Hepatitis C is a liver infection caused by the hepatitis C virus (HCV). Hepatitis C is spread through contact with blood from an infected person. Today, most people become infected with the hepatitis C virus by sharing needles or other equipment used to prepare and inject drugs. For some people, hepatitis C is a short-term illness, but for more than half of people who become infected with the hepatitis C virus, it becomes a long-term, chronic infection. Chronic hepatitis C can result in serious, even life-threatening health problems like cirrhosis and liver cancer. People with chronic hepatitis C can often have no symptoms and don’t feel sick. When symptoms appear, they often are a sign of advanced liver disease. There is no vaccine for hepatitis C. The best way to prevent hepatitis C is by avoiding behaviors that can spread the disease, especially injecting drugs. Getting tested for hepatitis C is important, because treatments can cure most people with hepatitis C in 8 to 12 weeks.
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 mode of HCV transmission in the United States) (2)
Birth to an HCV-infected mother
Although less frequent, 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
Other health-care procedures that involve invasive procedures, such as injections (usually recognized in the context of outbreaks)
Unregulated tattooing
Receipt of donated blood, blood products, and organs (rare in the United States since blood screening became available in 1992)
Needlestick injuries in health-care settings
What is the prevalence of hepatitis C among people who inject drugs (PWID)?
No nationwide seroprevalence surveys targeting PWID have been conducted in the United States, and estimates based on smaller surveys in regional and metropolitan areas vary considerably. A 2017 review estimated an overall hepatitis C prevalence of about 53% among PWID in the United States, which varies from state to state (range: 38.1%–68.0%).
Is non-injection cocaine use associated with HCV transmission?
Possibly. Limited epidemiologic data suggest an additional risk from non-injection (snorted or smoked) use of cocaine, but this risk is difficult to differentiate from associated injection-drug use and sex with HCV-infected partners.
What is the risk of acquiring hepatitis C from transfused blood or blood products in the United States?
Now that more advanced screening tests for hepatitis C are used in blood banks, the risk of transmission to recipients of blood or blood products is considered extremely rare, at <1 case per 2 million units transfused. Before 1992 (the year that blood screening became available), blood transfusion was a leading cause of hepatitis C virus transmission (18,19).
Can hepatitis C be spread during medical or dental procedures?
As long as Standard Precautions and other infection-control practices are consistently implemented, medical and dental procedures performed in the United States generally do not pose a risk for the spread of hepatitis C. However, hepatitis C can be 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 include maintaining injection safety practices aimed at reducing bloodborne pathogen risks for patients and health-care personnel. Cases of suspected health-care-associated HCV infection should be reported to state and local public health authorities for prompt investigation and response.
Do hepatitis C outbreaks occur in health care settings?
Yes. Hepatitis C can be spread in health-care settings (20,21) when Standard Precautions and other infection-control practices are not consistently implemented. In the United States, health-care-associated transmission of hepatitis C has been associated with inadequate infection prevention practices during inpatient care, outpatient care, and hemodialysis. These infection control breaches have included reuse of syringes and other failures of aseptic technique, contamination of multidose vials, and inadequate cleaning of equipment. Diversion of controlled substances for illicit use has also been associated with outbreaks (22). Often, health-care-associated outbreaks are first detected by astute clinicians who find new infections in people without risk factors and then report cases to public health authorities.
Can hepatitis C be spread within a household?
Yes; however, transmission between household members does not occur very often. If hepatitis C is spread within a household, it is most likely a result of direct (i.e., 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
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).
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.
What are the extrahepatic manifestations of chronic HCV infection?
Some people with chronic HCV infection develop medical conditions due to hepatitis C that are not limited to the liver. Such conditions can include:
Diabetes mellitus
Glomerulonephritis
Essential mixed cryoglobulinemia
Porphyria cutanea tarda
Non-Hodgkin’s lymphoma
Testing and Diagnosis
Who should be tested for HCV infection?
CDC now recommends universal hepatitis C screening for all U.S. adults and all pregnant women during every pregnancy, except in settings where the prevalence of HCV infection is <0.1% (see How should providers determine hepatitis C prevalence?). This includes
All adults aged 18 years and older
All pregnant women during each pregnancy
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 with HIV
People who have 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
Health care, emergency medical, and public safety personnel after needle sticks, sharps, or mucosal exposures to HCV‑positive blood pdf icon[PDF – 177 KB]
Children born to mothers with HCV infection
Any person who requests hepatitis C testing
Who should be tested for HCV on a routine basis?
