Role of breast-feeding in transmission of hepatitis C virus to infants of HCV-infected mothers

Breastfeeding Initiation, Duration, and Associated Factors Among People With Hepatitis C Virus Infection

OBJECTIVE

To characterize breastfeeding behaviors and identify factors associated with breastfeeding initiation among people with hepatitis C virus (HCV) infection.

METHODS

We conducted a secondary analysis of a multicenter observational cohort of pregnant people with singleton gestations and HCV seropositivity. This analysis includes individuals with data on breastfeeding initiation and excludes those with human immunodeficiency virus (HIV) co-infection. The primary outcome was self-reported initiation of breastfeeding or provision of expressed breast milk. Secondary outcomes included duration of breastfeeding. Demographic and obstetric characteristics were compared between those who initiated breastfeeding and those who did not to identify associated factors. Univariable and multivariable analyses were performed.

RESULTS

Overall, 579 individuals (75.0% of participants in the parent study) were included. Of those, 362 (62.5%) initiated breastfeeding or provided breast milk to their infants, with a median duration of breastfeeding of 1.4 months (interquartile range 0.5-6.0). People with HCV viremia , defined as a detectable viral load at any point during pregnancy, were less likely to initiate breastfeeding than those who had an undetectable viral load (59.4 vs 71.9%, adjusted odds ratio [aOR] 0.61, 95% CI, 0.41-0.92). People with private insurance were more likely to initiate breastfeeding compared with those with public insurance or no insurance (80.0 vs 60.1%; aOR 2.43, 95% CI, 1.31-4.50).

CONCLUSION

Although HCV seropositivity is not a contraindication to breastfeeding regardless of viral load, rates of breastfeeding initiation were lower among people with HCV viremia than among those with an undetectable viral load.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT01959321 .

Viruses and Human Milk: Transmission or Protection?

Human milk (HM) is considered the best source of nutrition for infant growth and health. This nourishment is unique and changes constantly during lactation to adapt to the physiological needs of the developing infant. It is also recognized as a potential route of transmission of some viral pathogens although the presence of a virus in HM rarely leads to a disease in an infant. This intriguing paradox can be explained by considering the intrinsic antiviral properties of HM. In this comprehensive and schematically presented review, we have described what viruses have been detected in HM so far and what their potential transmission risk through breastfeeding is. We have provided a description of all the antiviral compounds of HM, along with an analysis of their demonstrated and hypothesized mechanisms of action. Finally, we have also analyzed the impact of HM pasteurization and storage methods on the detection and transmission of viruses, and on the antiviral compounds of HM. We have highlighted that there is currently a deep knowledge on the potential transmission of viral pathogens through breastfeeding and on the antiviral properties of HM. The current evidence suggests that, in most cases, it is unnecessarily to deprive an infant of this high-quality nourishment and that the continuation of breastfeeding is in the best interest of the infant and the mother.

Clinical practice guidelines for the management of children with mother-to-child transmitted hepatitis C virus infection

BACKGROUND

The first guidelines for care of pregnant women carrying the hepatitis C virus (HCV) and their infants were published in 2005 in Japan. Since then, evidence has gradually accumulated worldwide regarding the natural course and treatment of this condition and, especially in recent years, treatment for chronic hepatitis C in adult patients has made great progress. However, the clinical practice policy for children has not been standardized, and new clinical practice guidelines for children with mother-to-child (MTC) transmitted HCV infection have become necessary.

METHODS

In the development of the current guideline, we requested cooperation from The Japanese Society for Pediatric Infectious Diseases, The Japan Society of Hepatology, and the Japan Society of Obstetrics and Gynecology. The committee members were recommended and approved by each society to participate in developing the guidelines. The guideline was also created in accordance with the Minds Guide for Practice Guideline Development. The statements were prepared by consensus-building using the Delphi method, based on the comprehensively searched academic papers and guidelines. These articles were retrieved through searching the PubMed, Cochrane Library, and the Igaku Chuo Zasshi databases.

RESULTS

Eight clinical questions (CQs) with clinical statements were developed regarding etiology (CQs 1-3), diagnosis (CQs 4 and 5), and treatment (two CQs 6 and 7). In each statement, the consensus rate, evidence level, and recommendation level were determined.

CONCLUSION

The guidelines will be helpful in the management of children with hepatitis C MTC transmission.

