Perinatal Transmission of Hepatitis C Virus: Defining the Cascade of Care

Cost-Effectiveness of Strategies for Treatment Timing for Perinatally Acquired Hepatitis C Virus

Importance

Prevalence of chronic hepatitis C virus (HCV) infection among pregnant people is increasing in the US. HCV is transmitted vertically in 7% to 8% of births. Direct-acting antiviral (DAA) therapy was recently approved for children with HCV who are 3 years or older. The clinical and economic impacts of early DAA therapy for young children with HCV, compared with treating at older ages, are unknown.

Objective

To develop a state-transition model to project clinical and economic outcomes for children with perinatally acquired HCV to investigate the cost-effectiveness of treating at various ages.

Design, Setting, and Participants

The study team modeled the natural history of perinatally acquired HCV to simulate disease progression and costs of a simulated a cohort of 1000 US children with HCV from 3 years old through death. Added data were analyzed January 5, 2021, through July 1, 2022.

Interventions

The study compared strategies offering 8 weeks of DAA therapy at 3, 6, 12, or 18 years old, as well as a comparator of never treating HCV.

Main Outcomes and Measures

Outcomes of interest include life expectancy from 3 years and average lifetime per-person health care costs. Other clinical outcomes include cases of cirrhosis, decompensated cirrhosis, and hepatocellular carcinoma (HCC).

Results

The study team projected that treating HCV at 3 years old was associated with lower mean lifetime per-person health care costs ($148 162) than deferring treatment until 6 years old ($164 292), 12 years old ($171 909), or 18 years old ($195 374). Projected life expectancy was longest when treating at 3 years old (78.36 life years [LYs]) and decreased with treatment deferral until 6 years old (76.10 LYs), 12 years old (75.99 LYs), and 18 years old (75.46 LYs). In a cohort of 1000 children with perinatally acquired HCV, treating at 3 years old prevented 89 projected cases of cirrhosis, 27 cases of HCC, and 74 liver-related deaths compared with deferring treatment until 6 years old. In sensitivity analyses, increasing loss to follow-up led to even greater clinical benefits and cost savings with earlier treatment.

Conclusions and Relevance

These study results showed that DAA therapy for 3-year-old children was projected to reduce health care costs and increase survival compared with deferral until age 6 years or older. Measures to increase DAA access for young children will be important to realizing these benefits.

Forecasting Hepatitis C Virus Status for Children in the United States: A Modeling Study

BACKGROUND

Virtually all cases of hepatitis C virus (HCV) infection in children in the United States occur through vertical transmission, but it is unknown how many children are infected. Cases of maternal HCV infection have increased in the United States, which may increase the number of children vertically infected with HCV. Infection has long-term consequences for a child's health, but treatment options are now available for children ≥3 years old. Reducing HCV infections in adults could decrease HCV infections in children.

METHODS

Using a stochastic compartmental model, we forecasted incidence of HCV infections in children in the United States from 2022 through 2027. The model considered vertical transmission to children <13 years old and horizontal transmission among individuals 13-49 years old. We obtained model parameters and initial conditions from the literature and the Centers for Disease Control and Prevention's 2021 Viral Hepatitis Surveillance Report.

RESULTS

Model simulations assuming direct-acting antiviral treatment for children forecasted that the number of acutely infected children would decrease slightly and the number of chronically infected children would decrease even more. Alone, treatment and early screening in individuals 13-49 years old reduced the number of forecasted cases in children and, together, these policy interventions were even more effective.

CONCLUSIONS

Based on our simulations, acute and chronic cases of HCV infection are remaining constant or slightly decreasing in the United States. Improving early screening and increasing access to treatment in adults may be an effective strategy for reducing the number of HCV infected children in the United States.

Food Pantry Referral and Utilization in a Pediatric Primary Care Clinic

INTRODUCTION

This study aimed to characterize progression from screening for food insecurity risk to on-site food pantry referral to food pantry utilization in pediatric primary care.

METHODS

This retrospective study included 14,280 patients aged 0-21 years with ≥1 pediatric primary care visit from March 2018 to February 2020. Analyses were conducted in 2020-2022 using multivariable regression to examine patient-level demographic, clinical, and socioeconomic characteristics and systems-related factors associated with progression from screening positive for food insecurity risk to food pantry referral to completing ≥1 food pantry visit.

RESULTS

Of patients screened for food insecurity risk, 31.9% screened positive; 18.5% of food-insecure patients received an on-site food pantry referral. Among patients referred, 28.9% visited the food pantry. In multivariable models, higher odds of referral were found for patients living near the clinic (AOR=1.28; 95% CI=1.03, 1.59), for each additional health-related social need reported (AOR=1.23; 95% CI=1.16, 1.29), and when the index clinic encounter occurred during food pantry open hours (AOR=1.62; 95% CI=1.30, 2.02). Higher odds of food pantry visitation were found for patients with a preferred language of Haitian Creole (AOR=2.16; 95% CI=1.37, 3.39), for patients of Hispanic race/ethnicity (AOR=3.67; 95% CI=1.14, 11.78), when the index encounter occurred during food pantry open hours (AOR=1.96; 95% CI=1.25, 3.07), for patients with a clinician letter referral (AOR=6.74; 95% CI=3.94, 11.54), or for patients with a referral due to a screening-identified food emergency (AOR=2.27; 95% CI=1.30, 3.96).

CONCLUSIONS

There was substantial attrition along the pathway from screening positive for food insecurity risk to food pantry referral and utilization as well as patient-level characteristics and systems-related factors associated with successful referrals and utilization.

Maternal neighbourhood-level social determinants of health and their association with paediatric hepatitis C screening among children exposed to hepatitis C in pregnancy

BACKGROUND

Current guidelines recommend HCV screening by 18 months of age for those exposed to HCV in utero; yet, screening occurs in the minority of children.

OBJECTIVES

To evaluate the association between maternal neighbourhood-level social determinants of health (SDOH) and paediatric HCV screening in the general population in a publicly funded healthcare system in Canada.

METHODS

Retrospective cohort study using administrative healthcare data held at ICES. Children born to individuals positive for HCV RNA in pregnancy from 2000 to 2016 were identified and followed for 2 years. Major SDOH were identified, and the primary outcome was HCV screening in exposed children (HCV antibody and/or RNA). Associations between SDOH and HCV screening were determined using multivariate Poisson regression models adjusting for confounding.

RESULTS

A total of 1780 children born to persons with +HCV RNA were identified, and 29% (n = 516) were screened for HCV by age two. Most mothers resided in the lowest income quintile (42%), and most vulnerable quintiles for material deprivation (41%), housing instability (38%) and ethnic diversity (26%) with 11% living in rural locations. After adjustment for confounding, maternal rural residence (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.62, 1.07) and living in the highest dependency quintile (RR 0.83, 95% CI 0.65, 1.07) were the SDOH most associated with paediatric HCV screening. Younger maternal age (RR 0.98 per 1-year increase, 95% CI 0.97, 0.99), HIV co-infection (RR 1.69, 95% CI 1.16, 2.48) and GI specialist involvement (RR 1.18, 95% CI 1.00, 1.39) were associated with higher probabilities of screening.

