Hepatitis C

When Going Viral is a Bad Thing

By Ruth Werner
[Pathology Perspectives]

Cameron is a part-time carpenter and musician living in a rural community. Now in his mid-60s, the hepatitis C he probably picked up during his time in Vietnam is seriously impacting his life. The decades he spent as a musician—and indulging in the behaviors that were part of that culture—have also contributed to his condition.
Cameron’s situation is a textbook example of someone diagnosed with hepatitis C: an undetermined date of infection followed by years of slowly progressive liver damage, until one day the liver can’t compensate any more, and scarring, cirrhosis, or other serious changes can set in.
Hepatitis C is sometimes called a silent epidemic. It affects more than 4 million Americans, but for the majority of them, it is hidden until the liver cannot take any more challenges, and then the symptoms and complications come on with a vengeance. The good news is that new treatment options have emerged, and they appear to actually cure hepatitis C for many patients. Cameron may be one of them—he was recently evaluated to take part in this new protocol.

Hepatitis C: The Problem
Our understanding of viral attacks on the liver began with the identification of the hepatitis A and B viruses. It wasn’t long before scientists became aware that another virus was capable of attacking the liver. For decades, it was labeled “hepatitis non-A, non-B,” until it was isolated and labeled hepatitis C in 1990. This discovery was followed with the identification of hepatitis viruses D, E, F, and G. In the United States more than 90 percent of viral infections involve hepatitis A, B, C, or some combination.
Hepatitis C is a retrovirus. It mutates relatively easily; to date, six different genotypes and 50 subtypes of hepatitis C have been identified. This tendency to change—called antigenic drift—means that unlike versions A and B, no vaccine has yet been developed against hepatitis C. Further, it is possible (but rare) to be super-infected with more than one version of hepatitis C.
Estimates about the incidence of hepatitis C vary, but most agree it affects between 4 and 4.5 million people in the United States (that’s more than 1 in 100), and up to 200 million people worldwide. It causes some 15,000 deaths each year in the United States, and up to 350,000 deaths each year around the globe.

Hepatitis C is the most common blood-borne infection in the United States, but exactly how it gets from one person to another is still not fully understood. We do know that the most efficient way for the virus to spread is through direct or indirect blood-to-blood contact. Intravenous drug users, people who get tattoos or piercings with contaminated equipment, and people who received blood products or transplant organs before 1993 are among the highest-risk populations.
It seems that this virus can also be transferred through sexual activity, but that mechanism is not particularly efficient for spreading the infection. And some research suggests that sharing personal items that might have blood on them—razors, toothbrushes, tweezers—may also allow hepatitis C to move within households; the virus can be active for anywhere from 16 hours to four days outside a host. Again, this is not the most efficient or common mechanism.
In up to 10 percent of all diagnoses, the method of transmission is never identified.
How It Works
Like many viruses, hepatitis C starts with a core of genetic material that is housed inside a protein coat. This capsid has an outside protective lipid membrane. The blood-borne virus is quickly carried to the liver, and its lipid covering allows it to attach to receptor sites on liver cells: the lipids merge with the cell membrane of the hepatocyte. Then, the protein coat dissolves, and the ribonucleic acid (RNA) enters the cell.
Once inside a hepatocyte, the viral RNA changes the activity of normal ribosomes (the organelles that produce cellular secretions). In this process, all normal cell function is halted, and the ribosomes are instructed to produce an enzyme called transcriptase, which allows the RNA molecules to replicate—thousands of times in each infected cell.
Next, the co-opted ribosomes produce protein coats to cover the new RNA molecules, making new capsids. As the capsids are completed, they migrate to the cell membrane and bud into new viruses, taking some of the lipid cell membrane with them as they escape to find new cells to attack. Ultimately, the infected cell is destroyed, either by viral overload or an immune system response.
Hepatitis C usually incubates for two weeks to six months. During this time, it is slowly progressing, but not aggressively enough to stimulate an immune system response. When that happens, some patients experience a period called acute hepatitis C. During this time, signs include about 2–12 weeks of fever, fatigue, abdominal pain, nausea, and vomiting. However, up to 80 percent of all patients don’t go through this stage. For this reason, hepatitis C is seldom diagnosed until extensive liver damage has accrued.

Symptoms and Complications
While viral activity inside hepatocytes is aggressive, the symptoms of a hepatitis C infection can be delayed for 20 years or more because the liver compensates for lost cells by replacing them with new ones. When at last the liver can no longer keep up with the damage, we begin to feel the effects of lost function. These symptoms and complications include debilitating fatigue, general malaise, and headache. More advanced liver damage can involve the accumulation of fluid in the peritoneum, a condition called ascites. The liver itself, under both viral and immune system attack, can accumulate scar tissue, leading to cirrhosis (Image 1).
When the highly organized channels between hepatocytes are blocked with scar tissue, bilirubin (a golden-brown component of bile and the coloring agent for feces) can back up into the circulatory system, staining the skin, mucous membranes, and eyes yellow in jaundice (Image 2).
Other liver functions that are frequently interrupted with cirrhosis include the metabolism of toxic materials into less toxic substances, the removal of excessive male and female hormones, the production of clotting factors, and the management of blood sugar.
Not everyone who is exposed to the hepatitis C virus (HCV) gets sick; the infection spontaneously clears in up to 25 percent of all cases. Of all the people exposed to HCV, 75–85 percent develop chronic infection and are communicable for the rest of their lives; 60–70 percent will develop liver disease; 5–20 percent will develop cirrhosis; and 1–5 percent will die of cirrhosis or liver cancer.
Chronic hepatitis C is the leading cause for liver transplant today, but the reinfection rate of the transplanted livers approaches 100 percent.