Hepatitis C Virus Infection in Pregnancy: An Update

Parenteral transmission is the major route of hepatitis C virus transmission in adults; however, vertical transmission is most common in children. There are several factors that have been shown to be associated with vertical transmission of hepatitis C virus, including hepatitis C virus RNA, human immunodeficiency virus coinfection, and peripheral blood mononuclear cell infection. As there is no effective vaccine to prevent hepatitis C virus infection, and there are no human data describing the safety of the new direct acting antiviral agents in pregnancy, the only preventive strategy for vertical transmission is to treat the hepatitis C virus infection before becoming pregnant. Direct acting antiviral agents are interferon-free, and many are also ribavirin-free. Based on animal studies, sofosbuvir plus ledipasvir may be the best safety profile during pregnancy for now; however, it is too early to recommend treating hepatitis C virus-infected pregnant women with these direct acting antiviral agents currently.

Management of viral hepatitis A, C, D and E in pregnancy

Viral hepatitis can cause significant maternal and neonatal morbidity and mortality. Hepatitis A and E mainly present as acute hepatitis during pregnancy, while hepatitis C and D are usually found as chronic infection in pregnant women. Hepatitis A remains self-limiting during pregnancy while hepatitis E has a higher prevalence and manifests with a rigorous course in pregnant women. Screening of hepatitis C during pregnancy and its subsequent management during pregnancy are still a debatable topic. New treatments of hepatitis C and E require further evaluation for use in pregnancy. This review summarizes the prevalence, clinical manifestations, maternal, foetal and neonatal effects, and the management of hepatitis A, C, D and E viral infection during pregnancy.

Hepatitis C virus infection in mothers and children

Many unique challenges are associated with hepatitis C infection in mothers and children. The preconception, antenatal, and postnatal phases each offer opportunities to reduce transmission of the virus from mother to infant or to identify the need for treatment. Management of children and youth with hepatitis C is now entering the era of direct-acting antivirals. Improvements are needed in the identification of infected mothers and children and their linkage to appropriate expert care.

Mother-to-child transmission of hepatitis C virus

This review reinforces the lack of a single maternal risk factor that is highly associated with vertical transmission (VT) of the infection with hepatitis C virus (HCV): indeed HCV RNA levels, mode of delivery, breast feeding, viral genotype or maternal IL28B status were not associated with HCV VT.

Hepatitis B and C

Chronic viral hepatitis is a global health threat and financial burden. Hepatitis B and C viruses (HBV and HCV) are the most common causes of chronic viral hepatitis in the United States. Most cases are asymptomatic before adulthood. Research has resulted in effective therapy for HCV and the promise of effective therapies for HBV. For HCV, therapy is pegylated interferon and ribavirin. Clinical trials with effective direct-acting antiviral agents are underway in pediatrics. For HBV, approved agents are alpha-interferon, lamivudine, adefovir, tenofovir, and entecavir. However, treatment seldom results in functional cure and more effective therapies are urgently needed.

Prevention strategies for blood-borne viruses-in the Era of vaccines, direct acting antivirals and antiretroviral therapy

Blood-borne viruses, such as hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and the facultative blood-borne hepatitis E virus, are considered a major public health problem given that they are accountable for millions of deaths each year. Treatment options, including effective vaccine design, development of antiviral strategies and the implementation of antiretroviral therapy have improved substantially over the last couple of years and contribute to successful treatment and prevention of these infectious diseases. In this review, we summarise the current knowledge and concepts in prevention of transmission of these blood-borne viruses.

Hepatitis B and C in pregnancy: a review and recommendations for care

Our objective was to provide a comprehensive review of the current knowledge regarding pregnancy and hepatitis B virus (HBV) or hepatitis C virus (HCV) infection as well as recent efforts to reduce the rate of mother-to-child transmission (MTCT). Maternal infection with either HBV or HCV has been linked to adverse pregnancy and birth outcomes, including MTCT. MTCT for HBV has been reduced to approximately 5% overall in countries including the US that have instituted postpartum neonatal HBV vaccination and immunoprophylaxis with hepatitis B immune globulin. However, the rate of transmission of HBV to newborns is nearly 30% when maternal HBV levels are greater than 200 000 IU ml(-1) (>6 log10 copies ml(-1)). For these patients, new guidelines from the European Association for the Study of the Liver (EASL) and the Asian Pacific Association for the Study of the Liver (APASL) indicate that, in addition to neonatal vaccination and immunoprophylaxis, treating with antiviral agents such as tenofovir disoproxil fumarate or telbivudine during pregnancy beginning at 32 weeks of gestation is safe and effective in preventing MTCT. In contrast to HBV, no therapeutic agents are yet available or recommended to further decrease the risk of MTCT of HCV, which remains 3 to 10%. HCV MTCT can be minimized by avoiding fetal scalp electrodes and birth trauma whenever possible. Young women with HCV should be referred for treatment post delivery, and neonates should be closely followed to rule out infection. New, better-tolerated treatment regimens for HCV are now available, which should improve outcomes for all infected individuals.

