Recombinant interferon-alfa therapy in children with chronic hepatitis C

Systematic review with meta-analysis: comparison between therapeutic regimens for paediatric chronic hepatitis C

BACKGROUND

To decide when and how to treat children with chronic hepatitis C is an ongoing debate.

AIM

To compare the outcomes of therapy for children with chronic hepatitis C.

METHODS

An electronic database assessed clinical trials with sustained virological response rates specified by genotype. The data were extracted according to the therapeutic regimen; interferonα±ribavirin and pegylated interferonα±ribavirin.

RESULTS

The search sourced 23 peer-reviewed articles which enrolled 934 cases, aged 2-19 years. Sustained virological response rates were significantly higher with the addition of ribavirin to either interferonα or pegylated nterferonα vs. their monotherapies for genotypes 1,2&3 with crude and weighted estimates. The weighted estimate indicated higher sustained virological response rates for those treated with pegylated interferonα+ribavirin vs. interferonα+ribavirin for genotype 1 (50% vs. 40%) and genotypes 2&3 (90% vs. 84%), (odds ratio 1.5, 95% confidence interval 1.2-1.8, and 1.8, 1.2-2.9 respectively). Cases with genotype 4 treated with pegylated interferonα+ribavirin had a lower sustained virological response (41%) vs. genotype 1 (1.4, 1.2-1.8), and vs. genotypes 2&3 (13.5, 10.3-17.9). Some adverse events were significantly higher among cases treated with pegylated interferonα+ribavirin vs. interferonα+ribavirin.

CONCLUSIONS

Despite the superiority of pegylated interferonα+ribavirin to interferonα+ribavirin for the treatment of chronic hepatitis C among children, the significant higher adverse events along with the modest outcome for genotypes 1&4 render that regimen a suboptimal therapy. These data indicated the need for the future comparison with clinical trials of direct anti-viral drugs for children with chronic hepatitis C.

Pegylated IFN-α and ribavirin: emerging data in the treatment of special populations

Hepatitis C virus (HCV) is one of the most common causes of chronic liver disease and is currently the leading indication for liver transplantation in the USA. Pegylated IFN-α (PEG-IFN-α) and ribavirin comprise the standard of care for the treatment of chronic HCV. The expansion of antiviral therapy to include special populations that were not well represented or excluded from registration trials has occurred in recent years. Data have emerged that demonstrate that these groups have variable responses to therapy and, in some cases, different side-effect profiles. The etiologies for the varied response rates remain under investigation. This review will address the clinical efficacy and safety profiles of PEG-IFN-α and ribavirin in populations of patients coinfected with HIV, obese patients, liver transplant recipients, children and African-Americans.

Current treatment options and response rates in children with chronic hepatitis C

Vertical transmission has become the most common mode of transmission of hepatitis C virus (HCV) in children. The rate of perinatal transmission from an HCV-infected mother to her child ranges from 2% to 5% and the prevalence of HCV in children in developed countries ranges between 0.1% and 0.4%. Spontaneous viral clearance seems to be dependent on the genotype and has been reported between 2.4%-25%. For chronically infected patients, treatment with recombinant polyethylene glycol (PEG)-interferon α-2b and daily ribavirin has now been approved as standard treatment for children 2-17 years of age. In five large prospective studies, a total of 318 children and adolescents aged 3-17 years were treated either with subcutaneous PEG-interferon α-2b at a dose of 1-1.5 μg/kg or 60 μg/m² once a week in combination with oral ribavirin (15 mg/kg per day) or PEG-interferon α-2a with ribavirin. Subjects with genotype 1 and 4 received the medication for 48 wk and individuals with genotype 2 and 3 mainly for 24 wk. Overall sustained viral response (SVR) was achieved in 193/318 (60.7%) of treated patients. Stratified for genotype; 120/234 (51%) with genotype 1, 68/73 (93%) with genotype 2/3, and 6/11 (55%) with genotype 4 showed SVR. Relapse rate was between 7.7% and 17%. Overall, treatment was well tolerated; however, notable side effects were present in approximately 20%. According to recent experiences in the treatment of chronic hepatitis C in children and adolescents, a combination of PEG-interferon α with ribavirin has been found to be well tolerated and highly efficacious, particularly in individuals with genotype 2/3. Thus, this treatment can be recommended as standard of care until more effective treatment options will become available for genotype 1 patients.

Treatment and follow up of children with chronic hepatitis C in Albania

BACKGROUND

Treatment of Hepatitis C in children has a better outcome than in adults, and for this reason the treatment had different views. However, in pediatric age hepatitis C is seen to have an evolution towards chronicity. Today is a normal option to treat chronic hepatitis C as early as possible according to certain criteria. The aim of this study is to show the results of treatment with interferon and ribavirin and the follow-up of children diagnosed with chronic hepatitis C in our service.

PATIENTS AND METHODS

This is a prospective study which has included children 3 up to 15 years old (13 boys and 4 girls) diagnosed with chronic hepatitis C. All patients underwent a certain protocol, including liver biopsy prior to treatment. Treatment consisted in use for 48 weeks of INF α-2b, 3 MIU/m2 three times a week s/c and ribavirin 15 mg/kg orally divided bid. Two patients were treated with PEGINF α-2b with dose 1.5 mcg/kg once a week s/c and ribavirin 15 mg/kg. After the treatment all patients have stayed under our control for an average period of 24 weeks.

RESULTS

At the end of the treatment we detected a patient with HCV-RNA positive. End Treatment Viral Response was 94%. Six months later we found three patients who showed relapse of disease. Sustained Viral Response was approximately 83%

CONCLUSION

The combination therapy of interferon with Ribavirin in treatment of children with chronic hepatitis C provides a higher SVR when treatment is initiated at the earliest stages of hepatic changes. Side effects of therapy are insignificant in comparison with results obtained.

Management of chronic hepatitis C in childhood: the impact of therapy in the clinical practice during the first 2 decades

BACKGROUND AND AIM

Treatment of chronic hepatitis C in children is controversial and its role in the clinical practice is unknown. We retrospectively investigated the impact of treatment in a large cohort of children with chronic hepatitis C over the past 20 years.

METHODS

376 hepatitis C virus RNA positive children were recruited consecutively in five Italian centres since 1990 and followed for 1-17 years.

RESULTS

86 (23%) subjects were treated: 73 with recombinant interferon alone and 13 with pegylated-interferon and ribavirin. Sustained clearance of hepatitis C virus RNA was observed in 25% of the former, in 92% of the latter and in 9% of untreated cases (p < 0.001). Loss of viraemia was recorded in all children with genotype 2-3 and in 6 of 7 with hepatitis C virus genotype 1 treated with combination therapy. At last evaluation 45% of patients were young adults and 15% had cleared viraemia. Overall, 152 (40%) were putative candidates to therapy.

