is suspected, this should be reported to state and local public health authorities.

Can HCV be spread within a household?

Yes, but this does not occur very often. If HCV is spread within a household, it is most likely a result of direct, –parenteral or percutaneous– exposure to the blood of an infected household member.

What are the signs and symptoms of acute HCV infection?

People with newly acquired HCV infection usually are asymptomatic or have mild symptoms that are unlikely to prompt a visit to a health care professional. When symptoms do occur, they can include:

  • Fever
  • Fatigue
  • Dark urine
  • Clay-colored stool
  • Abdominal pain
  • Loss of appetite
  • Nausea
  • Vomiting
  • Joint pain
  • Jaundice

What percentage of persons infected with HCV develop symptoms of acute illness?

Approximately 20%–30% of those newly infected with HCV experience fatigue, abdominal pain, poor appetite, or jaundice (12).

How soon after exposure to HCV do symptoms appear?

In those people who do develop symptoms, the average period from exposure to symptom onset is 2–12 weeks (range: 2–26 weeks) (13, 14).

What are the signs and symptoms of chronic HCV infection?

Most people with chronic HCV infection are asymptomatic or have non-specific symptoms such as chronic fatigue and depression. Many eventually develop chronic liver disease, which can range from mild to severe, including cirrhosis and liver cancer. Chronic liver disease in HCV-infected people is usually insidious, progressing slowly without any signs or symptoms for several decades. In fact, HCV infection is often not recognized until asymptomatic people are identified as HCV-positive when screened for blood donation or when elevated alanine aminotransferase (ALT, a liver enzyme) levels are detected during routine examinations.


Testing and Diagnosis

Who should be tested for HCV infection?

CDC recommends:

  • Hepatitis C screening at least once in a lifetime for all adults aged 18 years and older, except in settings where the prevalence of HCV infection (HCV RNA‑positivity) is less than 0.1%
  • Hepatitis C screening for all pregnant women during each pregnancy, except in settings where the prevalence of HCV infection (HCV RNA‑positivity) is less than 0.1%
  • One‑time hepatitis C testing regardless of age or setting prevalence among people with recognized conditions or exposures:
    • People with HIV
    • People who ever injected drugs and shared needles, syringes, or other drug preparation equipment, including those who injected once or a few times many years ago
    • people who ever received maintenance hemodialysis
    • people with persistently abnormal ALT levels
    • people who received clotting factor concentrates produced before 1987
    • people who received a transfusion of blood or blood components before July 1992
    • people who received an organ transplant before July 1992
    • people who were notified that they received blood from a donor who later tested positive for HCV infection
    • Healthcare, emergency medical, and public safety personnel after needle sticks, sharps, or mucosal exposures to HCV‑positive blood
    • Children born to mothers with HCV infection
  • Routine periodic testing for people with ongoing risk factors:
    • People who currently inject drugs and share needles, syringes, or other drug preparation equipment
    • People who ever received maintenance hemodialysis
  • Any person who requests hepatitis C testing should receive it

Source: CDC Recommendations for Hepatitis C Screening Among Adults – United States, 2020. MMWR 2020 (RR 69)

What blood tests are used to detect HCV infection?

Several blood tests are performed to test for HCV infection, including:

  • Screening tests for antibody to HCV (anti-HCV)
    • enzyme immunoassay (EIA)
    • enhanced chemiluminescence immunoassay (CIA)
  • Qualitative tests to detect presence or absence of virus (HCV RNA polymerase chain reaction [PCR])
  • Quantitative tests to detect amount (titer) of virus (HCV RNA PCR)

How do I interpret the different tests for HCV infection?

A table on the interpretation of results of tests for hepatitis C virus (HCV) infection and further actions is available at https://www.cdc.gov/hepatitis/HCV/PDFs/hcv_graph.pdf pdf icon[PDF – 1 page].

Is an algorithm for HCV diagnosis available?

A flow chart that outlines the serologic testing process beginning with anti-HCV testing is available at https://www.cdc.gov/hepatitis/HCV/PDFs/hcv_flow.pdf pdf icon[PDF – 541 KB].

How soon after exposure to HCV can anti-HCV be detected?

HCV infection can be detected by anti-HCV screening tests (enzyme immunoassay) 4–10 weeks after infection. Anti-HCV seroconversion occurs, on average, 8-11 weeks after exposure (303112, 1619) although cases of delayed seroconversion have been documented with immunosuppression such as in HIV infection (32, 33).

How soon after exposure to HCV can HCV RNA be detected by PCR?

HCV RNA appears in blood and can be detected as early as 2–3 weeks after infection (12, 1619).

Under what circumstances is a false-positive anti-HCV test result likely?

False-positive anti-HCV tests appear more often when people at low risk for HCV infection (e.g., blood donors) are tested. Therefore, it is important to follow-up all positive anti-HCV tests with an RNA test to establish current infection.

Under what circumstances might a false-negative anti-HCV test result occur?

People with early HCV infection might not yet have developed antibody levels high enough that the test can measure. In addition, some people might lack the (immune) response necessary for the test to work well. In these people, further testing such as PCR for HCV RNA may be considered.