CONCLUSIONS

Among children exposed to HCV during pregnancy, rural residences and living in highly dependent neighbourhoods showed a potential association with a lower probability of HCV screening by the age of 2. Future work evaluating barriers to paediatric HCV screening among rural residing and dependent residents is needed to enhance the screening.

Hepatitis C virus detection and management after implementation of universal screening in pregnancy

BACKGROUND

Accurately identifying cases of hepatitis C virus has important medical and public health consequences. In the setting of rising hepatitis C virus prevalence and highly effective treatment with direct-acting antivirals, the Society for Maternal-Fetal Medicine guidelines recently changed to recommend universal screening for hepatitis C virus during pregnancy. However, there is little data on the influence of this policy change on case identification and management.

OBJECTIVE

We aimed to examine the influence of universal hepatitis C virus screening on our patient population. Our primary objective was to determine if there was a difference in the detected hepatitis C virus prevalence after the policy change. Our secondary objectives were to determine which factors were associated with a positive test for hepatitis C virus and to examine postpartum management of pregnant patients living with hepatitis C virus, including the (1) gastroenterology referral rate, (2) treatment rate, (3) infantile hepatitis C virus screening rate, and (4) factors associated with being referred for treatment.

STUDY DESIGN

We conducted a single-center, retrospective cohort study of deliveries that occurred before (July 2018-June 2020) and after (July 2020-December 2021) the implementation of universal hepatitis C virus screening. Information on hepatitis C virus and HIV status, if patients were screened for hepatitis C virus, history of intravenous drug use, and basic demographic information were abstracted from the electronic medical records. A subset of patients was administered a questionnaire regarding hepatitis C virus risk factors. For all patients who tested positive for hepatitis C virus, information on if they were referred for treatment in the postpartum period and if their infant was screened for hepatitis C virus were abstracted from the electronic medical records.

RESULTS

A total of 8973 deliveries occurred during this study period. A total of 71 (0.79%) patients had a detectable viral load. With implementation of universal screening, hepatitis C virus screening rates increased from 5.78% to 77.25% of deliveries (P<.01). The hepatitis C virus prevalence rates before and after universal screening was implemented were 0.78% and 0.81%, respectively (P=.88). There were significant demographic shifts in our pregnant population over this time period, including a reduction in intravenous drug use. A subset of 958 patients completed a hepatitis C virus risk factor questionnaire, in addition to undergoing universal hepatitis C virus screening. Ten patients screened positive with universal screening; only 8 of these individuals would have been identified with risk-based screening. Among the patients with a detectable viral load, 67.61% were referred for treatment and 18.75% were treated. A multivariate logistic regression model indicated that intravenous drug use was associated with significantly decreased odds of being referred for treatment (odds ratio, 0.14; 95% confidence interval, 0.04-0.59; P=.01). At the time of our evaluation, 52 infants were at least 18 months old and thus eligible for hepatitis C virus screening. Among these infants, 8 (15.38%) were screened for hepatitis C virus, and all were negative.

CONCLUSION

Following the practice shift, we saw a significant increase in hepatitis C virus screening during pregnancy. However, postpartum treatment and infant screening remained low. Intravenous drug use was associated with a decreased likelihood of being referred for treatment. Pregnancy represents a unique time for hepatitis C virus case identification, although better linkage to care is needed to increase postpartum treatment.

CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children - United States, 2023

The elimination of hepatitis C is a national priority (https://www.hhs.gov/sites/default/files/Viral-Hepatitis-National-Strategic-Plan-2021-2025.pdf). During 2010-2021, hepatitis C virus (HCV) acute and chronic infections (hereinafter referred to as HCV infections) increased in the United States, consequences of which include cirrhosis, liver cancer, and death. Rates of acute infections more than tripled among reproductive-aged persons during this time (from 0.8 to 2.5 per 100,000 population among persons aged 20-29 years and from 0.6 to 3.5 among persons aged 30-39 years). Because acute HCV infection can lead to chronic infection, this has resulted in increasing rates of HCV infections during pregnancy. Approximately 6%-7% of perinatally exposed (i.e., exposed during pregnancy or delivery) infants and children will acquire HCV infection. Curative direct-acting antiviral therapy is approved by the Food and Drug Administration for persons aged ≥3 years. However, many perinatally infected children are not tested or linked to care. In 2020, because of continued increases in HCV infections in the United States, CDC released universal screening recommendations for adults, which included recommendations for screening for pregnant persons during each pregnancy (Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC recommendations for hepatitis C screening among adults-United States, 2020. MMWR Recomm Rep 2020;69[No. RR-2]:1-17). This report introduces four new CDC recommendations: 1) HCV testing of all perinatally exposed infants with a nucleic acid test (NAT) for detection of HCV RNA at age 2-6 months; 2) consultation with a health care provider with expertise in pediatric hepatitis C management for all infants and children with detectable HCV RNA; 3) perinatally exposed infants and children with an undetectable HCV RNA result at or after age 2 months do not require further follow-up unless clinically warranted; and 4) a NAT for HCV RNA is recommended for perinatally exposed infants and children aged 7-17 months who previously have not been tested, and a hepatitis C virus antibody (anti-HCV) test followed by a reflex NAT for HCV RNA (when anti-HCV is reactive) is recommended for perinatally exposed children aged ≥18 months who previously have not been tested. Proper identification of perinatally infected children, referral to care, and curative treatment are critical to achieving the goal of hepatitis C elimination.

Hepatitis C

Hepatitis C virus (HCV) is a hepatotropic RNA virus that can cause acute and chronic hepatitis, with progressive liver damage resulting in cirrhosis, decompensated liver disease, and hepatocellular carcinoma. In 2016, WHO called for the elimination of HCV infection as a public health threat by 2030. Despite some progress, an estimated 57 million people were living with HCV infection in 2020, and 300 000 HCV-related deaths occur per year. The development of direct-acting antiviral therapy has revolutionised clinical care and generated impetus for elimination, but simplified and broadened HCV screening, enhanced linkage to care, and higher coverage of treatment and primary prevention strategies are urgently required.

Retrospective analysis of vertical Hepatitis C exposure and infection in children in Western New York

BACKGROUND

Vertical transmission of hepatitis C virus (HCV) is the primary cause of hepatitis C in the pediatric population. Nonetheless, only a small proportion of HCV-exposed children are tested. This study aimed to measure the proportion of HCV-exposed children tested and infected in Western New York and to identify factors influencing the odds of testing and infection in this population.

METHODS

This was a 11-year retrospective chart review study in which clinical, demographic, and behavioral data for HCV-exposed children and their mothers were collected. This period included year 2019 when a hepatitis C program began promoting early hepatitis C screening among infants born to mothers positive for hepatitis C. PCR-based detection of hepatitis C was used for children under 18 months of age and antibody testing for children above 18 months of age, followed by PCR if the antibody testing was positive. Logistic regression models were used to determine which characteristics associate with testing and infection status.