CONCLUSIONS

Few Italian children with chronic hepatitis C have been treated in the past 20 years. The poor propensity to spontaneous clearance of viraemia and the efficacy of combination therapy should encourage to consider treatment in attempt to shorten the duration of viral replication.

Guidance for clinical trials for children and adolescents with chronic hepatitis C

Most children with chronic hepatitis C are infected vertically, have a low natural seroconversion rate, and carry a lifetime risk of cirrhosis and cancer. Affected children are usually asymptomatic, and histological findings are mild with a low risk of progression, although 5% develop significant liver disease in childhood.The use of combination treatment with pegylated interferon-α and ribavirin has changed the outcome and prognosis for this disease, with approximately 60% of children achieving sustained viral clearance. Combination therapy is not ideal for children because pegylated interferon is administered subcutaneously, impairs growth velocity, and both interferon and ribavirin have significant adverse effects that affect compliance. In addition, approximately 50% of children infected with genotype 1 do not respond to therapy. Thus, additional treatment options are required including improvement in dosing, reduction in the length of treatment, and evaluation of new drugs, such as protease inhibitors, which could be more effective for patients infected with genotype 1.The primary goal of treatment is to eradicate the infection. The future clinical trial design should ensure that any new drugs demonstrate noninferiority to the present standard regimen in both children and adults. The measure for documenting substantial improvement above present therapy should be increased viral clearance rate or the same clearance rate, with a shorter duration of treatment and/or fewer adverse effects. We do not believe there is any need for a placebo arm because approved therapy is available and new treatments can be compared with present therapy.Safety measures should include the standard recommended laboratory investigations, growth parameters, quality-of-life or psychological measures, and a requirement for long-term follow-up for up to 5 years.

Treatment of hepatitis C in children: a systematic review

BACKGROUND

Current guidelines recommend children be treated for hepatitis C virus (HCV) using the same principles applied in adults. There are however few published studies which assess the efficacy and safety of HCV therapy in children.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic review of the literature was completed for studies of any design that evaluated HCV therapy in children. The primary outcome was sustained virologic response (SVR), with sub-group analysis of response rates by genotype. There were 4 randomized controlled trials (RCTs) and 31 non-randomized studies, all involving interferon, pegylated interferon (PEG-IFN), or combinations of these drugs with ribavirin. The SVR rate could not be directly compared as the populations and interventions differed across studies. Genotype was not reported or differed substantially from study to study. The overall SVR rate for PEG-IFN and ribavirin ranged from 30 to 100% which is comparable to the rate in adults. Similar to adults, the SVR rates were significantly higher in children with genotype 2 or 3 compared to genotype 1. Adverse effects were primarily flu-like symptoms and neutropenia. There were insufficient data to assess the applicability of the week 12 stop rule (stopping therapy at week 12 if there is less than a 2 log drop in HCV RNA) or the efficacy of shortening therapy to 24 weeks in children with genotype 2 and 3.

CONCLUSIONS/SIGNIFICANCE

Current guidelines for the treatment of HCV in children are based on limited data. Further research is needed to define the optimal therapy for HCV in children.

Treatment of hepatitis C in children

Hepatitis C affects 4-10% of children born to infected mothers, and 80% of them develop chronic infection. Most patients with chronic hepatitis C virus infection are asymptomatic, with persistent or intermittent biochemical abnormalities. Severe liver disease may develop 10 years after onset of infection, with a less than 2% overall risk during the pediatric age. Available therapies have no contraindication in children if otherwise healthy. The US FDA and EMEA have recently approved combined pegylated-IFN-alpha 2b plus ribavirin treatment for children, who should be over 3 years of age in order to avoid severe side effects. Experiences in pilot trials and international studies indicate a response rate of 50% in genotype 1 patients, and more than 90% in genotype 2 or 3 patients, indicating resolution of chronic disease.

Hepatitis C in children

Mother-to-child, or vertical transmission, of hepatitis C virus is now the dominant mode of acquisition of infection for children. The rate of transmission is low in women who are not also HIV-positive. Whether the mode of delivery is associated with transmission remains questionable; breast-feeding does not appear to be a source of infection. The detection of hepatitis C virus RNA using the polymerase chain reaction is a sensitive method for the early diagnosis of infection in perinatally exposed infants, but false positive results can occur. The natural history of hepatitis C virus infection in children is not well defined, but chronic infection is common in most cases. The disease progression is slower than in adults. Therapeutic trials (not placebo controlled) in a small number of children suggested a sustained response to interferon treatment in only a minority of cases. The option of combination therapy with ribavirin looks promising and needs evaluation.

Interferon alpha in the treatment of chronic hepatitis C in children: a meta-analysis [correction of metanalysis]

Children with chronic hepatitis C may be ideal candidates for treatment with interferon alpha (IFNalpha) as they have liver disease at an early stage. However, adverse drug reactions need to be considered. The aim of this study was to conduct a systematic review of literature on interferon therapy of chronic hepatitis C in children, and to perform a meta-analysis of pooled data. A computerized search gave 18 articles on IFNalpha therapy in children with chronic hepatitis C; after exclusion of uncontrolled trials and of trials including patients with comorbidities, data from two studies could be pooled (48 patients). The outcomes assessed were biochemical, defined as normalization of alanine transaminase, and virologic, defined as HCV-RNA loss, both sustained at 24 months after enrollment. Results of the studies were homogenous. Risk difference was 37% (95%CI: 12.9-61) in favour of IFNalpha treated children for sustained biochemical response, and 36.8% (95%CI: 14.3-59.3) in favour of treated children for sustained HCV clearance, respectively. The differences were highly significant (P = 0.007 and P = 0.004, respectively). The histological end-point, as well as side-effects, could not be analysed, due to lack of data. This review identifies the poor methodology of the majority of the published trials. The study provides support for the efficacy of IFNalpha in improving both biochemical and virologic outcomes in chronic hepatitis C in children, but evidence is confined to these surrogate end-points.

Efficacy of interferon-alpha treatment in Japanese children with chronic hepatitis C

BACKGROUND

We investigated the efficacy of natural interferon (IFN)-alpha treatment in 34 Japanese children with chronic hepatitis C.

METHODS

Thirty-four children completed 6 months of therapy with natural IFN-alpha and were followed for 12 months or longer. We examined the serum hepatitis C virus (HCV) RNA titer and liver histology before, during, and after IFN treatment.

RESULTS

At 6 months after the cessation of IFN-alpha treatment, 16 patients (47%) had normal serum alanine aminotransferase concentration and no detectable serum HCV RNA. There were no major side-effects, excluding some influenza-like symptoms during the IFN-alpha treatment. Most genotype 2a patients had a complete response (80%). Moreover, patients who had a low HCV RNA titer (<102 copies/mL) after 1 month of IFN-alpha treatment became complete responders at 6 months after the cessation of treatment. Histological improvement was observed in almost all patients after IFN-alpha treatment.