Can a patient have a normal liver enzyme (e.g., ALT) level and still have chronic hepatitis C?

Yes. It is common for patients with chronic hepatitis C to have liver enzyme levels that go up and down, with periodic returns to normal or near normal levels. Liver enzyme levels can remain normal for over a year despite chronic liver disease (17).

Where can I learn more about hepatitis C serology?

CDC offers an online training that covers the serology of acute and chronic hepatitis C and other types of viral hepatitis, available at https://www.cdc.gov/hepatitis/resources/professionals/training/serology/training.htm.


Management and Treatment

What should be done for a patient with confirmed HCV infection?

HCV-positive patients should be evaluated (by referral or consultation, if appropriate) for presence of chronic liver disease, including assessment of liver function tests, evaluation for severity of liver disease and recommended HCV treatment, and determination of the need for hepatitis A and hepatitis B vaccination. More information on recommendations for testing, management, and treating hepatitis C are available at: http://www.hcvguidelines.orgexternal icon.

When might a specialist be consulted in the management of HCV-infected persons?

Any clinician who manages a person with hepatitis C should be knowledgeable and current on all aspects of the care of a person with hepatitis C; this can include some internal medicine and family practice physicians, nurse practitioners, physician assistants, pharmacists, as well as specialists such as infectious disease physicians, gastroenterologists, or hepatologists.

What is the treatment for acute hepatitis C?

New treatment guidelines recommend no treatment of acute hepatitis C. Patients with acute HCV infection should be followed and only considered for treatment if HCV RNA persists after 6 months. For more information see http://www.hcvguidelines.orgexternal icon.

What is the treatment for chronic hepatitis C?

The treatment for hepatitis C virus (HCV) infection has evolved substantially since the introduction of highly effective HCV protease inhibitor therapies in 2011. Since that time new drugs with different mechanisms of action have become and continue to become available. Currently available therapies can achieve sustained virologic response (SVR) defined as the absence of detectable virus 12 weeks after completion of treatment; an SVR is indicative of a cure of HCV infection. Over 90% of HCV infected persons can be cured of HCV infection regardless of HCV genotype, with 8-12 weeks of oral therapy (20). For a complete list of currently approved FDA therapies to treat hepatitis C, please visit http://www.hepatitisc.uw.edu/page/treatment/drugsexternal icon.

To provide health care professionals with timely guidance as new therapies are available and integrated into HCV regimens, the Infectious Diseases Society of America (IDSA) and American Association for the Study of Liver Diseases (AASLD), in collaboration with the International Antiviral Society–USA (IAS–USA), developed evidence-based, expert-developed recommendations for hepatitis C management: http://www.hcvguidelines.orgexternal icon.

Are patients undergoing treatment for HCV at risk for HBV reactivation?

Because of recent reports of HBV reactivation in HCV co-infected patients receiving direct acting antiviral (DAA) therapy for HCV, all patients initiating HCV DAA therapy should be tested for HBV with HBsAg, anti-HBs, and anti-HBc. Persons testing positive for HBsAg and/or anti-HBc should be monitored while receiving HCV treatment. More information about treating HBV/HCV co-infected patients can be found on these sites: http://hcvguidelines.org/external icon and https://www.aasld.org/publications/practice-guidelines-0external icon. For more information on HBV reactivation please see the American Gastroenterological Association’s Hepatitis B Reactivation During Immunosuppressive Drug Therapyexternal icon. Similar guidance from the European Association for the Study of Liver Disease (EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus infection. Journal of Hepatology 2017; 67:370–398.)

How many different genotypes of HCV exist?

Seven distinct HCV genotypes and more than 67 subtypes have been identified (21). Genotype 1 is the most common HCV genotype in the United States (22, 23).

Is it necessary to do viral genotyping when managing a person with chronic hepatitis C?

Yes. Because there are seven distinct genotypes and more than 67 subtypes of HCV, genotype information is helpful in defining the epidemiology of hepatitis C and in making recommendations regarding appropriate treatment regimen. In the United States, HCV genotype 1 is most common, accounting for approximately 70% of prevalent cases. Once the genotype is identified, it need not be tested again; genotypes do not change during the course of infection (22, 23).

Can superinfection with more than one genotype of HCV occur?

Superinfection is possible if risk behaviors (e.g., injection drug use) for HCV infection continue; however, superinfection does not appear to complicate decisions regarding treatment, and new HCV antivirals with pangenotypic activity are available.

Does chronic hepatitis C affect only the liver?

A small percentage of people with chronic HCV infection develop medical conditions due to hepatitis C that are not limited to the liver. Such conditions can include:

  • Fatigue
  • Diabetes mellitus
  • Glomerulonephritis
  • Essential mixed cryoglobulinemia
  • Porphyria cutanea tarda
  • Non-Hodgkin’s lymphoma


Counseling Patients

What topics should be discussed with patients who have HCV infection?