RESULTS

From a total of 133 children evaluated in clinic for hepatitis C from 2011 to 2021, 96.2% (128/133) were seen from 2019 to 2021. Among the 133 HCV-exposed children in our sample, 72.1% (96/133) were tested for HCV, 62.4% (83/133) were tested by PCR, 9.0% (12/133) tested by antibody, and 5.2% (5/95) of those tested were infected. Only one child out of 12 was positive for hepatitis C antibody yet, subsequent PCR testing was negative in this child. Among all five hepatitis C infected children, four were diagnosed with neonatal abstinence syndrome, five had maternal history of illicit drug use, one had maternal history of HIV infection, and all of them were identified after the hepatitis C program open in 2019. The odds of a child being tested were lower for those accompanied by their biological mother at their clinic visit (odds ratio, 0.16; 95% CI, 0.06-0.45).

CONCLUSIONS

Screening programs on hepatitis C vertical transmission improved detection of hepatitis C among exposed children. The proportion of children born to mothers with hepatitis C in Western New York that were positive for hepatitis C was 5.2%, suggesting that similar proportion of exposed infants born before 2019 were lost for follow up.

Trends in the Prevalence of Hepatitis C Infection During Pregnancy and Maternal-Infant Outcomes in the US, 1998 to 2018

Importance

Injection drug use is the primary risk factor for hepatitis C virus (HCV) infection in adults. More than one-third of newly reported HCV cases occur in women, particularly among persons aged 20 to 39 years. However, nationally representative data on HCV during pregnancy are limited.

Objective

To estimate the temporal trend of HCV-positive pregnancies during the opioid epidemic and identify HCV-associated maternal and perinatal outcomes.

Design, Setting, and Participants

A cross-sectional study was performed with data from the US, from calendar year 1998 through 2018. Data analysis was conducted from November 14, 2021, to May 14, 2023. Participants included women during in-hospital childbirth or spontaneous abortion in the National Inpatient Sample of the Healthcare Cost and Utilization Project.

Exposure

Maternal HCV infection.

Main Outcomes and Measures

The main outcome was the temporal trend, measured as change in the annual prevalence, in the prevalence of HCV positivity among pregnant women since the start of the opioid epidemic in the late 1990s. Secondary outcomes were the associations shown as relative odds between maternal HCV infection and maternal and perinatal adverse events.

Results

During the study period, more than 70 million hospital admissions resulted in childbirth or spontaneous abortion. Among them, 137 259 (0.20%; 95% CI, 0.19%-0.21%) involved mothers with HCV; these individuals were more often White (77.4%; 95% CI, 76.1%-78.6%), low-income (40.0%; 95% CI, 38.6%-41.5%), and likely to have histories of tobacco (41.7%; 95% CI, 40.6%-42.9%), alcohol (1.8%; 95% CI, 1.6%-2.0%), and opioid (28.9%; 95% CI, 27.3%-30.6%) use compared with HCV-negative mothers. The median age of women with HCV was 28.0 (IQR, 24.3-32.2) years, and the median age of HCV-negative women was 27.2 (IQR, 22.7-31.8) years. The prevalence of HCV-positive pregnancies increased 16-fold during the study period, reaching 5.3 (95% CI, 4.9-5.7) cases per 1000 pregnancies in 2018. Age-specific prevalence increases ranged from 3-fold (age, 41-50 years) to 31-fold (age, 21-30 years). Higher odds of cesarean delivery, preterm labor, poor fetal growth, or fetal distress were associated with HCV-positivity during pregnancy. However, no significant differences were observed in gestational diabetes, preeclampsia, eclampsia, or stillbirths.

Conclusions and Relevance

In this cross-sectional study, the prevalence of HCV-positive pregnancies increased markedly, and maternal HCV infection was associated with increased risks for adverse perinatal outcomes. These data may support recent recommendations for universal HCV screening with each pregnancy.

Cost-Effectiveness of Strategies to Identify Children with Perinatally Acquired Hepatitis C Infection

OBJECTIVE

To determine the optimal testing strategy to identify children with perinatally acquired hepatitis C virus (HCV) infection.

STUDY DESIGN

We used a decision-tree framework with a Markov disease progression model to conduct an economic analysis of 4 strategies, based on combinations of type and timing of test: anti-HCV with reflex to HCV RNA at 18 months among children known to be perinatally exposed (ie, baseline comparison strategy); HCV RNA testing at 2-6 months among infants known to be perinatally exposed (test strategy 1); universal anti-HCV with reflex to HCV RNA at 18 months among all children (test strategy 2); and universal HCV RNA testing at 2-6 months among all infants (test strategy 3). We estimated total cost, quality-adjusted life years, and disease sequalae for each strategy.

RESULTS

Each of the 3 alternative testing strategies resulted in an increased number of children tested and improved health outcomes. HCV RNA testing at 2-6 months (test strategy 1) was cost-saving and resulted in a population-level difference in cost of $469 671. The 2 universal testing strategies resulted in an increase in quality-adjusted life years and an increase in total costs.

CONCLUSIONS

Testing of perinatally exposed infants at age 2-6 months with a single HCV RNA test will reduce costs and improve health outcomes, preventing morbidity and mortality associated with complications from perinatal HCV infections.

Spontaneous Clearance of Vertically Acquired Hepatitis C Infection: Implications for Testing and Treatment

BACKGROUND

Current guidelines recommend that infants born to women with hepatitis C virus (HCV) viremia be screened for HCV antibody at age 18 months and, if positive, referred for RNA testing at 3 years to confirm chronic infection. This policy is based, in part, on analyses that suggest that 25%-40% of vertically acquired HCV infections clear spontaneously within 4-5 years.

METHODS

Data on 179 infants with HCV RNA and/or anti-HCV evidence of vertically acquired infection in 3 prospective European cohorts were investigated. Ages at clearance of infection were estimated taking account of interval censoring and delayed entry. We also investigated clearance in initially HCV RNA-negative infants in whom RNA was not detectable until after 6 weeks.

RESULTS

Clearance rates were initially high then declined slowly. Apparently, many infections clear before they can be confirmed. An estimated 65.9% (95% credible interval [CrI], 50.1-81.6) of confirmed infections cleared by 5 years, at a median 12.4 (CrI, 7.1-18.9) months. If treatment were to begin at age 6 months, 18 months, or 3 years, at least 59.0% (CrI, 42.0-76.9), 39.7% (CrI, 17.9-65.9), and 20.9% (CrI, 4.6-44.8) of those treated would clear without treatment. In 7 (6.6%) confirmed infections, RNA was not detectable until after 6 weeks and not until after 6 months in 2 (1.9%). However, all such cases subsequently cleared.

CONCLUSIONS

Most confirmed infection cleared by age 3 years. Treatment before age 3, if it was available, would avoid loss to follow-up but would result in substantial overtreatment.