CONCLUSION

Interferon-alpha treatment is safe and effective for children with chronic hepatitis C and has no serious side-effects. A HCV RNA concentration of <102 copies/mL after 1 month of IFN-alpha treatment and genotype 2a may be useful predictors of long-term IFN efficacy.

Hepatitis B and C infection in children undergoing chemotherapy or bone marrow transplantation

Despite preventive measures, patients who have cancer or who undergo bone marrow transplantation remain at higher risk of viral infection since they often receive multiple blood products. This category of patients also includes subjects from countries that are highly endemic for hepatitis B virus and hepatitis C virus infection and who travel to developed countries for specialized treatment. This review discusses the current opinions concerning the diagnostic, clinical, and therapeutic aspects of hepatitis B and C virus infection in different groups of patients: children with chronic infection before chemotherapy, children infected during chemotherapy or bone marrow transplantation, and patients with chronic infection after the end of treatment.

Hepatitis C virus infection in children coinfected with HIV: epidemiology and management

Mothers with hepatitis C virus (HCV) and HIV coinfection are the major source of HCV/HIV coinfection in infancy and childhood. There is no known intervention capable of interrupting HCV spread from mother to child, while the majority of infant HIV infections occurring in the developed world can be prevented by antiretroviral prophylaxis in the mother and child, elective caesarean section, and formula-feeding. In the era preceding treatment of HIV infection with highly active antiretroviral therapy, HCV coinfection was of little concern because the short-term survival of patients with HIV infection prevented the slowly developing consequences of chronic hepatitis C. As the life expectancy of patients with HIV infection increased with therapy, HCV has emerged as a significant pathogen. Several lines of evidence in adult patients suggest that liver disease may be more severe in patients coinfected with HIV and that progression of HIV disease may be accelerated by HCV coinfection. Whether coinfected children may share these clinical patterns remains a matter of speculation. Chronic hepatitis C in otherwise healthy children is usually a mild disease; liver damage may be sustained and fibrosis may increase over the years, suggesting slow progression of the disease. Interferon-alpha has been the only drug used in the past decade to treat hepatitis C in children and adolescents, with average response rates of 20%. Preliminary results of treatment with interferon-alpha and ribavirin suggest that the efficacy would be greater with combined therapy. These treatment protocols have not yet been applied to children coinfected with HIV, but the increasing number of long-term survivors will probably prompt further investigation in the near future. At present, treating HIV disease and monitoring HCV infection and hepatotoxicity induced by antiretroviral drugs seem to be the more reasonable approach to HCV/HIV coinfection in childhood.

Hepatitis C virus infection associated with liver-kidney microsomal antibody type 1 (LKM1) autoantibodies in children

OBJECTIVE

To evaluate the clinical pattern and evolution of chronic hepatitis C in children with liver/kidney microsomal antibody type 1 autoantibodies (LKM1).

STUDY DESIGN

A multicenter, retrospective study, including the following groups of children with hepatitis C virus infection: (1). 21 consecutive LKM1-positive patients, (2). 42 age- and sex- matched LKM1-negative patients, and (3). 4 interferon-induced LKM1-positive cases. LKM1 reactivity to human microsomes and recombinant cytochrome P450IID6 (CYP2D6) was assayed by immunoblotting.

RESULTS

Clinical and biochemical features overlapped in LKM1-positive and LKM1-negative children, but a fibrosis score >3 (range 0-6) was significantly more frequent (P =.04) in the former. Reactivity to microsomal protein and CYP2D6 was significantly (P =.02) associated with LKM1 titers >or=1:320 and was found in 39% of patients, including severe cases and both children (of 4 treated) who achieved a sustained alanine aminotransferase (ALT) normalization after steroid treatment. Five of 7 LKM1-positive children treated with interferon had an ALT exacerbation.

CONCLUSIONS

LKM1-positive hepatitis C in children is characterized by a wide spectrum of biochemical, serologic, and histologic features. Whether autoimmunity may contribute to liver damage in a subgroup of patients with more severe liver disease, high LKM1 titers, and reactivity to CYP2D6 is a question deserving further investigation.

[Dual infection with hepatitis B and C. Spontaneous course and response to virostatic therapy in children following neoplastic diseases]

Combined chronic hepatitis B and C is a long-term complication in children surviving malignancy. We report on seven children who acquired hepatitis B as well as C virus infection during treatment for different malignancies. Four patients showed a spontaneous HBe Ag/anti-HBe seroconversion, two patients spontaneous clearance of hepatitis C virus, and one patient showed both HBe Ag/anti-HBe seroconversion and clearance of hepatitis C virus. One patient developed HBe Ag/anti-HBe seroconversion after antiviral interferon monotherapy and another patient after combination therapy with interferon/famcyclovir. Three patients developed complete sustained response of hepatitis C to a combined virostatic therapy with interferon and ribavirin. A total of 4 of 7 patients had a clearance of both infections and 3 of 7 patients had a clearance of at least one infection.

CONCLUSION

Our data in long-term survivors of childhood cancer with combined hepatitis B and C showed a remarkably high rate of spontaneous cure and a favourable response to antiviral therapy.

Recombinant alfa-interferon plus ribavirin therapy in children and adolescents with chronic hepatitis C

Treatment with alfa-interferon alone yielded poor results in children with chronic hepatitis C and was not generally recommended. Owing to limited experience with combination therapy in children, the aim of the study was to evaluate the efficacy and tolerability of alfa-interferon 2b in combination with ribavirin in these patients with different routes of viral transmission. In an uncontrolled pilot study, 41 children and adolescents ranging from 3 to 16 years were treated with alfa-interferon at a dose of 3 or 5 MU/m(2) 3 times weekly in combination with oral ribavirin (15 mg/kg/d) for 12 months. The mode of infection was unknown in 4, parenterally transmitted in 16, and vertically transmitted in 21 children. Forty patients completed the study. Eleven children, who remained hepatitis C virus (HCV)-RNA positive 6 months after the beginning, discontinued therapy. One boy stopped treatment because of side effects. At the end of treatment 25 patients were HCV-RNA negative (61%). All individuals remained HCV-RNA negative during the 6-month follow-up period. Nine of 15 children with parenteral (56.3%), 14 of 21 with vertical (66.6%), and 2 of 4 with unknown route of infection responded. Side effects included minor clinical signs such as fever, flu-like symptoms, anorexia, and more severe signs (21.4%) such as the development of thyroid autoantibodies and impairment of thyroid function. In conclusion, combination of alfa-interferon with ribavirin seems to be an important advance in the treatment of chronic hepatitis C in children and adolescents. This also is true for both vertically infected patients and for individuals with normal transaminase levels before therapy.