Hepatitis C Virus in Pregnancy and Early Childhood: Current Understanding and Knowledge Deficits

Hepatitis C virus (HCV) is a well known cause of chronic liver disease in adults, but the burden of HCV in pregnant women and children is underappreciated. The leading route of HCV acquisition in children is vertical transmission. This review will discuss previous studies on the impact of HCV on pregnancy, risk factors for perinatal transmission, HCV transmission rates from mother to infant, what influence the virus has on the exposed or infected infant, and those areas where additional studies are required to advance our understanding of HCV pathogenesis during pregnancy. The rapid expansion of HCV treatment regimens free of interferon and ribavirin will expand future therapeutic opportunities for pregnant women and infected infants.

Epidemiology and associated risk factors of hepatitis e virus infection in plateau state, Nigeria

A cross-sectional study in Nigeria was undertaken to determine the epidemiology, seroprevalence, and associated risk factors, of hepatitis E virus (HEV). A total of 462 subjects were used for the study, categorized into four groups: apparently healthy persons, pregnant women, HIV positive subjects, and animal handlers. Information was obtained from subjects using interviewer-administered questionnaire. Blood samples were collected and analyzed for HEV antibodies (IgG and IgM) using enzyme-linked immunosorbent assay (ELISA) technique. Results obtained were analyzed using Statistical Package for Social Sciences (SPSS) version 17.0 statistical software. The overall seroprevalence of IgG and IgM was 42.7 and 0.9%, respectively. Animal handlers had the highest seroprevalence (66.7%). The associated risk factors for IgM seroprevalence were rural dwelling (P = 0.039, odds ratio (OR) 3.3, 95% confidence interval (CI) 0.7–15.4), blood transfusion (P < 0.001, OR 9.6, 95% CI 2.6–35.6), attending to animals (P = 0.032, OR 4.9, 95% CI 0.9–26.6), and waste disposal (P < 0.001). Factors associated with IgG were age (P = 0.044), location (P < 0.001), marital status (P < 0.001), formal education (P < 0.001), farming as occupation (P < 0.001), rural dwelling (P = 0.001), waste disposal (P < 0.001), alcohol consumption (P = 0.001, OR 2.4, 95% CI 1.4–4.0), open defecation (P < 0.001, OR 2.9, 95% CI 1.4–5.7), attending to animals (P < 0.001, OR 2.3, 95% CI 1.6–3.4), consuming unwashed fruits/vegetables (P < 0.001, OR 4.2, 95% CI 0.3–54.1), and stream/river as a source of drinking water (P < 0.001, OR 3.6, 95% CI 1.6–7.8). Preventive public health measures should be reinforced among all communities, particularly domestic animal handlers and pregnant women. Potable water should be provided for all communities. Data suggest that HEV remains an under-recognized and significant public health problem, warranting further attention and research.

Inactivation of hepatitis C virus infectivity by human breast milk

BACKGROUND

Hepatitis C virus (HCV) is spread through direct contact with blood, although alternative routes of transmission may contribute to the global burden. Perinatal infection occurs in up to 5% of HCV-infected mothers, and presence of HCV RNA in breast milk has been reported. We investigated the influence of breast milk on HCV infectiousness.

METHODS/RESULTS

Human breast milk reduced HCV infectivity in a dose-dependent manner. This effect was species-specific because milk from various animals did not inhibit HCV infection. Treatment of HCV with human breast milk did not compromise integrity of viral RNA or capsids but destroyed the lipid envelope. Fractionation of breast milk revealed that the antiviral activity is present in the cream fraction containing the fat. Proteolytic digestion of milk proteins had no influence on its antiviral activity, whereas prolonged storage at 4°C increased antiviral activity. Notably, pretreatment with a lipase inhibitor ablated the antiviral activity and specific free fatty acids of breast milk were antiviral.