  • First and foremost, patients should be informed about the effectiveness and benefits of new direct acting antivirals (DAAs) and referred for prompt assessment and treatment, if indicated.
  • Patients should be informed about the low but present risk for transmission with sex partners.
  • Sharing personal items that might have blood on them, such as toothbrushes or razors, can pose a risk to others.
  • Cuts and sores on the skin should be covered to keep from spreading infectious blood or secretions.
  • Donating blood, organs, tissue, or semen can spread HCV to others.
  • HCV is not spread by sneezing, hugging, holding hands, coughing, sharing eating utensils or drinking glasses, or through food or water.

What should HCV-infected persons be advised to do to protect their livers from further harm?

  • Patients should be informed about the effectiveness and benefits of new direct acting antivirals (DAAs) and referred for prompt assessment and treatment, if indicated.
  • HCV-positive patients should be advised to avoid alcohol because it can accelerate cirrhosis and end-stage liver disease.
  • Viral hepatitis patients should also check with a health professional before taking any new prescription pills, over-the counter drugs (such as non-aspirin pain relievers), or supplements, as these can potentially damage the liver.
  • Clinicians may wish to consider vaccinating HCV-positive patients against hepatitis A and hepatitis B even in the absence of liver disease.

Should HCV-infected persons be restricted from working in certain occupations or settings?

CDC’s recommendations for prevention and control of HCV infection specify that people should not be excluded from work, school, play, child care, or other settings on the basis of their HCV infection status. There is no evidence of HCV transmission from food handlers, teachers, or other service providers in the absence of blood-to-blood contact.


Hepatitis C and Health Care Personnel

What is the risk for HCV infection from exposure to HCV-contaminated blood?

After a needlestick or sharps exposure to anti-HCV positive blood, a recent report of data from more than 1,300 potentially exposed HCP estimated the risk of HCV infection as approximately 0.2% for percutaneous injuries and 0% for mucocutaneous exposures [24]. A range of 0-10% has been reported in earlier studies [MMWR 2001]; variability may be in part explained by mechanism of injury and HCV RNA status of anti-HCV positive sources. If the HCP does become infected, follow updated guidelines from the American Association for the Study of Liver Disease (AASLD) and the Infectious Diseases Society of America (IDSA) (www.hcvguidelines.orgexternal icon ) for management and treatment of hepatitis C.

Other than needlesticks, do other exposures, such as splashes to the eye, pose a risk to health care personnel for HCV transmission?

Although a few cases of HCV transmission via blood splash to the eye have been reported, the risk for such transmission is expected to be very low. Avoiding occupational exposure to blood is the primary way to prevent transmission of bloodborne illnesses among health care personnel. All health care personnel should adhere to Standard Precautions. Depending on the medical procedure involved, Standard Precautions may include the appropriate use of personal protective equipment (e.g., gloves, masks, and protective eyewear).

Should HCV-infected health care personnel be restricted in their work?

There are no CDC recommendations to restrict a health care worker who is infected with HCV. The risk of transmission from an infected health care worker to a patient appears to be very low. All health care personnel, including those who are HCV positive, should follow a strict aseptic technique and Standard Precautions, including appropriate hand hygiene, use of protective barriers, and safe injection practices.

What is the recommended management of a health care worker with occupational exposure to HCV?

Postexposure prophylaxis (PEP) for hepatitis C is not recommended, as outlined in the 2001 MMWR on management of health-care personnel (HCP) who have occupational exposure to blood and other body fluids. Test the source for HCV RNA. If the source is HCV RNA positive, or if HCV infection status is unknown, follow this testing algorithm [PDF – 2 pages] (update to 2001 guidance).

After a needlestick or sharps exposure to HCV-positive blood, the risk of HCV infection is 0.1% (24). If the health care worker does become infected, follow AASLD/IDSA guidelines for management and treatment of hepatitis Cexternal icon.


Pregnancy and HCV Infection

Should pregnant women be routinely tested for anti-HCV?

At this time, pregnant women should be tested for anti-HCV if they have or are suspected to have risk factors for HCV infection (20, 25. 26). CDC is in the process of reviewing the evidence to determine if additional HCV screening recommendations, specific to pregnant women, are warranted.

What is the risk that an HCV-infected mother will spread HCV to her infant during birth?

The overall risk of an HCV-infected mother transmitting infection to their infant is approximately 4% to 7% per pregnancy. Transmission occurs at the time of birth, and no prophylaxis is available to prevent it. The risk is significantly higher if the mother has a high viral load or is coinfected with HIV. Most infants infected with HCV at birth have no symptoms and do well during childhood. More research is needed to find out the long-term effects of perinatal HCV infection (27).

Should a woman with HCV infection be advised against breastfeeding?

No. There is no evidence that breastfeeding spreads HCV. While there is currently not enough information on the risks of transmission through breastfeeding by HCV-positive mothers with cracked or bleeding nipples, precautions may be considered (28).

When should children born to HCV-infected mothers be tested to see if they were infected at birth?

Children should be tested for anti-HCV no sooner than age 18 months because anti-HCV from the mother might last until this age. If diagnosis is desired before the child reaches 18 months, testing for HCV RNA can be performed at or after the infant’s first well-child visit at age 1–2 months. HCV RNA testing should then be repeated at a subsequent visit, independent of the initial HCV RNA test result (29).


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