Children with hepatitis C

An estimated 240,000 children in the United States have antibody to hepatitis C virus (HCV) and 68,000 to 100,000 are chronically infected with HCV. Acute HCV infection is rarely recognized in children outside of special circumstances such as a known exposure from an HCV-infected mother or after blood transfusion. Most chronically infected children are asymptomatic and have normal or only mildly abnormal alanine aminotransferase levels. Although the natural history of HCV infection acquired in childhood seems benign in the majority of instances, the infection takes an aggressive course in a proportion of cases leading to cirrhosis and end-stage liver disease during childhood; the factors responsible for a more aggressive course are unidentified. An optimal approach to management of hepatitis C in children would be prevention, particularly of perinatal transmission, which is now the major cause of new cases of hepatitis C in children. Obstetrical factors may be important determinants of transmission, which, if confirmed, should lead to changes in the care of infected women. Therapy of HCV infection in children is also not well defined. There have been no large randomized, controlled trials of therapy in children with chronic hepatitis C. Small heterogeneous studies of interferon monotherapy have reported sustained virological response rates of 35% to 40%. There are few data regarding the use of combination therapy with interferon and ribavirin in children and no information on the use of peginterferon. Clearly, there are important needs for future epidemiologic and clinical research on hepatitis C in childhood.

Children with hepatitis C

An estimated 240,000 children in the United States have antibody to hepatitis C virus (HCV) and 68,000 to 100,000 are chronically infected with HCV. Acute HCV infection is rarely recognized in children outside of special circumstances such as a known exposure from an HCV-infected mother or after blood transfusion. Most chronically infected children are asymptomatic and have normal or only mildly abnormal alanine aminotransferase levels. Although the natural history of HCV infection acquired in childhood seems benign in the majority of instances, the infection takes an aggressive course in a proportion of cases leading to cirrhosis and end-stage liver disease during childhood; the factors responsible for a more aggressive course are unidentified. An optimal approach to management of hepatitis C in children would be prevention, particularly of perinatal transmission, which is now the major cause of new cases of hepatitis C in children. Obstetrical factors may be important determinants of transmission, which, if confirmed, should lead to changes in the care of infected women. Therapy of HCV infection in children is also not well defined. There have been no large randomized, controlled trials of therapy in children with chronic hepatitis C. Small heterogeneous studies of interferon monotherapy have reported sustained virological response rates of 35% to 40%. There are few data regarding the use of combination therapy with interferon and ribavirin in children and no information on the use of peginterferon. Clearly, there are important needs for future epidemiologic and clinical research on hepatitis C in childhood.

Advances in therapy for hepatitis C infection

The first approved therapy for chronic hepatitis C virus (HCV) infection was recombinant interferon. Subsequently, controlled studies demonstrated that the combination of interferon-alpha and ribavirin leads to significantly higher virologic sustained responses in patients with chronic hepatitis C. A novel modification of the interferon molecule resulted in the formulation of pegylated interferons, which have a longer half-life than standard interferon. Two recent trials have established the superiority of pegylated interferons compared with interferon-alpha in inducing sustained virologic responses in patients with chronic HCV infection, with or without cirrhosis. Presumably, pegylated interferons will replace standard interferon in treating HCV infection. Phase 3 trials of pegylated interferons in combination with ribavirin are currently under way. Noninterferon-based therapies for the treatment of HCV infection are also in the developmental and experimental phases. Our aims in this review are to present the currently available therapeutic options for HCV infection and the evidence supporting their use in typical patients with chronic hepatitis C or in patients with special circumstances. We also briefly review novel therapeutic approaches, including noninterferon-based therapies.

Management of chronic hepatitis B and C virus infections

Hepatitis B and C virus (HBV and HCV) infections present an important health problem causing significant morbidity and mortality on a worldwide scale. The younger the subjects infected, the higher the risk predisposing to progression towards chronic infection. Treatment of chronic HBV and HCV infections is aimed at reducing hepatic inflammation and thus improving the symptoms, decreasing the likelihood of long-term sequelae such as hepatocellular carcinoma, and increasing the survival rate. Interferon accelerates the spontaneous course of chronic HBV infection in children with greater disease activity and lower levels of replication. There is limited information on the use of lamivudine and its long-term benefit in children with chronic HBV infection. The response of combination therapy with IFN and ribavirin in children with chronic HCV infection is still under investigation. The long-term clinical and virological effects of various drugs used in chronic HBV and HCV infections on children remain to be evaluated.

Does interferon and ribavirin combination therapy increase the rate of treatment response in children with hepatitis C?

BACKGROUND

Interferon-alpha was the first accepted treatment of chronic hepatitis C. In recent years, adding ribavirin has produced better response rates in adult patients than monotherapy with interferon-alpha. Whether adding ribavirin also improves treatment results in pediatric patients remains unclear.

METHODS

Twelve patients were given 3 million U/m 2 subcutaneous interferon-alpha three times weekly and 15 mg/kg oral ribavirin daily, and 10 patients were given only 3 million U/m 2 subcutaneous interferon-alpha three times weekly for a total of 12 months.

RESULTS

The dropout rate was 22.8% (25% for patients receiving combination treatment versus 20% for those receiving monotherapy). At the end of treatment, viral clearance was achieved in 50% of the patients who received combination treatment versus 30% of those who received monotherapy. After 12 months of posttreatment follow-up, sustained response rates were 30% and 41.7%, respectively. Of those who responded to treatment, 66.7% had received ribavirin whereas 37.5% of nonresponders had received ribavirin therapy.

CONCLUSION

Adding ribavirin to interferon treatment improved end-of-treatment response rates in children with chronic hepatitis C. Tolerance of treatment was similar to tolerance of monotherapy. However, studies of greater numbers of pediatric patients with longer follow-up periods are necessary to determine prolonged sustained response.

An analysis of published trials of interferon monotherapy in children with chronic hepatitis C

BACKGROUND

Although no therapeutic regimen has received Food and Drug Administration approval for treating children with chronic hepatitis C viral infection (CHC), there have been a number of pediatric interferon-alpha (IFN-alpha) trials. The purpose of this study was to perform a critical review of these trials to determine 1) end-of-treatment (ETR) and sustained-response (SR) rates, 2) predictors of response to therapy, and 3) safety of and tolerance to IFN-alpha in children with CHC.

METHODS

Relevant studies in the English-language medical literature and abstracts (January 1990 through November 2000) were identified by searching for manuscripts that contained the key words "children," "hepatitis C," and "interferon." Trials were considered eligible for inclusion in this analysis if criteria for treatment included positive serum polymerase chain reaction for hepatitis C virus RNA (HCV PCR).