CONCLUSIONS

The antiviral activity of breast milk is linked to endogenous lipase-dependent generation of free fatty acids, which destroy the viral lipid envelope. Therefore, nursing by HCV-positive mothers is unlikely to play a major role in vertical transmission.

Hepatitis C virus in pregnancy

Despite recent advances in the pathogenesis, treatment, and public health response to hepatitis C virus (HCV), HCV as it specifically relates to pregnancy has been a neglected condition. HCV-monoinfected pregnant women have a 2-8% risk of viral transmission to their infant, but the mechanism and timing of mother to child transmission (MTCT) are not fully understood, nor is the natural history of the illness in pregnant women and their offspring. Recognition of HCV-infected pregnant women is relevant because of the long-term health implications for the mother, potential adverse effects of infection on pregnancy outcomes, and the possibility of transmission to their infants. Certain risk factors for MTCT of HCV appear similar to those for human immunodeficiency virus (HIV); however, unlike HIV, effective methods for prevention of HCV vertical transmission have not been developed. It is possible that a better understanding of HCV MTCT and pathogenesis in pregnancy will guide development of useful prevention strategies, particularly as we enter an era where interferon-free drug cocktails may emerge as viable treatment options for HCV.

Hepatitis C virus in Arab world: a state of concern

Hepatitis C virus has been considered to be one of the most important devastating causes of chronic hepatitis, cirrhosis, and hepatic cellular carcinoma. The prevalence of such virus varies greatly over the world. Arab world has a unique geography and consists over nineteen countries who share the same heritage and customs and do speak the same language. In this area, the epidemiology of hepatitis C is not well understandable. Hepatitis C virus was found to be endemic in Arabia. The serostatus of such virus was found to be variable among these countries with uniform patterns of genotypes. Such prevalence varies tremendously according to the risk factors involved. Blood and blood products, haemodialysis, intravenous, and percutaneous drug users, and occupational, habitual, and social behavior were found to be the important factors involved. Hepatitis C will have major social, economic, and even political burdens on such young and dynamic societies. Thus, strategies and clear policy of intervention are urgently needed to combat the consequences of HCV both regionally and at state level of each country.

Human milk donation is an alternative to human milk bank

BACKGROUND AND AIMS

Human milk bank is a source of human milk supply in many neonatal intensive care units. However, there are some hospitals without this facility because of financial or religious impediments, such as the Muslim community.

METHODS

We introduced human milk donation as an alternative to human milk banking based on Islamic principles. The suitable donor is a healthy rooming-in mother whose expressed breastmilk is in excess of her baby's demand. The milk is used after 72 hours of freezing at -20°C. The donor must fulfill the criteria for selection of donors and be nonreactive to human immunodeficiency virus and syphilis. Once the recipient's family and the donor state their desire for the human milk donation, a meeting with both parties is made. Unpasteurized frozen-thawed donor's milk will be provided to the recipient after written consents are obtained from both parties.

RESULTS

This study was carried out in the Duchess of Kent Hospital (Sandakan, Sabah, Malaysia) between January 2009 and December 2010. A total of 48 babies received donated breastmilk. Forty-two infants were from the special care nursery, and the remaining six were from the pediatric ward. Eighty-eight percent of the donors and 77% of the recipients were Muslims. Sixty percent of the infants who received donated human milk were premature. Two infants died because of the underlying nature of their disease.

CONCLUSION

Human milk donation is an option for hospitals without a human milk bank or in the Muslim community.

Hepatitis C virus infection during pregnancy and the newborn period--are they opportunities for treatment?

The worldwide prevalence of hepatitis C virus (HCV) infection in pregnant women is estimated to be between 1 and 8% and in children between 0.05% and 5%. While parenteral transmission is still common in children living in developing countries, perinatal transmission is now the leading cause of HCV transmission in developed countries. The absence of an HCV vaccine or approved therapy during pregnancy means that prevention of vertical transmission is still not possible. However, a low vertical transmission rate of 3-5%, a high rate of spontaneous clearance (25-50%) and delayed morbidity have resulted in HCV being overlooked in pregnant women and their infants. Yet a study of the natural history in mothers and children demonstrates that the prognosis of HCV can vary greatly and should be taken seriously. Factors known to increase the risk of perinatal transmission include HIV coinfection and higher maternal viral loads, while elective C-section and withholding breastfeeding have not been demonstrated to reduce vertical transmission. Current guidelines for the diagnosis of persistent perinatal infection require a positive anti-HCV test in infants born to infected mothers after 12 months or two positive HCV RNA tests at least 6 months apart. Current HCV treatment options using pegylated interferon and ribavirin are both unsuitable for use in pregnancy and infancy. However, new agents currently in preclinical phases of development, along with the recently identified association between single-nucleotide polymorphisms within the IL28 gene and treatment response, may serve to create a therapeutic window for these patients.