Routine periodic testing is recommended for people with ongoing risk factors, while risk factors persist, including those who currently inject drugs and share needles, syringes, or other drug preparation equipment, along with people who have certain medical conditions (e.g., people who ever received maintenance hemodialysis). Testing of people at risk should occur regardless of setting prevalence.
How should providers determine hepatitis C prevalence to inform testing within their practices?
In the absence of hepatitis C prevalence data in a particular practice or patient catchment area, providers and program directors should immediately begin screening all adults and all pregnant women during each pregnancy for HCV infection. To determine the baseline prevalence, providers and program directors are encouraged to consult CDC or their state and local health departments to determine a reasonable estimate in their setting or a methodology for determining how many people they need to screen before confidently being able to establish that the prevalence is below 0.1%. See CDC’s hepatitis C testing guidelines for detailed information on calculating prevalence in a health-care setting.
What blood tests are used to detect HCV infection?
Several blood tests can detect HCV infection, including:
Screening tests for antibody to HCV (anti-HCV)
enzyme immunoassay (EIA)
enhanced chemiluminescence immunoassay (CLIA)
Chemiluminescence microparticle immunoassay (CMIA)
Microparticle immunoassay (MEIA)
Electrochemiluminescence immunoassay (ECLIA)
Immunochromatographic assay (rapid test)
Qualitative nucleic acid tests to detect presence HCV RNA
Quantitative nucleic acid tests to detect levels of HCV RNA
How do I interpret the different tests for HCV infection?
A table on the interpretation of results of tests for HCV infection and further actions is available at https://www.cdc.gov/hepatitis/HCV/PDFs/hcv_graph.pdfpdf icon.
Is an algorithm for hepatitis C diagnosis available?
A flow chart that outlines the serologic testing process beginning with HCV antibody testing is available at https://www.cdc.gov/hepatitis/HCV/PDFs/hcv_flow.pdfpdf icon.
How soon after exposure to HCV can HCV antibodies be detected?
Anti-HCV seroconversion occurs an average of 8–11 weeks after exposure, although cases of delayed seroconversion have been documented in people who are immunosuppressed (e.g., those with HIV infection)
How soon after exposure to HCV can HCV RNA be detected?
People with recently acquired acute infection typically have detectable HCV RNA levels as early as 1–2 weeks after exposure to the virus.
Is an HCV antibody (anti-HCV) test sufficient to diagnose current HCV infection?
No. The anti-HCV test only provides information about past exposure to HCV. A negative anti-HCV result indicates that a patient has never been exposed to the virus, and therefore the anti-HCV test is only used to rule out HCV infection. If a person tests positive for HCV antibodies, hepatitis C testing is not considered complete unless the initial positive anti-HCV test is followed by a test for HCV RNA as per CDC guidelines. A positive test for HCV RNA is needed before a patient can be diagnosed with current HCV and begin receiving treatment. Ideally, positive antibody tests are “reflexed” to an HCV RNA test automatically from the same blood sample. However, reflex testing is not possible in every laboratory or clinical setting.
Is someone with a positive anti-HCV test still at risk for hepatitis C?
Yes. A person with a positive anti-HCV test is susceptible to future HCV infections. People with ongoing risk factors, such as those who currently inject drugs and those who have previously tested anti-HCV positive and HCV RNA negative, should receive periodic HCV RNA testing.
Under what circumstances might a false-negative HCV antibody (anti-HCV) test result occur, even when a person has been exposed to HCV?
People who have been very recently infected with HCV might not yet have developed antibody levels high enough to be detected by the anti-HCV test. The window period for acute HCV infection before the detection of antibodies averages 8 to 11 weeks, with a reported range of 2 weeks to 6 months. In addition, some people might lack the immune response necessary to develop detectable antibodies within this time range (31,32). In these people, virologic testing (e.g., PCR for HCV RNA) can 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 fluctuating liver enzyme levels, with periodic returns to normal or near normal levels. Liver enzyme levels can remain normal for over a year despite chronic liver disease.
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