Overall Vertical Transmission of Hepatitis C Virus, Transmission Net of Clearance, and Timing of Transmission

BACKGROUND

It is widely accepted that the risk of hepatitis C virus (HCV) vertical transmission (VT) is 5%-6% in monoinfected women, and that 25%-40% of HCV infection clears spontaneously within 5 years. However, there is no consensus on how VT rates should be estimated, and there is a lack of information on VT rates "net" of clearance.

METHODS

We reanalyzed data on 1749 children in 3 prospective cohorts to obtain coherent estimates of overall VT rate and VT rates net of clearance at different ages. Clearance rates were used to impute the proportion of uninfected children who had been infected and then cleared before testing negative. The proportion of transmission early in utero, late in utero, and at delivery was estimated from data on the proportion of HCV RNA positive within 3 days of birth, and differences between elective cesarean and nonelective cesarean deliveries.

RESULTS

Overall VT rates were 7.2% (95% credible interval [CrI], 5.6%-8.9%) in mothers who were human immunodeficiency virus (HIV) negative and 12.1% (95% CrI, 8.6%-16.8%) in HIV-coinfected women. The corresponding rates net of clearance at 5 years were 2.4% (95% CrI, 1.1%-4.1%), and 4.1% (95% CrI, 1.7%-7.3%). We estimated that 24.8% (95% CrI, 12.1%-40.8%) of infections occur early in utero, 66.0% (95% CrI, 42.5%-83.3%) later in utero, and 9.3% (95% CrI, 0.5%-30.6%) during delivery.

CONCLUSIONS

Overall VT rates are about 24% higher than previously assumed, but the risk of infection persisting beyond age 5 years is about 38% lower. The results can inform design of trials of interventions to prevent or treat pediatric HCV infection, and strategies to manage children exposed in utero.

Pediatric Hepatitis C Quality Improvement Project Improves Healthcare Access

OBJECTIVES

Incidence of hepatitis C virus (HCV) infection is increasing in women of reproductive age, leading to increased prevalence of HCV infection in children via vertical transmission. This quality improvement (QI) project aimed to increase referrals to and appointments scheduled with a specialty pediatric gastroenterology HCV clinic and the number of eligible children with HCV who completed treatment.

METHODS

From July 2020 to August 2021, the QI team designed a project using the Model for Improvement and completed Plan Do Study Act cycles to test change ideas to improve HCV awareness and education for medical providers and families; standardize the referral process; track patients; increase clinic capacity; and connect families with community resource care coordination. Referrals to the pediatric HCV clinic, appointments scheduled, no shows, and treatment follow-up were tracked during the project period and a comparison timeframe from July 2019 to June 2020.

RESULTS

There were improvements in several measures during the project period versus the comparison timeframe, with 80 versus 48 referrals received (66% increase), 115 versus 59 scheduled clinic visits (95% increase), and 7 versus 5 treatment completers (40% increase), along with a small (7%) decline in the proportion of scheduled clinic visits that were no shows.

CONCLUSION

Application of QI methodology increased medical provider and caregiver awareness and engagement in accessing HCV healthcare available for at-risk children. More QI efforts should be accelerated to identify best practices amidst a nationwide HCV epidemic.

Hepatitis C Virus Cascade of Care Among Perinatal Patients in Maine Diagnosed With Opioid Use Disorder, 2015-2020

OBJECTIVE

This is a quality improvement project to determine the best process to identify and address gaps in care for perinatal patients in receiving appropriate hepatitis C virus (HCV) testing and treatment across the largest health system in Maine.

STUDY DESIGN

We reviewed electronic medical record data between October 1, 2015, and February 1, 2020, to investigate rates of HCV testing and treatment among 916 perinatal patients with opioid use disorder across 8 hospitals using a "cascade of care" framework, a model used previously to identify gaps in care and treatment of chronic diseases.

MAIN OUTCOME MEASURE

We examined HCV testing and treatment rates along the cascade of care and patient characteristics associated with HCV antibody testing and treatment, separately, using log binomial regression models. Models were adjusted for age, residential distance to medical center, psychiatric diagnosis, and opioid agonist therapy at delivery.

RESULTS

Of pregnant patients eligible for screening, 64% (582/916) received HCV antibody testing. Of 136 patients with active HCV infection, 32% (n = 43) received a referral for treatment, 21% (n = 28) were treated, and 13% (n = 18) achieved sustained virologic response. In the adjusted regression models, only opioid agonist therapy was associated with HCV antibody testing (adjusted risk ratio, 1.31; 95% confidence interval, 1.18-1.46), and no factors were significantly associated with receipt of treatment among HCV viremic patients.

CONCLUSION

Low referral and treatment rates signify the need for quality improvement interventions to improve coordination of care between multiple disciplines and practice settings to increase access to HCV treatment.

Hepatitis C Virus Exposure and Infection in the Perinatal Period

BACKGROUND

Hepatitis C virus infection is a leading cause of blood-borne hepatitis disease worldwide. Hepatitis C is a silent liver disease that, without treatment, leads to late-onset complications, including chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma, in 10-40% of patients.

OBJECTIVE

This study aimed to review the epidemiology, clinical features, diagnosis, treatment, and prevention of hepatitis C among perinatally exposed children.

METHODS

Public databases, including MEDLINE and PubMed, and websites from the Centers for Disease Control and Prevention, the Food and Drug Administration, the World Health Organization, and the National Institutes of Health were searched for relevant articles published between 2006 and 2021.

RESULTS

The prevalence of hepatitis C has increased among women of childbearing age in the United States and is associated with risk factors, such as intravenous drug use, health inequities, and low socioeconomic background. Infants born to hepatitis C virus-infected mothers have a 6% risk of vertical transmission, and among those infected, 75% will develop chronic hepatitis C and late complications. However, hepatitis C-exposed infants are frequently lost to follow-up, and those infected have delayed diagnosis and treatment and are at high risk for late-onset complications. Direct- acting antivirals and the establishment of effective treatment guidelines cure hepatitis C virus infections.

CONCLUSION

Hepatitis C predominantly affects underserved communities. Early screening of mothers and infants is critical for the diagnosis, treatment, and prevention of chronic infections and lateonset complications. New policies are needed to address hepatitis C health care inequities affecting mothers and infants in the United States.

Nucleic Acid Testing for Diagnosis of Perinatally Acquired Hepatitis C Virus Infection in Early Infancy

BACKGROUND

Most US children with perinatal hepatitis C virus (HCV) exposure fail to receive the recommended anti-HCV antibody test at age ≥18 months. Earlier testing for viral RNA might facilitate increased screening, but sensitivity of this approach has not been established. We hypothesized that modern HCV-RNA RT-PCR platforms would adequately detect infected infants.

METHODS

Nationwide Children's Hospital electronic health records from 1/1/2008 to 30/6/2018 were reviewed to identify perinatally exposed infants tested by HCV-RNA RT-PCR at age 2-6 months. Diagnostic performance was determined using a composite case definition: (1) infected children had positive repeat HCV-RNA testing or positive anti-HCV at age ≥24 months; (2) uninfected children lacked these criteria and had negative anti-HCV at age ≥18 months.