Hidden hazards of HCV transmission

Hepatitis C virus infection is a global health problem that has important epidemiological and clinical consequences. It has been well established that exposure to infected blood is the main risk factor for HCV transmission. However, in 20% of cases the agent transmission occurs by unknown route or in the presence of an unidentified source of infection. Understanding of the epidemiology of HCV is needed to help us define future control and preventive strategies. Herein, we discuss about diagnosis of HCV infection and hepatitis C surveillance in the context of its transmission.

Perinatal transmission of hepatitis C virus infection

In industrialized countries, hepatitis C virus (HCV) is the most common cause of chronic liver disease in children. Perinatal transmission is the leading cause of infection. Perinatal transmission is confined almost always to women with detectable HCV ribonucleic acid (RNA) in the peripheral blood by the polymerase chain reaction but all children born to women with anti-HCV antibodies should be tested for HCV. Some but not all studies found that a high concentration of serum HCV RNA is associated with a higher risk of transmission. Maternal peripheral blood mononuclear cell infection by HCV, membrane rupture of longer than 6 hr before delivery, and procedures exposing the infant to maternal blood infected with HCV during vaginal delivery are associated with an increased risk of transmission. Maternal coinfection with HCV and human immunodeficiency virus, maternal history of intravenous drug use and of HCV infection of the sexual partner of the mother predict the risk of perinatal transmission and are dependent on the peripheral blood mononuclear cell infection by HCV. Delivery by Cesarean section is not recommended in pregnant women infected with HCV. Infected mothers can breast feed safely their infants if the nipples are not damaged. A previous delivery of a child infected perinatally with HCV does not increase the risk of transmission in subsequent pregnancies. Immunogenetic factors and HCV genotypes are not related to HCV perinatal transmission. Despite an increased understanding of the risk factors involved in perinatal transmission of HCV, to date little is known about the transmission mechanisms and timing.

Transmission of hepatitis C virus infection from asymptomatic mother to child in southern India

BACKGROUND

Little information is available on the mother-to-child transmission of hepatitis C virus (HCV) in India, and no interventions to decrease transmission rates have been identified. Hence, we performed a long-term prospective study in infants born to HCV-positive mothers, with the aim of evaluating vertical transmission of HCV and correlated risks factors.

METHODS

Three thousand one hundred and fifteen healthy asymptomatic pregnant women were included in the study. We used third-generation (Murex anti-HCV) ELISA and HCV RNA reverse transcription PCR (RT-PCR) for screening, and the commercial line probe assay (Inno-LiPA) and direct sequencing HCV genotyping assays were performed to confirm the transmitted HCV genotypes.

RESULTS

Of the total 3115 healthy asymptomatic pregnant women, 18 (0.6%) were positive for anti-HCV. Of the 18 anti-HCV-positive women, eight (44.4%) were positive for HCV RNA RT-PCR. HCV transmission was observed in two of the eight babies born to eight HCV RNA-positive mothers who were followed up for 12 months. HCV genotyping of the mother/child pairs revealed the persistent presence of mixed genotypes 1a and 4 throughout the follow-up period. None of the non-viremic (HCV RNA-negative) mothers transmitted HCV infection to their baby. In our study approximately 25% of vertical/perinatal transmission of HCV was observed among HCV RNA-positive antenatal women.

CONCLUSIONS

This study is of importance as it is the first report from India of a successful attempt to analyze the rate of vertical/perinatal transmission of HCV from infected mothers to their children by a prospective longitudinal follow-up study, and to characterize the pattern of genotype(s) of HCV present in the infected mother/baby pairs, so as to confirm the source of HCV acquired by the newborn babies.