RESULTS

Twenty published manuscripts of the use of IFN-alpha in children with CHC were found, of which 12 met our inclusion criteria. Twenty-two abstracts, of which seven met our inclusion criteria, were identified. In the 19 included trials, 366 treated and 105 untreated children were observed; five countries were represented. Average ETR was 54% (0%-91%) and average SR was 36% (0%-73%). The SR in children with genotype 1 was 27% versus 70% for nongenotype 1 ( P = 0.001). Five of 105 (5%) untreated controls exhibited spontaneous viral clearance.

CONCLUSIONS

To date, there is no published large-scale, multicenter, prospective, placebo-controlled randomized trial of the use of IFN-alpha in children with CHC. The data in this review suggest that IFN-alpha in children with CHC does have reasonable efficacy and safety. This review highlights the need for a more systematic design of future pediatric CHC trials. Ideally, such trials would be large scale, prospective, and controlled, and would include HCV genotype and viral load, histology, quality of life measures, and systematic recording of adverse events and of effects of therapy on growth and development.

Hepatitis C virus transmission in a pediatric oncology ward: analysis of an outbreak and review of the literature

Hospital-related hepatitis C virus (HCV) infections continue to occur even after the introduction of blood donor screening. We report an outbreak of HCV in nine patients of a pediatric oncology ward in 1996/1997. Sequencing of the hypervariable genomic region 1 (HVR1) of the E2/NS1 region showed near identity between HCV isolates from these patients as evidence for infection with the same virus. Despite a detailed and careful investigation, the source of infection and the mode of virus transmission could not be established. Based on a review of the current literature about nosocomial HCV infection and HCV infection in children, hypotheses for possible means of transmission in this outbreak are discussed.

Interferon-alpha treatment of chronic hepatitis C in children with hemophilia

BACKGROUND

In children with hemophilia, hepatitis C virus (HCV) is the major cause of chronic liver disease. In this study, long-term efficacy of interferon-alpha was studied to determine the factors that predict a sustained response to interferon therapy in young children with hemophilia who have chronic hepatitis C.

METHODS

Seventeen Korean children with hemophilia and chronic hepatitis C were treated with 3.7 million units/m2 of interferon-alpha2a three times weekly for 6 months. Liver biopsy, pretreatment serum HCV RNA quantitation with competitive reverse transcription assay, and HCV genotyping with reverse hybridization assay were performed.

RESULTS

Hepatitis C virus genotypes 1a, 1b, and 2a were found in three (18%), five (29%), and six (35%) patients, respectively. Interferon-alpha was well tolerated, and the frequency of bleeding did not increase. Of the 17 patients, 7 (41%) had a sustained response for 3 years after the end of therapy. Patients with a sustained response had lower pretreatment serum HCV RNA levels. One (13%) of eight patients with genotype 1 and five (83%) of six with genotype 2 had a sustained response (P < 0.05).

CONCLUSIONS

Interferon-alpha treatment of chronic hepatitis C in children with hemophilia was safe and effective in producing sustained responses. The pretreatment serum HCV RNA level and viral genotype may be predictive factors for sustained response to interferon therapy.

Viral hepatitis. From prevention to antivirals

The challenge of viral hepatitis has been acknowledged and confronted in the last decade. Significant progress in prevention of infection with HAV and HBV may eradicate these serious infections from the United States and other parts of the world in the coming decades. Application of prophylactic strategies to children will be a major mechanism in accomplishing this task. The quest for potent antiviral medications continues. The next critically important development will be ways to prevent new HCV infections and to treat the millions of already infected individuals at risk for the serious consequences of this disease. For pediatricians, realizing these goals requires a greater understanding of perinatal HCV transmission, use of vaccines for prevention of viral hepatitis, and identification of HCV-infected children who are likely to benefit from new therapeutic strategies as they become available.

Interferon-alpha and ribavirin in treating children and young adults with chronic hepatitis C after malignancy

OBJECTIVE

Chronic hepatitis C is a major long-term problem for children who survive cancer. Interferon (IFN)-alpha has been shown to be effective in treating patients with chronic hepatitis C; however, the rate of sustained response is low. Combining IFN-alpha and ribavirin (RBV) has been shown to significantly improve the response in adult patients with chronic hepatitis C. The aim of this pilot study was to evaluate the efficacy and safety of a combined virostatic treatment with IFN-alpha and RBV in a small cohort of children and adolescents with chronic hepatitis C and previous malignancy.

METHODS

Twelve patients with a history of a hematooncologic disease (median follow-up: 13.5 years; range: 7-14.7 years) and chronic hepatitis C were treated with recombinant IFN-alpha-2a (6 megaunits/m(2) body surface area, 3 times a week, subcutaneously) combined with RBV (15 mg/kg body weight/day, orally) for 12 months. They were tested monthly for blood counts and liver function, and for serum virus concentrations (hepatitis C virus RNA by polymerase chain reaction) every 3 months.

RESULTS

At the end of the treatment, hepatitis C virus RNA could not be detected in the serum of 8 of the 12 patients; 2 of these patients relapsed soon after therapy withdrawal, whereas 6 patients maintained in sustained virologic and biochemical remission (follow-up: 12 months). Treatment-induced toxicity was moderate and reversible with influenza-like symptoms and a decrease in blood counts in all 12 patients, alopecia in 5 of the 12, hemolysis in 4 of the 12, and weight loss of >10% in 2 of the 12.

CONCLUSIONS

As demonstrated in adults with chronic hepatitis C, treatment with IFN-alpha and RBV also seems to be an effective and safe therapeutic option for children and adolescents with chronic hepatitis C after malignancy.

Treatment of chronic hepatitis C virus infection in children

Hepatitis C virus (HCV) infection may occur in infants and children, although it is much less common than it is in adults. The main transmission routes include mother-to-infant transmission, use of HCV infected blood products, unsterile needles or syringes and other invasive procedures. The natural course of HCV infection in children is variable: some (20-40%) develop an acute resolving infection and spontaneous regression occurs in approximately one-third of infants of HCV infected mothers before 2 years of age. Approximately 60-80% of HCV infected children develop a chronic infection with varying degrees of activity and fibrosis, mostly mild during childhood. However, the potential risks of liver cirrhosis and hepatoma during later life are obvious. Interferon is the main agent used to treat HCV infection in children. The response to interferon at the end of 4-12 months of therapy ranges from 25-90%. A sustained response was found in 36-56% of children 6-36 months after the end of therapy. The duration of therapy is recommended to be 12 months. At the end of 3 months, an evaluation of the response is indicated in the majority of children, except those with thalassemia, in whom evaluation of response should be conducted at the end of 6 months of therapy. The benefit of other therapies, such as combination therapy with interferon and ribavirin in children with hepatitis C is currently under investigation.

