Report all suspect or confirmed cases of hepatitis C infection for Toronto residents to Toronto Public Health’s Surveillance Unit at 416-392-7411 during work hours (Monday to Friday, 8:30 a.m. to 4:30 p.m.) or 311 after hours or on statutory holidays.
Hepatitis C (HCV) is a bloodborne liver infection caused by the hepatitis C virus. Infections with hepatitis C that become chronic can lead to liver damage and liver cancer in the long-term. However, hepatitis C is curable. Treatment can prevent transmission and liver damage, making proactive screening, early detection, and early treatment critical. Many people with hepatitis C are not aware of their infections until the disease has progressed.
Although prevalence of hepatitis C in Canada is less than one per cent, some communities are disproportionately impacted, like people who come from countries where it is more prevalent, people who use drugs, and Indigenous people. People with hepatitis C are eligible for free hepatitis A and B vaccinations.
Report suspected or confirmed cases of Hepatitis C to Toronto Public Health using the Reportable Disease Notification Form and Surveillance Form.
Testing
HCV Antibodies: Anti-HCV (also identified as HCV Ab). Check Hepatitis C on the Public Health Ontario Laboratory (PHOL) General Test Requisition.
- Anti-HCV Negative: No HCV infection, request HCV RNA in immunocompromised patients and patients who may still be in the acute phase of infection (within 12 weeks of exposure or symptom onset).
- Anti-HCV Positive: If no results for reflex RNA testing, order HCV RNA and genotype through the PHOL HCV RNA Requisition.
- HCV RNA: Check viral load and genotyping on the PHOL HCV RNA Requisition
- If HCV RNA positive (detected): Acute or chronic HCV infection; ensure linkage to care and treatment referral to a health care provider with expertise in HCV care is recommended (e.g. a hepatologist, gastroenterologist, infectious disease specialist, or family physician with experience in HCV management).
- Learn more about HCV treatment: Providers can complete asynchronous, on-demand, CME accredited training to provide HCV treatment.
- If HCV RNA negative (not detected): Previously infected and cleared; consider testing between 4-6 months to confirm negative status if recent exposure. Retest if new HCV exposure risk or elevated ALT – patients can be re-infected.
New Case Follow-Up
- Report to TPH: Report suspected or confirmed cases of Hepatitis C to Toronto Public Health using the Reportable Disease Notification Form and Surveillance Form or call TPH Surveillance Line 416-392-7411.
- Prevent progression of Fibrosis: Avoid alcohol, assess hepatoxic medications, smoking cessation, and weight management. Additional Fibrosis risk factors include: Older age at infection, Male, HBV & HIV Co-Infection, longer duration of infection, central obesity
- Basic labs: CBC, ALT, AST, bilirubin, INR, albumin, creatinine, work-up by calculating the AST to Platelet Ratio Index (APRI) or Fibrosis-4
- Rule out co-infections: Hepatitis B (HBsAg, anti-HBs(HBsAb), anti-HBc (HBcAb)), HIV (HIV serology), Hepatitis A (IgG, IgM).
- Tests of HCV Replication: HCV RNA viral load, HCV genotype.
- Screening: Abdominal ultrasound and then every 6-12 months if evidence of cirrhosis, alcohol intake, and/or drug use.
Counselling for Prevention of Transmission
- Do not donate blood, tissue, semen, or breast milk.
- Do not share personal hygiene items
- Do not share drug paraphernalia, consider needle exchange.
- Sexual transmission: is rare, higher risk in HIV+ MSM, counsel on safer sex practices.
- Vertical transmission: is rare, higher with HIV co-infection – test infants 18 months; recommend breastfeeding unless nipples are cracked, damaged or bleeding.
- Vaccination: offer publicly funded hepatitis A and B vaccine if non-immune and pneumococcal vaccine (order online).
- Progression to liver fibrosis/ hepatocellular carcinoma (HCC) can occur with normal ALT levels
- Do cover open wounds, don’t share personal hygiene items.
- Do share virus status with all health care providers and partners
Ongoing Care
There is no ‘inactive’ HCV infection and no spontaneous clearance of chronic HCV infection. Progression to liver fibrosis/hepatocellular carcinoma (HCC) can occur with normal ALT levels.
Risk factors for fibrosis progression include:
- Older age at infection
- Alcohol intake
- Male
- Coinfection with HBV or HIV
- Longer duration of infection
- Central obesity
- Smoking increases HCC risk
Screen for HCC
- With ultrasound every 6 to 12 months only if evidence of cirrhosis (low platelets, splenomegaly, portal hypertension, imaging results)
Treatment & Referral
Assess if treatment is appropriate. If appropriate:
- Prescribe treatment or
- Refer all HCV RNA positive patients to a health care provider with expertise in HCV care.
- Learn more about HCV treatment: Providers can complete asynchronous, on-demand, CME accredited training to provide HCV treatment.
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- Treatment with oral medications for 8-12 weeks with few or no side effects and can cure HCV infection in >95 per cent of cases. All people who are HCV RNA positive should be offered treatment.
- Any child with a positive HCV RNA should be referred to a pediatric infectious disease specialist or gastroenterologist with expertise in HCV management.
- Efficacy of treatment depends on HCV genotype, but newer treatment regimens are highly effective for nearly all genotypes and those who have failed previous treatment attempts.
- After successful treatment, people will remain anti-HCV positive lifelong. Antibodies do not protect against reinfection – if ongoing risk exposures, serial screening with HCV RNA is required.
- If cured before cirrhosis and no ongoing risk exposures, no specific follow-up is required. If cirrhosis is present prior to cure, ongoing ultrasound surveillance for liver cancer every 6-12 months is required.
Resources
For Patients, Caregivers and the General Public
More Information
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