Reproductive assistance for infected couples with bloodborne viruses

During the past 15 years Assisted Reproduction has been facing a new demand from patients requiring ART: couples at risk of partner to partner, and mother to child transmission of viral infections, mainly HIV-1, HCV and HIV-HCV co-infected partners. The general conditions and life expectancy of many patients with HIV infection are very good, and three-quarters of these individuals are in their reproductive years. For these reasons, a large number of young couples are expected to make future plans to have children. This desire is not easy to realize for serodiscordant couples, if we consider that, in order to avoid HIV virus transmission, it is necessary to encourage the condom use in vaginal and anal contacts. On the other hand infertile discordant HCV couples need to be included in protocols of controlled assisted reproduction procedures to avoid any risk of HCV transmission to the partner. In this paper we consider assisted reproduction in discordant couples for HIV or HCV-positive men.

Breastmilk handling routines for preterm infants in Sweden: a national cross-sectional study

BACKGROUND

In Sweden preterm infants born <32 gestational weeks are fed maternal breastmilk or, if not available, donor breastmilk. Nutritional and immunological composition of human milk is affected by processing and storage procedures. Additionally, freezing of breastmilk may reduce cytomegalovirus transmission. The present recommendations for human milk use in Sweden are outdated. However, new guidelines to standardize routines are underway. This study was designed to document current routines pertaining to breastmilk use for preterm infants in Sweden.

METHODS

A questionnaire regarding breastmilk handling and routines was sent to all 36 neonatal units in Sweden in November 2006 and February 2007.

RESULTS

Of the 36 participating neonatal units 27 had their own milk bank. Milk donors were screened for human immunodeficiency virus, human T-lymphotropic virus, and hepatitis B and C viruses by 27, 14, and 22 of the milk banks, respectively. Bacterial culture was performed on donor milk in 24 milk banks. Donor milk was pasteurized in 22 milk banks. In 11 of the 36 neonatal units maternal milk was frozen to reduce the risk of cytomegalovirus transmission. No neonatal unit performed bacterial culture or pasteurization of maternal milk. Breast milk was kept frozen for a maximum of 3-6 months before use. Nutritional analysis of donor and/or maternal milk was performed in 25 units. All neonatal units enriched donor milk and maternal milk.

CONCLUSIONS

Routines for breastmilk handling differ among the 36 neonatal units in Sweden. New guidelines can standardize the handling of human milk, thereby improving nutrition and minimizing the risk of breastmilk-induced infection in the preterm infant.

Re-evaluation of the true rate of hepatitis C virus mother-to-child transmission and its novel risk factors based on our two prospective studies

OBJECTIVE

To re-evaluate the true hepatitis C virus (HCV) mother-to-child transmission (MTCT) rate and its novel risk factors.

STUDY DESIGN

A comparative study based on our own two prospective studies done during the two periods, 'early' (1989-1994) and 'recent' (1995-2004).

RESULTS

All carrier infants became HCV RNA-positive within 3 months after birth. The MTCT and de-carrier rates were, respectively, higher (14.2%) and lower (16.7%) in the recent period, although liver dysfunction of carrier infants was found very frequently (66.7%) in both groups. MTCT occurred significantly when the maternal viral load, serum alanine aminotransferase (sALT) levels and blood loss at delivery were, respectively, more than 10(5) copies/mL, 110 IU/L, and 500 g. No MTCT was found when elective cesarean section was done.

CONCLUSIONS

The true HCV MTCT and de-carrier rates were found to be much higher and lower than those reported previously. The maternal liver dysfunction (sALT >or=110 IU/mL) and blood loss (>or=500 g) at delivery are the next risk factors to maternal viral load (>or=10(5) copies/mL) for MTCT.

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.

Hepatitis C virus infection

The prevalence of chronic hepatitis C infection in the general paediatric population varies between 0.1 and 15% around the world, with the highest numbers noted in endemic areas of Africa. The risk of viral transmission from an infected mother to her child is approximately 5% and there are currently no effective preventative measures to lower it. All children born to infected mothers should be tested for hepatitis C. The progression to liver damage in infected children is slow. However, in the perspective of 15-20 years of infection or in the presence of other risk factors, such as concomitant chronic disease, a progression to more severe liver damage can be seen. Thus, the use of antiviral treatment may be of importance. Treatment combinations of interferon and ribavirin seem to be at least as effective in children as in adults. However, the negative effect on growth of interferon requires specific attention by paediatricians.