The Cure?
Until about two years ago, the only treatment option for hepatitis C patients was a 24-week course of interferon (a synthetic form of a natural protein that stimulates immune system activity against viruses) and ribavirin, a drug that helps to stop or slow RNA synthesis. This protocol helped many people with the hepatitis C genotype 1 (the most common in the United States), but the side effects were so severe that many patients were forced to stop treatment—these included flu-like symptoms with joint pain, nausea, diarrhea, insomnia, and low blood-cell count. Over a six-month treatment period, these problems can become unmanageable, and when treatment is not completed, it allows the virus to mutate into drug-resistant forms.
More recently, new options have become available. A drug called sofosbuvir and its analogues, used with interferon and ribavirin, are capable of completely clearing the virus from the system—in short, curing hepatitis C—with fewer side effects and a shorter course of treatment. This appears to work in up to 75 percent of all patients, compared to 44 percent with the older treatment. This protocol was approved for hepatitis C treatment in 2013. There’s just one hitch: it costs up to $100,000 for a complete course of treatment. We can only hope that with the high rates of hepatitis C infection, the volume of potential customers may help to bring the price down.

Can massage therapists catch hepatitis C from clients with open, uncovered lesions? The risk is low, but not zero. This infection is yet another reason it is absolutely critical to observe standard precautions to the best of our ability. We should treat every client as though it were possible he or she is carrying a blood-borne disease. For a refresher on good hygienic practices for massage therapists, read “Hygiene Fact and Fiction” (Massage & Bodywork, May/June 2012, page 36).
Because more than 4 million people in the United States have hepatitis C, your chances of working with a client who has this condition are high. Further, research suggests that many people with chronic diseases seek out CAM therapies, either as an alternative to conventional treatment or as a way to manage side effects of medication. For that reason alone, we need to be well informed about this condition.
As we know, the liver is central to fluid flow in the abdomen. If it doesn’t work well, the whole system can back up and cause many symptoms and complications, some of which are very serious. Therefore, further challenging fluid management systems with rigorous circulatory massage may not be the best strategy for clients living with this infection, especially if they are in an advanced stage of liver disease.
Among the many complications of liver disease are some issues that are of particular relevance to massage therapists. Ascites can make abdominal massage and lying prone uncomfortable or completely unmanageable. If the liver doesn’t produce adequate clotting factors, then our clients become at risk for spontaneous bleeds or bleeding with only minor tissue disruption; that is to say, bruising following even gentle strokes. And liver dysfunction in general can lead to skin rashes and open lesions. Obviously, these at least locally contraindicate massage.
On the other hand, many people with hepatitis C may have only minimal symptoms. In these cases, massage choices can be kept within the demands of normal daily activities.
The overall goal needs to be to offer the best of what massage therapy has to offer—possible relief from the anxiety, depression, fatigue, headaches, joint pain, and other side effects of the infection and its treatment—while avoiding overwhelming a system that is already working hard to simply keep up with moment-to-moment needs.
To date, no research has been published (none that is indexed in PubMed Central, at any rate) that explores the value of massage therapy for patients with hepatitis C, or those undergoing hepatitis C treatment. Because this infection is so common, it is certain that some massage therapists are working with clients who have this condition. We need to ask those practitioners these questions:
• What are your clients’ goals?
• How do you strategize to meet those goals?
• How effective have your strategies been?
• What mistakes have you made?
This is information we need so that we as a profession can build a body of knowledge about working with clients who have hepatitis C. I hope someday to read what massage therapists discover about working with this large and underresearched population.

Who Should Be Tested?
Readers may be feeling some interesting sensations at this point. Maybe you have a feeling of heaviness in the abdomen, or an ache under your rib cage on the right side. That little niggling headache—could that be related to a liver problem? The National Institutes of Health suggest you should be tested for hepatitis C if any of the following apply to you:

1. You were born between 1945 and 1965.
2. You have ever used intravenous drugs—even
if it was only once, and even if it was many
years ago.
3. You were treated for a blood-clotting problem before 1987.
4. You received a blood transfusion or any organ transplant before 1993.
5. You are on long-term hemodialysis.
6. You have abnormal liver tests or known current liver disease.
7. You work in public health or safety, and were exposed to blood through a needle-stick or sharp object injury at any time.
8. You are HIV-positive.

1.    Centers for Disease Control and Prevention, “Hepatitis C FAQs for the Public,” accessed January 2015, www.cdc.gov/hepatitis/C/cFAQ.htm.
2.    World Health Organization, “Hepatitis C. Fact sheet No. 164,” accessed January 2015, www.who.int/mediacentre/factsheets/fs164/en/.
3.    The C. Everett Koop Institute, “Transmission of Hepatitis C,” accessed January 2015, www.epidemic.org/thefacts/hepatitisc/transmission/.
4.    J. Wapner, “We Now Have the Cure for Hepatitis C, But Can We Afford It?” Scientific American 331, Issue 3 (April 2014), www.scientificamerican.com/article/we-now-have-the-cure-for-hepatitis-c-but-can-we-afford-it/.

Ruth Werner, BCTMB, is a former massage therapist, a writer, and an NCTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2013), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.