Treatment of chronic hepatitis C in children

Chronic hepatitis C is a mild disease in childhood; however, it has a low rate of spontaneous remission over the years and fibrosis seems to increase along with the duration of the illness. Therefore, interferon treatment has been proposed in recent years. Unfortunately, available therapeutic trials include very few children, often with underlying diseases, and the results, sometimes very encouraging, have to be interpreted with caution. Overall, it seems that the rate of end-of-treatment and of sustained response to interferon reported in more recent studies may be similar to that in adults (8-20% for sustained response). HCV genotypes 2 and 3 and low levels of viremia could be factors in the selection of candidates with greater chances of response to interferon.

Hepatitis C virus infection in children

The prevalence of hepatitis C virus (HCV) infection is relatively low in childhood, with anti-HCV prevalence rates of 0.1-0.4% in the Western world. To date, blood transfusion has been the principal route of acquisition of HCV in children, but there is evidence that vertical transmission is overtaking it. The overall risk of vertical perinatal transmission of HCV is about 5%, although it increases with HIV co-infection and higher maternal viraemia. The mode of delivery and breastfeeding do not seem to affect the vertical transmission of HCV. Diagnosis of perinatal transmission relies on determination of ALT levels and the presence of HCV after the second month, while maternal anti-HCV antibodies may persist until 18 months of life. After infancy, a variable percentage of perinatally infected children are anti-HCV negative; thus, detection of HCV-RNA is necessary for accurate diagnosis. The natural history of HCV in childhood is not well understood and the outcome depends on host and viral factors. The rate of progression to chronicity is about 60-80% in both post-transfusion and vertically acquired HCV infection. Compared with adult patients, chronic hepatitis C in children is characterized by both low ALT levels and low viral load, as well as by the mildest histological and immunohistochemical forms of chronic hepatitis. The prognosis is usually worse in multitransfused, thalassaemic children and those who have had cancer. Experience of treatment of chronic hepatitis C in children is limited, with about 40% having a sustained response to the interferon therapy. It is necessary to perform long-term follow-up and multicentre treatment studies to improve knowledge of the natural history of HCV in children, as well as that of the efficacy of anti-viral therapy in childhood.

Cost effectiveness analysis of different strategies of management of chronic hepatitis C infection in children

BACKGROUND

Chronic hepatitis C virus infection in the pediatric patients is commonly encountered by clinicians, and although interferon-based therapy has been shown to be reasonably effective in children no formal economic analysis of such treatment strategies is available.

METHODS

With a Markov cycle tree simulation model, a cost effectiveness analysis was done to compare interferon-based treatment strategies for chronic HCV infection in children with a strategy of no treatment in a cohort of 10-year-old otherwise healthy children. Clinical probabilities used in the model was obtained from available literature, and cost estimates were obtained from two teaching hospitals. Cost per patient, quality-adjusted life years gained in each strategy and incremental cost-effective ratio were the primary outcome measures compared.

RESULTS

In the baseline analysis the treatment strategies dominated the strategy of no treatment. A 12-month treatment strategy was better than the 6-month treatment strategy. Combination therapy for 6 months with interferon and ribavirin was at least equally if not more effective than 12-month monotherapy. All treatment strategies decreased the number of patients developing decompensated cirrhosis, hepatocellular carcinoma and also number of orthotopic liver transplants in the lifetime of the model cohort.

CONCLUSIONS

Interferon-based treatment strategies were more effective in terms of quality-adjusted life years saved and at the same time cheaper when compared with the strategy of no treatment. Combination therapy may be more cost-effective than interferon monotherapy, and clinical trials of combination therapy in pediatric patients are needed.

Dual or Single Hepatitis B and C Virus Infections in Childhood Cancer Survivors: Long-Term Follow-Up and Effect of Interferon Treatment

We conducted a long-term prospective study of 89 cancer survivor children who had acquired hepatitis B virus (HBV) and/or hepatitis C virus (HCV) during treatment for neoplasia, the aim being to evaluate the natural history of the diseases and the effect of interferon (IFN) treatment. Patients were followed up for a median period of 13 years (range, 8 to 20); 46 were infected by HBV, 11 by HCV, and 32 coinfected by HBV and HCV. A spontaneous clearance of hepatitis B surface antigen (HBsAg) occurred more frequently in coinfected patients (19%) than in the HBV-infected (2%; P = .004), with an annual seroconversion rate of 2.1% and 0.2%, respectively (P= .008). Loss of hepatitis Be antigen (HBeAg) occurred in 44% of coinfected and in 28% of HBV-infected patients. Clearance of serum HCV-RNA was observed in 34% and 9%, respectively, of coinfected and HCV-infected patients. Seventeen HBV-infected, 4 HCV-infected, and 16 coinfected patients received -IFN treatment. In the HBV group, 6 patients (35%) cleared serum HBV DNA and seroconverted to anti-HBe; in the HCV-group, none cleared HCV-RNA. In the coinfected group, 1 patient cleared both HBV DNA and HCV-RNA, 6 patients cleared serum HCV-RNA alone, and 1 only HBV DNA and HBeAg. Overall, the diseases showed a mild histological course with no evidence of liver cirrhosis. A reciprocal interference on viral replication between HBV and HCV may occur in coinfected patients. Treatment seems to be effective for selected cases and is justified in view of the uncertain prognosis of the disease in these patients.

Dual or Single Hepatitis B and C Virus Infections in Childhood Cancer Survivors: Long-Term Follow-Up and Effect of Interferon Treatment

We conducted a long-term prospective study of 89 cancer survivor children who had acquired hepatitis B virus (HBV) and/or hepatitis C virus (HCV) during treatment for neoplasia, the aim being to evaluate the natural history of the diseases and the effect of interferon (IFN) treatment. Patients were followed up for a median period of 13 years (range, 8 to 20); 46 were infected by HBV, 11 by HCV, and 32 coinfected by HBV and HCV. A spontaneous clearance of hepatitis B surface antigen (HBsAg) occurred more frequently in coinfected patients (19%) than in the HBV-infected (2%; P = .004), with an annual seroconversion rate of 2.1% and 0.2%, respectively (P= .008). Loss of hepatitis Be antigen (HBeAg) occurred in 44% of coinfected and in 28% of HBV-infected patients. Clearance of serum HCV-RNA was observed in 34% and 9%, respectively, of coinfected and HCV-infected patients. Seventeen HBV-infected, 4 HCV-infected, and 16 coinfected patients received -IFN treatment. In the HBV group, 6 patients (35%) cleared serum HBV DNA and seroconverted to anti-HBe; in the HCV-group, none cleared HCV-RNA. In the coinfected group, 1 patient cleared both HBV DNA and HCV-RNA, 6 patients cleared serum HCV-RNA alone, and 1 only HBV DNA and HBeAg. Overall, the diseases showed a mild histological course with no evidence of liver cirrhosis. A reciprocal interference on viral replication between HBV and HCV may occur in coinfected patients. Treatment seems to be effective for selected cases and is justified in view of the uncertain prognosis of the disease in these patients.