Management of chronic hepatitis C

Hepatitis C virus (HCV) infection is transmitted primarily through percutaneous exposure to blood, and most infections are associated with injection drug use. Progression to chronic HCV occurs in 55% to 86% of infected people, and persistent infection is a major cause of cirrhosis, end stage liver disease, and hepatocellular carcinoma. The detection of HCV antibodies should be performed initially to screen at risk populations. In those who are seropositive, HCV viraemia should be assessed to determine if chronic HCV is present. The HCV genotype should also be determined, as this is the strongest predictor of response to available treatment. A liver biopsy is very often helpful because it can estimate degree of hepatic fibrosis, identify concurrent diseases that might contribute to hepatic injury, and aid in selection of patients for treatment. The decision to start antiviral therapy should take into account potential contraindications to therapy, patient motivation, severity of disease, age, and HCV genotype. Combination therapy with weekly subcutaneous pegylated interferon and daily oral ribavirin is the standard of care for treating patients with chronic HCV.

The management of HCV infected pregnant women and their children European paediatric HCV network

BACKGROUND/AIMS

As evidence accumulates relating to mother-to-child (vertical) transmission of hepatitis C virus (HCV), it is timely to draw up guidelines for the clinical management of HCV infected pregnant women and their children.

METHODS

A review of evidence from the European Paediatric HCV Network (EPHN) prospective study of HCV infected women and their children and other published studies. Meeting of EPHN clinical experts to reach a consensus on recommendations for management. Each recommendation was graded according to the level of evidence.

RESULTS/CONCLUSIONS

Although several risk factors for mother-to-child transmission have been identified, none are modifiable and there are currently no interventions available to prevent vertical transmission of HCV. Data on timing of loss of maternal antibodies and reliability of diagnostic tests inform the optimum follow-up schedule for confirmation or exclusion of infection in children born to HCV infected women. Based on the current evidence, routine antenatal screening for HCV should not be introduced and neither elective caesarean section nor avoidance of breastfeeding should be recommended to HCV infected women to prevent mother-to-child transmission of HCV. HCV/HIV co-infected women should follow existing HIV guidelines.

Detection of HCV-RNA in Cerumen of Chronically HCV-Infected Patients

OBJECTIVES/HYPOTHESIS

Viral hepatitis C is a worldwide public health problem. Hepatitis C virus is mainly transmitted by parenteral or percutaneous route. Nonparenteral transmission, such as through sexual activity, household contact, and vertical or perinatal exposure to body fluids or secretions, can occur, which has been studied before. Cerumen, however, has not been investigated for its ability to transmit hepatitis C virus. The aim of this study is to evaluate the importance of cerumen in transmission of hepatitis C virus infection.

STUDY DESIGN

This study was performed on 35 patients with confirmed chronic hepatitis C virus infection.

METHODS

Thirty-five cerumen specimens collected from the patients with hepatitis C virus RNA in their sera were prospectively analyzed for the presence of hepatitis C virus RNA by polymerase chain reaction.

RESULTS

None of the 35 cerumen specimens were positive for hepatitis C virus RNA.

CONCLUSION

This study showed that cerumen has no risk for transmission of hepatitis C virus infection, even in patients with high hepatitis C virus RNA serum levels; however, standard infection control precautions should be applied carefully in all examinations and surgical operations of the ears.

When does mother to child transmission of hepatitis C virus occur?

OBJECTIVE

To investigate when hepatitis C virus (HCV) infection from mother to child occurs, and evaluate possible associated factors.

DESIGN

Prospective cohort study.

PATIENTS

Fifty four HCV infected children tested within three days of birth and their mothers.

MAIN OUTCOME MEASURES

HCV RNA polymerase chain reaction (PCR) results.

RESULTS

Seventeen of the children (31%, 95% confidence interval 19% to 46%) were positive in the first 3 days of life and could be assumed to have acquired infection in utero. Testing PCR positive was not associated with sex (53% v 49% boys; p=0.77) or mode of delivery (29% elective caesarean section in both groups; p=0.98). Children with evidence of intrauterine infection were significantly more likely to be of lower birth weight and infected with genotype 1 (58% v 12%, p=0.01). Although a higher proportion of infants born to HCV/HIV co-infected women were PCR positive in the first 3 days of life, this difference did not reach statistical significance; excluding infants born to co-infected women did not affect the results. Thirty seven of the children (68%) were negative in the first 3 days of life, 27 of whom were positive when tested again at 3 months, and nine were first PCR positive after 3 months (one child had no further tests).

CONCLUSIONS

These results suggest that at least one third and up to a half of infected children acquired infection in utero. Although postpartum transmission cannot be excluded, these data suggest that it is rare. The role of HCV genotypes in the timing and mechanism of infection should be explored further.