RESULTS

770 perinatally exposed infants underwent HCV-RNA testing at age 2-6 months. Of these, 28 (3.6%) tested positive; viremia was confirmed in all who underwent repeat testing (n = 27). Among 742 infants with negative HCV-RNA results, 226 received follow-up anti-HCV testing at age ≥18 months, of whom 223 tested negative. Three children had low-positive anti-HCV results at age 18-24 months that were negative upon retesting after age 24 months, possibly indicating waning maternal antibodies. Using the composite case definitions, early HCV-RNA screening demonstrated sensitivity of 100% (87.5-100%, Wilson-Brown 95% CI) and specificity of 100% (98.3-100%).

CONCLUSIONS

Modern HCV-RNA RT-PCR assays have excellent sensitivity for early diagnosis of perinatally acquired infection and could aid HCV surveillance given the substantial loss to follow-up at ≥18 months of age.

An Evaluation of Hepatitis C Screening in Infants and Children Born to Seropositive Mothers in Saint John, New Brunswick

Background: The primary route of hepatitis C virus (HCV) infection in children is vertical transmission, from mother to fetus in utero. There is a lack of data on the prevalence of pediatric HCV acquired through vertical transmission in Saint John, New Brunswick. Furthermore, what risk factors may be associated with an increased likelihood for a child born to an HCV-seropositive mother should be known to direct screening practices.

Methods: A retrospective chart review of the active charts from the local HCV clinic, the Centre for Research, Education & Clinical Care of At-Risk Populations (RECAP), identified HCV-seropositive women who had children at-risk of HCV through vertical transmission. Sociodemographic information and various risk factors were collected, including maternal HCV genotype, non-prescription drug use subcategorized into intravenous drug use and snorting, transfusion history, involvement in opiate substitution therapy, postal code as a proxy for socioeconomic status, and issues of custodianship within the family. A 2 x 2 chi-square analysis was conducted to assess the frequency of HCV screening for children by the presence or absence of familial custodianship issues.

Results: In total, data from 62 HCV-seropositive women and 123 infants and children at-risk for HCV were included in this study. HCV status at the time of pregnancy revealed 18 (14.6%) with a positive HCV screen, 14 (11.4%) with a positive viral load, and 91 (74.0%) with unknown status. A total of 30 children (24.4%) had HCV screening performed, of which three (10.0%) were HCV-antibody positive and had a detectable viral load. Results of the chi-square analysis indicated that issues of custodianship had no significant influence on child screening rates.

Conclusion: Overall, this study highlighted the inconsistent screening practices of children at-risk for HCV through vertical transmission, as well as the need for improvement in chart documentation and follow-up. Clinicians and researchers should focus their efforts toward proactively identifying children at-risk for HCV through vertical transmission. This could involve screening during pregnancy and subsequent follow-up, or at other points of contact with the healthcare system, such as parental involvement with opioid substitution therapy or well-child visits. Implementation of a targeted screening program could be considered in urban centers similar to the one in this study to connect at-risk populations with essential medical and community services.

Enhancing Linkage to Hepatitis C Virus Treatment Following Pregnancy in Women Identified During Perinatal Care

Amid the current US opioid crisis, hepatitis C virus (HCV) infection rates continue to rise in young adults, including among pregnant women, yet few studies describe linkage to care and treatment in pregnant or postpartum women with HCV infection. We used electronic health record data to estimate HCV treatment rates for postpartum women before (January 2014-September 2016) and during (October 2016-March 2018) implementation of a maternal-infant HCV linkage program in combination with a multidisciplinary clinic to colocate mother and infant care. Using Poisson regression models, we compared HCV treatment initiation rates, adjusting for demographics, substance use, and treatment. From January 2014 through March 2018, 343 women who were HCV seropositive delivered at our institution. Of these, 95% completed HCV nucleic acid testing and 255 women had chronic HCV infection. Mean age was 30 years, 96% were publicly insured, and 94% had documented substance use. HCV treatment initiation increased from 28/164 (17.1%) women with chronic HCV infection in the preintervention period to 16/66 (24.2%) with the linkage-only intervention and 13/25 (52.0%) with the linkage intervention and colocated care. Adjusted analyses demonstrated that women delivering during the intervention period initiated HCV treatment at 2.40 times (95% confidence interval [CI], 1.10-5.25; linkage only) and 3.36 times (95% CI, 1.57-7.17; linkage and colocated care) the rate of women delivering preintervention. Women on buprenorphine had higher HCV treatment initiation rates compared with those on methadone (rate ratio, 2.10; 95% CI, 1.05-4.21). Conclusion: HCV linkage to care and treatment rates improved in the setting of mother-infant linkage and colocated care interventions. Perinatal care may represent a critical venue to identify, link, and treat women for HCV infection to improve their own health and prevent transmission to subsequent pregnancies.

Responsible Inclusion of Pregnant Individuals in Eradicating HCV

HCV infections have increased in recent years due to injection drug use and the opioid epidemic. Simultaneously, HCV cure has become a reality, with the advent of direct-acting antivirals (DAAs) and expansion of treatment programs. As a result, HCV screening recommendations now include all adults, including pregnant individuals; and many countries have endorsed widespread DAA access as a strategy to achieve HCV eradication. However, almost universally, pregnant individuals have been systematically excluded from HCV clinical research and treatment programs. This omission runs counter to public health strategies focused on elimination of HCV but is consistent with a historical pattern of exclusion of pregnant individuals from research. Our systematic review of publications on HCV treatment with DAAs in pregnancy revealed only one interventional study, which evaluated sofosbuvir/ledipasvir in 8 pregnant individuals. Given the paucity of research on this issue of great public health importance, we aimed to appraise the current landscape of HCV research/treatment and analyze the ethical considerations for responsibly including pregnant individuals. We propose that pregnancy may be an opportune time to offer HCV treatment given improved access, motivation, and other health care monitoring occurring in the antenatal period. Moreover, treatment of pregnant individuals may support the goal of eliminating perinatal HCV transmission and overcome the established challenges with transitioning care after delivery. The exclusion of pregnant individuals without justification denies them and their offspring access to potential health benefits, raising justice concerns considering growing data on DAA safety and global efforts to promote equitable and comprehensive HCV eradication. Finally, we propose a path forward for research and treatment programs during pregnancy to help advance the goal of HCV elimination.

