Medical certification and hepatitis C infection

Most people in the United States who acquire hepatitis C get it by intravenous drug use or blood transfusion. It is rare since 1990 to get hepatitis C by transfusion since all blood is now tested. Other ways a person can contract the disease include having sex with an IV drug user, having been in jail, undergoing religious scarification, getting stuck or cut with a bloody object, piercing body parts, and receiving medical treatment with immunoglobulin injection.

Most individuals with hepatitis C do not have any symptoms, but the most frequent symptom is fatigue. Others include loss of appetite, muscle aches, joint pains, weakness, and wight loss.

To make the diagnosis your physician needs to have a high index of suspicion. There is a wide variability in levels of liver function tests, which are some of the tests your doctor will request. Your doctor also can actually check the level of hepatitis virus in your blood stream.

The risk of developing what is called “chronic hepatitis C infection” is high. Fifty to 85 percent of patients remain chronically infected after the initial infection. It is at this point that airmen who are infected present their cases to the FAA for consideration for a special issuance. The reason why this condition requires following by the FAA is the potential for serious complications. People with chronic hepatitis C can develop cirrhosis of the liver and all the complications of that condition.

Cirrhosis occurs due to the chronic inflammation response in the liver. The usual tissue that makes up the liver is replaced by scarring (called fibrosis). Over a period of years the fibrosis in the liver obstructs the return of venous blood from portions of the body.

The blood supply to the liver comes from two sources, arterial blood as well as from the rest of the body called the hepatic portal system, which is blood that is coming from the, stomach, pancreas gland, spleen, and intestines. Because the main function of the liver is to assist in the metabolism of the nutrients from the intestines, it is the hepatic portal system that is affected by the formation of scar tissue in cirrhosis. This results in dilation of these blood vessels called varicosities. You may recall hearing the term “varicose veins.” Most people are aware of varicose veins in the legs. This condition occurs when valves that close and prevent blood from pooling in the legs (when we stand, for example) are defective or destroyed for one reason or another. The blood has a more difficult time traveling back to the heart and thus pools in the legs, especially when you stand. When cirrhosis occurs and the blood from the stomach and intestines has difficulty in getting through the liver it also results in varicose veins. This can result in another, more severe complication of cirrhosis, when a varicose vein close to the surface in the intestines ruptures and the person develops hemorrhaging, most commonly from the esophagus, or gullet, as well as elsewhere in the intestines. This hemorrhaging could result in death.

Most of the medications that physicians currently use to treat chronic hepatitis C are unacceptable to the FAA. They have side effects that are aeromedically significant. One of the more commonly used medications, Interferon Alpha, can cause depression in up to 40 percent of patients—even requiring the individual being placed on an antidepressant medication. The FAA has accepted one new medication for treatment called Harvoni (ledipasvir/sofosbuvir). This medication,which is administered orally, inhibits protein in the hepatitis C virus.

So the medical certification of these airmen requires that they either are being followed prior to starting any treatment or have received treatment and are now considered cured. The FAA also has granted special issuance to some airmen who have early cirrhosis and no evidence of venous varicosities.

Airmen with chronic hepatitis C who are stable, who have no complications, and whose liver function lab tests are not very high above normal can participate in the Conditions AMEs Can Issue (CACI) program. This means that as long as the airman brings a letter from their treating physician and a set of recent liver function tests to the AME’s office when he comes in for his exam, he could be issued a medical certificate without the requirement for a special issuance.

Airmen who require treatment with medications are denied a medical certificate until they have completed treatment and are free of adverse effects.

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