Treatment of chronic hepatitis C in pediatric patients

Although HCV infection in children shares some clinical features with that in adults, it is clearly different in several ways. These differences may have important implications for treatment. Some differences, such as milder disease, less frequent extrahepatic manifestations, and fewer comorbid conditions causing progression, argue against aggressive treatment in childhood. Other factors, such as less severe liver disease, shorter disease duration, possibly higher rates of sustained virologic response, and better tolerance of IFN, may be reasons to pursue treatment before advanced hepatic injury occurs. Given the relatively small number of pediatric patients with HCV infection and the gaps in the current understanding of natural history and effects of therapy in these patients, treatment should be undertaken only in clinical trials, so that careful data collection and monitoring can define more precisely the safety and efficacy of IFN therapy in children.

[The pediatrician and hepatitis C virus]

The recognition that hepatitis C virus can be transmitted perinatally or through blood transfusions warrants particular attention by the pediatrician. This paper highlights the epidemiology, diagnosis, natural history and management of hepatitis C in infants and children.

Low virological response to interferon in children with chronic hepatitis C

BACKGROUND/AIMS

Children with chronic hepatitis C were recently found to have higher rates of sustained response to interferon compared to adults. The aim of this study was to verify the response to interferon using frequent viremia measurements.

METHODS

Sera from 25 children (13 males; mean age 7.9 years) with chronic hepatitis C, treated with recombinant alpha-2b interferon for 12 months, were tested for liver function tests and viremia levels for a median of 27.5 months. Autoantibodies were evaluated during and after interferon.

RESULTS

Fifteen patients completed 12 months of interferon; treatment was stopped in 10 other patients. In 11 (44%) patients viremia was undetectable already at the second administration of interferon; one of them remained viremia-free up to the end of follow-up and had persistently normal alanine-aminotransferase levels (complete sustained responder). A complete sustained response was observed only in one other patient, who normalized alanine aminotransferase and cleared viremia from the 3rd month of therapy. Three patients with persistent viremia normalized alanine-aminotransferase from the 3rd week of therapy up to the end of follow-up (biochemical sustained responders). Viremia was undetectable during treatment in four patients, who stopped interferon because of worsening in hypertransaminasemia. Three of these four patients were anti-liver-kidney microsomal type 1-positive.

CONCLUSIONS

In this study the response rate to interferon was very low and viremia and transaminase findings were often discordant.

Interferon treatment of chronic active hepatitis C during therapy of acute lymphoblastic leukemia

Due to concerns that antineoplastic therapy produces prolonged decrease in immune function, interferon treatment of chronic active hepatitis C (CAHC) has been used only at one year or longer after the end of cancer therapy. We report the experience of an 11-year-old who developed symptomatic CAHC at the start of maintenance therapy for testicular relapse of acute lymphoblastic leukemia (ALL). Significant dose reduction of maintenance therapy did not improve the tolerance of antileukemic treatment. In an effort to improve his liver disease and to deliver effective antileukemic therapy, interferon alpha and an alternative maintenance therapy regimen for ALL were initiated. The patient tolerated the combined therapy well. Interferon therapy was continued for 27 months, which was three months from the end of antineoplastic therapy. At that time serum transaminase values were normal, and no HCV viral genome was detectable. Viral genome was detected 10 months later. The combined effects of interferon and antineoplastic therapy resulted in myelosuppression requiring dose reduction of both treatments. The patient remains asymptomatic and with no evidence of recurrent leukemia more than six years from diagnosis of relapse. The effect on the status of this patient's CAHC was similar to that reported among leukemic patients who underwent an interferon course more than one year from the end of antineoplastic therapy. Interferon treatment of CAHC can be given concomitantly with antineoplastic therapy.

De novo hepatitis C in children after liver transplantation

BACKGROUND

We describe the incidence, results of interferon therapy, and outcome of hepatitis C virus (HCV) hepatitis occurring de novo after pediatric orthotopic liver transplantation (OLT).

METHODS AND RESULTS

Of children undergoing OLT between 1984 and September 1996, 321 children survived for more than 1 year. Of these, 13 (4.0%) developed previously undiagnosed HCV disease, as suggested by HCV antibody testing and HCV polymerase chain reaction and confirmed by liver biopsy. Of the 117 children who received transplants before HCV screening of blood products or donors, 10.2% developed de novo HCV disease. The mean age at diagnosis of HCV hepatitis was 13.2+/-5.0 years, and the mean time to diagnosis after OLT was 8.1 years (range, 4-11 years). The mean alanine aminotransferase (ALT) level at diagnosis was 108 IU/ml, and the liver biopsy specimen showed chronic active or chronic persistent hepatitis in 11 children, cirrhosis in 1 child, and nonspecific changes in 1 child. Twelve children were treated with interferon-2alpha; children who weighed > or =20 kg received 3 x 10(6) units every other day, and those who weighed <20 kg received 1.5 x 10(6) units every other day. Four patients developed rapidly progressive liver failure while receiving interferon therapy and required urgent re-transplantation. Three of the four children again developed histologic evidence of recurrent HCV 4-6 months after the second OLT, and all three subsequently died of HCV-induced liver failure. One patient remains alive and well with no evidence of HCV recurrence and a negative HCV RNA. Of the remaining eight children treated with interferon, only two have had a sustained response (normal ALT) and one is now HCV RNA negative. HCV RNA levels did not correlate with outcome or disease severity. HCV antibody levels were unreliable, with two patients having negative HCV antibody but a positive HCV RNA at diagnosis. Six patients were able to be genotyped: four were la and two were 1b.

CONCLUSION

Overall mortality for de novo HCV hepatitis was 23%. Seventy-five percent of children who received a second transplant for HCV hepatitis had early histologic recurrence that led to liver failure and death. Interferon therapy resulted in a sustained improvement in ALT in only 15% of children. The time to onset and progression of clinical disease both in the original graft and the retransplant graft were accelerated compared with nonimmunosuppressed individuals.

Interferon-alpha treatment of chronic hepatitis C virus infection in children

OBJECTIVES

To determine the safety and efficacy of interferon-alpha therapy of chronic hepatitis C virus (HCV) infection in children.