Current impact of viral hepatitis on liver cancer development: The challenge remains

Chronic infections due to hepatitis B and hepatitis C viruses are responsible for most cases of hepatocellular carcinoma (HCC) worldwide, and this association is likely to remain during the next decade. Moreover, viral hepatitis-related HCC imposes an important burden on public health in terms of disability-adjusted life years. In order to reduce such a burden, some major challenges must be faced. Universal vaccination against hepatitis B virus, especially in the neonatal period, is probably the most relevant primary preventive measure against the development of HCC. Moreover, considering the large adult population already infected with hepatitis B and C viruses, it is also imperative to identify these individuals to ensure their access to treatment. Both hepatitis B and C currently have highly effective therapies, which are able to diminish the risk of development of liver cancer. Finally, it is essential for individuals at high-risk of HCC to be included in surveillance programs, so that tumors are detected at an early stage. Patients with hepatitis B or C and advanced liver fibrosis or cirrhosis benefit from being followed in a surveillance program. As hepatitis B virus is oncogenic and capable of leading to liver cancer even in individuals with early stages of liver fibrosis, other high-risk groups of patients with hepatitis B are also candidates for surveillance. Considerable effort is required concerning these strategies in order to decrease the incidence and the mortality of viral hepatitis-related HCC.

Hepatitis C Virus in Neonates and Infants

Hepatitis C virus prevalence has steeply risen among pregnant women in association with the opioid epidemic and the major national infectious diseases and liver society guidelines recommend universal hepatitis C virus testing in pregnancy. All infants born to mothers with hepatitis C virus infection should be evaluated. Many children spontaneously clear hepatitis C virus or remain minimally symptomatic, but some develop significant liver disease if untreated. With hepatitis C virus cure available starting at age 3, we must improve programs to identify and cure hepatitis C virus-infected women and infants with the goal of eliminating mother-to-child transmission.

Cascade of care for children and adolescents with chronic hepatitis C. World J Gastroenterol 2021;27:1117-1131. [PMID: 33828389 PMCID: PMC8006101 DOI: 10.3748/wjg.v27.i12.1117]

Chronic hepatitis C virus (HCV) infection presents a significant global public health burden. In 2015, over 400000 deaths worldwide were attributed to HCV infection. This led the World Health Organization (WHO) in 2016 to set the ambitious goal of eliminating HCV by 2030. Adult-centered guidelines have been established in order to provide direction for healthcare professionals, allowing integration of the newest screening policies and therapeutic strategies into their practices. However, for children and adolescents, HCV is a significant, unrecognized public health problem. HCV infection rates in the United States in women of childbearing age and those who are pregnant have increased in parallel with the rising opioid epidemic. An estimated 29000 women with HCV infection gave birth each year from 2011 to 2014 in the United States, with approximately 1700 of their infants being infected with HCV. Newer HCV-specific therapeutics, namely direct acting antivirals (DAA), has brought a new and highly successful approach to treatment of hepatitis C. Recent studies have confirmed similar levels of effectiveness and safety of DAA therapies in the pediatric population. Thus, an enhanced cascade of care, which should include the population under 18 years of age, can help achieve the WHO goal by focusing on elimination in the youngest populations. This review will present an overview of the natural history, clinical features, and management of HCV in children and adolescents.

Hepatitis C Virus in Children: Trying to Overcome the Domestic and Global Challenges of Cases and Cost

Over the last decade, Hepatitis C virus has persisted and evolved as a domestic and global health challenge for adults and children. The challenges involve both increased cases in the United States and cost of treatment both in the US and globally.

Maternal risk factors associated with inadequate testing and loss to follow-up in infants with perinatal hepatitis C virus exposure

OBJECTIVES

Inadequate testing (IT) and follow-up in infants with perinatal hepatitis C virus (HCV) exposure are challenging. We sought to identify maternal clinical and demographic risk factors that are associated with inadequate testing (IT) and follow-up of perinatally HCV-exposed infants.

METHODS

In a retrospective cohort study spanning a period of 23 years, medical records of HCV-infected women and their perinatally exposed infants were reviewed for maternal characteristics that could be associated with their infants' IT and loss to follow-up.

RESULTS

A total of 27% (108/407) of HCV-exposed infants were adequately tested (AT) for HCV perinatal transmission. Among AT infants, HCV transmission rate was 11% (12/108). History of maternal intravenous drug use (IVDU) was significantly higher in IT vs. AT infants [88% (193/218) vs. 76% (70/92); p = 0.005]. The percentage of mothers on methadone maintenance treatment during pregnancy was higher in AT vs. IT infants [53% (35/66) vs. 34% (65/186); p = 0.010]. The percentage of mothers with HCV medical care was higher among AT than IT infants [54% (56/102) vs. 41% (106/255); p = 0.022].

CONCLUSIONS

Infants born to HCV-infected mothers have suboptimal testing, possibly leading to an underestimation of the rate of HCV vertical transmission. Infants of mothers receiving HCV medical care and methadone treatment have improved testing. Infants of HCV-positive mothers with history of IVDU have lower rates of testing. Screening HCV-infected pregnant women for history of IVDU and linking them to drug treatment programs, and HCV medical care may improve testing and follow-up in their infants.

Prenatal hepatitis C screening, diagnoses, and follow-up testing in British Columbia, 2008-2019

OBJECTIVE

Current guidelines in British Columbia recommend prenatal screening for hepatitis C antibodies (anti-HCV) if risk factors are present. We aimed to estimate frequency of prenatal anti-HCV testing, new diagnoses, repeated and follow-up testing among BC women.

METHODS

BC Centre for Disease Control Public Health Laboratory data estimated the number of BC women (assigned female at birth or unknown sex) aged 13-49 who received routine prenatal serological screening (HIV, hepatitis B, syphilis and rubella) from 2008-2019. Anti-HCV tests ordered the same day as routine prenatal screens were considered prenatal anti-HCV tests. Assessment of follow-up was based on HCV RNA and/or genotype testing within one year of new prenatal anti-HCV diagnoses.

RESULTS

In 2019, 55,202 routine prenatal screens were carried out for 50,392 BC women. Prenatal anti-HCV tests increased significantly, from 19.6% (9,704/49,515) in 2008 to 54.6% (27,516/50,392) in 2019 (p<0.001). New prenatal anti-HCV diagnoses (HCV positive diagnoses at first test or seroconversions) declined from 14.3% in 2008 to 10.1% in 2019. The proportion of women with new prenatal anti-HCV diagnoses that were a result of a first HCV test declined from 0.3% (29/9,701) in 2008 to 0.03% (8/27,500) in 2019. For women known to be anti-HCV positive at the time of prenatal screening, the proportion who had a prenatal anti-HCV test increased from 35.6% in 2008 to 50.8% in 2019.

CONCLUSION

Prenatal anti-HCV testing increased substantially over the study period. However, new HCV diagnoses remained relatively stable, suggesting that a considerable proportion of BC women with low or no risk are being screened as part of prenatal care. The vast majority of women with new HCV diagnoses receive appropriate follow-up HCV RNA and genotype testing, which may indicate interest in HCV treatment. These findings contribute to the discussion around potential for prenatal anti-HCV screening in an effort to eliminate HCV.

Trends in heroin use among women of reproductive age in the United States, 2004-2017

Opioid use during pregnancy has been linked to several adverse outcomes including stillbirth, preterm birth and neonatal abstinence syndrome. Recent data suggest that heroin use has increased in the United States (US) whereas prescription opioid use has decreased. Prevalence estimates for reproductive age women combine heroin and non-medical prescription opioid use, which might mask the increasing heroin trend. The aim of the current study is to estimate the prevalence of heroin use among US women of reproductive age, stratified by pregnancy status. For each year, a representative sample of the US civilian non-institutionalized population is recruited for the National Survey on Drug Use and Health (NSDUH). Pregnancy status and heroin use were assessed in women 15-44 years of age (n = 277,333) using audio computerized-assisted self-interviews. From 2004 to 2017, the prevalence of past 30-day heroin use was 12 per 10,000 reproductive age women (95% confidence interval [CI] = 11, 14). Heroin use has increased from 6 per 10,000 women in 2004-05 to 18 per 10,000 women in 2016-17 (Average percent change = 20.8; 95% 11.2, 31.2). The increase was evident among non-pregnant women, but not among pregnant women. Heroin use remains uncommon among women of reproductive age, yet its prevalence has increased over time. Screening for heroin use might be needed at multiple time points including prior to pregnancy to mitigate adverse outcomes associated with use during pregnancy.

Estimates of Prenatal HIV, Hepatitis B Virus, and Hepatitis C Virus Testing Among Pregnant People Enrolled in Wisconsin Medicaid, 2011-2015

BACKGROUND

The opioid epidemic and rising rates of injection drug use are increasing the risk of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections among pregnant people. According to national clinical guidelines, pregnant people should be universally tested for HIV and HBV, and risk-based tested for HCV. The aim of this study was to determine the proportion and characteristics of prenatal HIV, HBV, and HCV testing and diagnosis among pregnant people with Wisconsin Medicaid coverage between 2011 and 2015.

METHODS

Wisconsin birth certificates and Medicaid enrollment data were used to identify the sample. Standard billing and diagnosis codes were used to assess study variables. Data for each pregnancy were analyzed to describe the proportion of pregnancies that had evidence of testing, diagnoses, and yearly trends.

RESULTS

Of the 78,917 pregnancies, prenatal testing estimates were 67% for HIV, 73% for HBV, and 6% for HCV. The estimated rate of infections during the study period was 1.82 for HIV, 2.09 for HBV, and 3.52 for HCV per 1000 pregnancies. Compared to the other race/ethnicity groups, pregnant people who were Black were most likely to be tested for HIV (78%) and HBV (80%), and pregnant people who were White were most likely to be tested for HCV (7%).

CONCLUSIONS

Clinical testing guidelines have not been effectively translated to practice. Additionally, compared to HIV and HBV, HCV infections during pregnancy are becoming more prevalent, yet current national HCV screening guidelines are the least comprehensive.

Hepatitis C in 2020: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper

In 1989, a collaboration between the Centers for Disease Control (CDC) and a California biotechnology company identified the hepatitis C virus (HCV, formerly known as non-A, non-B hepatitis virus) as the causative agent in the epidemic of silent posttransfusion hepatitis resulting in cirrhosis. We now know that, the HCV genome is a 9.6 kb positive, single-stranded RNA. A single open reading frame encodes a 3011 amino acid residue polyprotein that undergoes proteolysis to yield 10 individual gene products, consisting of 3 structural proteins (core and envelope glycoproteins E1 and E2) and 7 nonstructural (NS) proteins (p7, NS2, NS3, NS4A, NS4B, NS5A, and NS5B), which participate in posttranslational proteolytic processing and replication of HCV genetic material. Less than 25 years later, a new class of medications, known as direct-acting antivirals (DAAs) which target these proteins, were introduced to treat HCV infection. These highly effective antiviral agents are now approved for use in children as young as 3 years of age and have demonstrated sustained virologic responses exceeding 90% in most genotypes. Although tremendous scientific progress has been made, the incidence of acute HCV infections has increased by 4-fold since 2005, compounded in the last decade by a surge in opioid and intravenous drug use. Unfortunately, awareness of this deadly hepatotropic virus among members of the lay public remains limited. Patient education, advocacy, and counseling must, therefore, complement the availability of curative treatments against HCV infection if this virus is to be eradicated.

Hepatitis C virus screening in pregnancy

BACKGROUND

In 2016, the incidence of acute hepatitis C virus infection was 1.0 per 100,000 persons in the United States and 6.2 per 100,000 persons in Massachusetts. Hepatitis C virus infection among pregnant women in the United States increased by 89% from 2009 to 2014. The risk of a mother with hepatitis C virus infection transmitting the infection to her infant is approximately 4% to 7%. The Infectious Disease Society of America and the American Association for the Study of Liver Diseases recommend universal hepatitis C virus screening in pregnancy, whereas the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommend risk-based screening.

OBJECTIVE

The objective of this quality improvement project was to assess the hepatitis C virus screening practices of obstetricians and gynecologists at a tertiary care center located in a high endemic area for hepatitis C virus infection.

STUDY DESIGN

An electronic 10-question survey was reviewed by the Tufts Medical Center Institutional Review Board and found to be exempt from institutional review board approval. The survey was emailed to resident and attending physicians who provide obstetrical care.

RESULTS

Of a total of 41 respondents, 38 (92.6%) provided responses; of these 38 respondents, 17 (44.7%) were attending physicians, 4 (10.5%) were fellows, and 17 (44.7%) were resident physicians. In addition, 16 of 37 (43.2%) respondents answered that all pregnant women should be screened for hepatitis C virus, whereas 20 of 37 (54.1%) respondents thought only pregnant women with risk factors for hepatitis C virus infection should be screened. Furthermore, only 13 of 31 (41.9%) respondents correctly identified all of the recommended risk factors that should prompt screening for hepatitis C virus. When asked about their clinical practice, 5 of 36 (13.9%) respondents indicated that they screen all pregnant patients, whereas 28 of 36 (77.8%) respondents indicated that they screen patients based on their risk factors for hepatitis C virus infection.

CONCLUSION

Our survey showed that risk-based screening for hepatitis C virus may be less effective than universal screening because healthcare providers are not consistent in identifying risk factors for hepatitis C virus infection. Universal screening could decrease the amount of hepatitis C virus infections that go undiagnosed in pregnancy.

Hepatitis C Testing Among Perinatally Exposed Infants

BACKGROUND

Hepatitis C virus (HCV) prevalence doubled among pregnant women from 2009 to 2014, reaching 3.4 per 1000 births nationwide. Infants exposed to HCV may acquire HCV by vertical transmission. National guidelines recommend that infants exposed to HCV be tested; however, it is unclear if these recommendations are being followed. Our objectives were to determine if infants exposed to HCV were tested and to determine hospital- and patient-level factors associated with differences in testing.

METHODS

In this retrospective cohort study of infants exposed to HCV who were enrolled in the Tennessee Medicaid program, we used vital statistics-linked administrative data for infants born between January 1, 2005, and December 31, 2014. Infants were followed until 2 years old. Multilevel logistic regression was used to assess the association of HCV testing and hospital- and patient-level characteristics.