STUDY DESIGN

This was an open-labeled prospective trial of interferon-alpha-2a (IFN-alpha) in children with evidence of HCV infection for at least 6 months. Twenty-three children were enrolled and treated with IFN-alpha at a dosage of 3 million units/m2 three times weekly. Beginning in 1995 patients defined as complete or partial responders after 6 months were offered an additional 6 months of treatment. Endpoints were alanine aminotransferase normalization and loss of hepatitis C viral ribonucleic acid from serum. Responders were compared with nonresponders for age, gender, duration of infection, pretreatment alanine aminotransferase and hepatitis C viral ribonucleic acid levels, saturation of serum iron-binding capacity, histologic score of chronic hepatitis and viral genotype. Statistical methods used for these comparisons included the Kruskal-Wallis test, the Mann-Whitney two-sample test and the Fisher exact test.

RESULTS

Of the 21 children who completed at least 6 months of treatment, 4 (19%) had complete response, 8 (38%) had partial response and 9 (43%) had no response. Three of the 4 complete responders had prolonged treatment; in 2 the response was maintained. One responder relapsed but responded to a second, longer course of treatment. Four of the 8 partial responders had prolonged therapy and 3 of them became complete responders. One child who was originally a nonresponder lost HCV RNA within the first year after therapy. Thus eventually 7 (33%) of 21 patients were complete responders. After at least 12 months of follow-up on most of these children, no relapses have been observed. No differences in any of the variables tested could be demonstrated between responders and nonresponders, but small sample size limits power. IFN-alpha was discontinued in only one child because of side effects, and temporary dosage adjustments were needed in 4 children.

CONCLUSIONS

IFN-alpha is of some efficacy in the treatment of chronic HCV infection in children. Complete or partial responders at 6 months should undergo prolonged treatment.

Favorable response to lymphoblastoid interferon-alpha in children with chronic hepatitis C

BACKGROUND/AIMS

We investigated the efficacy of interferon therapy for the treatment of children with chronic hepatitis C virus infection.

METHODS

Twenty-four out of 26 children completed the 6-month treatment with lymphoblastoid interferon-alpha and were followed for 12 months or longer. Response to interferon therapy was defined by assaying for circulating HCV-RNA, using a nested PCR, at 6-month intervals after the end of the therapy.

RESULTS

At the end of treatment circulating HCV-RNA was undetectable in 18/24 patients and at 6 months in 12/24. Ten of these 12 primary responders have remained virus free for more than 2 years. One patient remained negative at 12 months. The remaining patient relapsed at 12 months. At 24 months 10 of 18 patients tested negative for HCV-RNA. Serum alanine aminotransferase was normal in 11/24 patients at the end of treatment, at 6 months 12/24 were normal, and at 12 months 11/12 were normal. In eight children with sustained response, repeated liver biopsies revealed a reduction in Knodell's scores for inflammation in the hepatic lobules and in the portal areas. In three of them neither plus nor minus strand of HCV-RNA was detectable in the liver tissue. Responders had a significantly lower level of viremia than non-responders. Side effects of interferon including fever, hair loss, neutropenia, and thrombocytopenia were not serious enough to warrant cessation of interferon treatment.

CONCLUSIONS

Interferon therapy in children with chronic hepatitis C may be beneficial as evaluated by sustained loss of viremia as well as by primary response.

High dosage alpha-interferon for treatment of children and young adults with chronic hepatitis C disease

BACKGROUND

There are limited data on the use of high interferon (IFN) dosage for treatment of children and young adults with hepatitis C virus infection and in those affected by thalassemia major (TM).

OBJECTIVES

To assess the response of children and young adults with chronic hepatitis C disease, including those affected by TM, to high dose natural alpha-interferon (IFN-alpha). To evaluate the effect of iron overload in response to high dose IFN-alpha in young chronic hepatitis C virus thalassemia patients.

METHODS

We conducted a therapeutic trial of natural IFN-alpha, using 10 million units/m2 three times a week for 6 months in 14 chronic hepatitis C patients ages 5 to 28 years; 7 also had TM. The follow-up period lasted 12 months.

RESULTS

Ten patients (73%) showed normal or nearly normal alanine aminotransferase values at the end of follow-up (biochemical response), but only five (35%) were negative for serum hepatitis C virus-RNA (complete responders). Four of the patients (57%) with TM were sustained complete responders. No correlation was found between the initial serum concentration of ferritin and response to IFN therapy. Patients infected with genotype 1b showed a poor response although high dose of natural IFN was used.

CONCLUSIONS

These results indicate that IFN-alpha can be used in children and young patients with chronic hepatitis C disease as well as in those affected by TM. Treatment with high dosage natural IFN-alpha in children and young adults with hepatitis C infection does not appear to be more effective than dosages previously used.

Hepatitis C virus infection in pediatric patients

In contrast to our understanding of hepatitis C virus infection in adults, relatively little is known about the evolution and treatment of HCV infection in pediatric patients. Children at risk for HCV infection include recipients of multiple blood-product transfusions, organ transplantation and infants born to HCV-infected mothers. A proportion of HCV-infected pediatric patients do not have an identifiable risk factor. HCV infection is commonly detected in children previously presumed to have non-A, non-B hepatitis and cryptogenic liver disease. HCV infection usually leads to mild chronic liver disease in children but is also associated with chronic active hepatitis and cirrhosis. Interferon therapy is effective in a proportion of patients with chronic hepatitis C.

Side effects of alpha-interferon therapy and impact on health-related quality of life in children with chronic viral hepatitis

BACKGROUND

Interferon (IFN) is standard therapy for chronic viral hepatitis in children. The aim of this study was to evaluate the side effects of alpha-interferon (IFN) in 94 consecutive children (58 males; age range, 3 to 14 years) affected by chronic viral hepatitis treated with different schedules ranging from 3 to 10 MU and from 3 to 12 months, and the impact of this therapy on health-related quality of life.

METHODS

Side effects were evaluated with clinical and laboratory examinations and were recorded on a diary card. The health-related quality of life was evaluated with a modified version of the Sickness Impact Profile.

RESULTS

All patients experienced at least one adverse reaction to IFN treatment; 80% had more than five side effects. There were no life-threatening reactions. Three children experienced severe reactions (febrile seizure, severe hypertransaminasemia and relapsing episodes of epistaxis, respectively) that required permanent IFN withdrawal. Another child had a febrile seizure requiring temporary IFN withdrawal. In seven children the neutrophil count fell below 1000/mm3 and promptly increased when IFN was temporarily discontinued. The remaining children had mild or moderate clinical and/or laboratory adverse reactions. Age, sex, viral etiology of chronic hepatitis and response to therapy were not significantly associated with the appearance of side effects. The pre-IFN health-related quality of life was good in all children; it deteriorated significantly during IFN therapy and returned to basal standards within 3 months after IFN withdrawal. No patient required suspension of IFN therapy because of worsening of health-related quality of life.

CONCLUSION

Children have a low risk of developing severe IFN-induced side effects. Adverse reactions and worsening of health-related quality of life were tolerable and did not seem to be a limiting factor for IFN therapy in young candidates.