RESULTS

Only 23% of 4072 infants exposed to HCV were tested. Infants whose mothers were white versus African American (96.6% vs 3.1%; P <.001), used tobacco (78% vs 70%; P <.001), and had HIV (1.3% vs 0.4%; P = .002) were more likely to be tested. Infants exposed to HCV who had a higher median of well-child visits (7 vs 6; P <.001) were more likely to be tested. After accounting for maternal and infant characteristics and health care use patterns, African American infants were less likely to undergo general testing (adjusted odds ratio 0.32; 95% confidence interval, 0.13-0.78).

CONCLUSIONS

Testing occurred in <1 in 4 infants exposed to HCV and less frequently among African American infants. Public health systems need to be bolstered to ensure that infants exposed to HCV are tested for seroconversion.

WITHDRAWN: The next frontier: universal hepatitis C virus screening in pregnant women

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Hepatitis C Virus Infection in Children and Pregnant Women: An Updated Review of the Literature on Screening and Treatments

Objective  The aim of the paper is to review the current information relating to the diagnosis and treatment of hepatitis C virus (HCV) infection in pregnant women and children, particularly those infected by mother-to-child transmission. Study Design  A review of published literature was performed to identify relevant articles published between January 2015 and March 2019 on: HCV infection in pregnant woman, mother-to child-transmission of HCV and HCV infection in pediatrics. The results of the evaluation of the different studies were summarized in two sections describing separately the screening and effective treatments in pregnant women and children. Results  The rate of mother-to-child transmission of HCV is approximately 5%. HCV infection is strongly associated with cholestasis and preterm birth. Prenatal diagnosis of hepatitis C virus has a dual benefit for mother and child. Perinatally infected children develop cirrhosis in earlier age than those who acquire HCV as adolescents. Pregnant women with cirrhosis have a higher risk of poor maternal and neonatal outcomes than those without cirrhosis. Conclusion  To improve public health, universal screening of pregnant women for HCV infection should be performed. Early identification of women and children with HCV infection is important to enable them to be included in assessment and/or treatment programs.

White Matter Injury and Structural Anomalies in Infants with Prenatal Opioid Exposure

Previous studies have not found structural injury or brain malformations in infants and children with prenatal opioid exposure. As part of an ongoing study evaluating neuroimaging in infants with prenatal opioid exposure, we reviewed structural brain MR imaging in 20 term infants with prenatal opioid exposure and 20 term controls at 4-8 weeks of age. We found that 8 of the 20 opioid-exposed infants had punctate white matter lesions or white matter signal abnormality on structural MR imaging, and 2 of the opioid-exposed infants had a septopreoptic fusion anomaly. No controls had white matter injury or structural malformations. Our findings underscore the importance of clinical neurodevelopmental follow-up and the need for more comprehensive imaging and long-term outcomes research following prenatal opioid exposure.

Addressing the Disease Burden of Vertically Acquired Hepatitis C Virus Infection Among Opioid-Exposed Infants

Background

This study aims to estimate the disease burden of vertically acquired hepatitis C virus (HCV) in a large Midwestern hospital and to identify factors associated with HCV diagnostic testing among high-risk infants.

Methods

This is a retrospective analysis of an infant cohort (n = 58 427) born from 2014 to 2016 in the Greater Cincinnati region, where universal maternal urine testing is conducted at delivery to assess for intrauterine drug exposure (IUDE). Demographics and birth characteristics were analyzed among high-risk infants to identify factors associated with receiving HCV testing. A nested, matched, case-control analysis examined the association of pediatric HCV infection and IUDE.

Results

The HCV prevalence rate among high-risk infants who received testing was 3.6%–5.2% of births. Approximately 66.7% of maternally acquired HCV infections may be missed using current testing recommendations. Prenatal care had no significant effect (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 0.4–3.5) on the odds of a high-risk infant receiving HCV testing. Opioid-exposed cases had a more than 6-fold increase in the odds of HCV infection (aOR, 6.2; 95% CI, 2.3–16.6]) compared with nonopioid exposed infants.

Conclusions

The IUDE was significantly associated with increased odds of pediatric HCV infection in this population. The gaps in pediatric HCV testing identified in this study, despite known risk level and maternal infection, suggest the need for increased focus on HCV identification in the pediatric population.

Children and families of the opioid epidemic: Under the radar

As increasing resources are now being directed towards addressing the growing U.S. opioid epidemic, the long-term care of children from opioid-affected families has been relatively neglected. While an array of evidence suggests long-term negative developmental, medical, and social impacts to children related to their parents' opioid use, there remains much to be learned about how best to support children and families to promote healthy outcomes. Here, we report on the launch of an innovative family-centered pediatric medical home for opioid-affected families in Boston. We describe the program, the patient cohort, and early lessons learned. Important themes include the vulnerability of families with infants whose parents are in early recovery, and the need for compassionate, high-touch, high-continuity, team-based care that views the needs of the family as a whole. We recommend a future emphasis on non-stigmatizing, trauma-informed care; centering the needs of the family by addressing social and logistics barriers and by expanding models of parent-child dyadic care; investing in attachment and mental health interventions; developing strategies for prevention of opioid use disorder (OUD) in the next generation; and grounding our advocacy and actions in a social justice approach.

Population-based screening of hepatitis C virus in the United States

PURPOSE OF REVIEW

This review summarized the recent evidence on the performance of population-based hepatitis C virus (HCV) screening, published and indexed to PubMed, in the Unite States during the 2-year window from 1 January 2017 to 31 December 2018.

RECENT FINDINGS

A majority of the selected articles in this review focused on the birth cohort 1945-1965 because of the HCV screening recommendations released after August 2012. However, the articles for the high-risk population applied to all ages because the recommendations for this specific population have remained largely unchanged since 1998. The reported rates of HCV screening varied substantially not only across the three different populations (i.e. general, underserved, and high-risk) but also within each population.

SUMMARY

More vigilant monitoring of HCV screening performance of younger birth cohorts is needed as these individuals have been experiencing a higher incidence of HCV infection than those in the birth cohort 1945-1965. In addition, to meet the goal of eliminating HCV infection as a US public health problem by 2030, significant improvement in more accurately and comprehensively reporting the trends in population-based HCV screening across different populations is warranted in the future.

Hepatitis C in Pregnant Women and Their Children

Hepatitis C virus (HCV) infection presents unique challenges in the setting of pregnancy. HCV can contribute to pregnancy-related morbidity and pregnancy can influence the course of HCV infection. There is a significant risk of transmission to the fetus and newborn infant. Identification of HCV infection in women of childbearing potential and those who are currently pregnant offers important opportunities for the woman and for past, present and future children.

Hepatitis C in Pregnancy: A Unique Opportunity to Improve the Hepatitis C Cascade of Care

Hepatitis C has increasingly affected women of child-bearing age over the past few years as a result of the opioid epidemic. In this review, we discuss the effect of hepatitis C on pregnancy outcomes, effect of pregnancy on hepatitis C, as well as implications on management of hepatitis C during pregnancy.