Hepatitis C in pregnancy

Hepatitis C is a worldwide health problem affecting men and women of all ages. In young pregnant women, however, the existence of hepatitis C presents a set of unique issues for the mother and the child. For the mother, therapeutic and medical decisions for hepatitis C are affected by pregnancy. For the child, transmission of hepatitis C from the mother can occur. Identification of risk factors for mother-to-child transmission and prevention of this transmission are the foremost concerns.

Transmission risk of hepatitis C virus via semen during assisted reproduction: how real is it?

The risk of viral transmissibility in assisted reproduction is still a much-debated issue, especially for hepatitis C virus (HCV). HCV is a common causative agent for parenterally transmitted viral hepatitis. In addition, it has been incriminated in other routes of transmission, including sexual transmission and nosocomial infections. The management of infertility, in association with HCV, has sparked debates about the potential risk of spread of infection to virus-free individuals, embryos and/or semen. The lack of worldwide-accepted screening policies has helped to fuel this debate. Today, it is evident that there is a potential risk of spread of HCV through biological fluids, including semen, to other individuals. This risk can only be marginalized by the use of well-established criteria for safety in infertility centres, and by the use of proper initial detection and segregation of potentially hazardous materials. Techniques and protocols have been established to help the andrologist and embryologist to safeguard patients against such dangers, and should be imposed in all centres, allowing HCV-positive males to enter their assisted reproduction programmes.

Guidelines for the screening and follow-up of infants born to anti-HCV positive mothers

Hepatitis C virus infection in infancy largely depends on vertical transmission. The transfer of hepatitis C virus from mother to child is almost invariably restricted to children whose mother is viremic, and the rate of transmission seems to be influenced by maternal virus load, although, in the single patient, the levels of viremia cannot be used as predictors of pediatric infection. In fact, the flow-chart for screening children at risk for vertically transmitted hepatitis C virus infection takes into account maternal viremia. In children born to anti-hepatitis C virus antibody positive, hepatitis C virus-RNA negative mothers, alanine aminotransferase and anti-hepatitis C virus should be investigated at 18-24 months of life. If alanine aminotransferase values are normal and anti-hepatitis C virus is undetectable, follow-up should be interrupted. In children born to hepatitis C virus-RNA positive mothers, alanine aminotransferase and hepatitis C virus RNA should be investigated at 3 months of age: (1) hepatitis C virus-RNA positive children should be considered infected if viremia is confirmed by a second assay performed within the 12th month; (2) hepatitis C virus-RNA negative children with abnormal alanine aminotransferase should be tested again for viremia at 6-12 months, and for anti-hepatitis C virus at 18 months; (3) hepatitis C virus-RNA negative children with normal alanine aminotransferase should be tested for anti-hepatitis C virus and alanine aminotransferase at 18-24 months, and should be considered non-infected if alanine aminotransferase is normal and anti-hepatitis C virus undetectable; (4) anti-hepatitis C virus seropositivity beyond the 18th month in a never-viremic child with normal alanine aminotransferase is likely consistent with past hepatitis C virus infection.

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.

Maternal-infant transmission of hepatitis C virus infection

Mother-to-infant transmission of hepatitis C virus (HCV) is comparatively uncommon. The prevalence of antibody to HCV (anti-HCV) in pregnant women is 0.1% to 2.4%, although in some endemic areas it is much higher. The proportion of women with anti-HCV who have active infection with viremia is 60% to 70%. Transmission of HCV occurs only when serum HCV RNA is detectable and may be related to higher levels (above 10(6) copies per mL). The rate of mother-to-infant transmission is 4% to 7% per pregnancy in women with HCV viremia. Co-infection with human immunodeficiency virus (HIV) increases the rate of transmission 4 to 5 fold. The actual time and mode of transmission are not known. Elective Cesarean section is not recommended for women with chronic HCV infection alone. The role of treatment to prevent transmission is limited by the fetal toxicity of currently available medications for hepatitis C. Breast feeding poses no important risk of HCV transmission if nipples are not traumatized and maternal hepatitis C is quiescent. Pregnant women at high risk for HCV infection should be screened for anti-HCV, and HCV RNA testing should be performed if anti-HCV is positive. Infants of women with hepatitis C should be tested for HCV RNA on two occasions, between the ages of 2 and 6 months and again at 18 to 24 months, along with serum anti-HCV. The natural history of mother-to-infant hepatitis C remains uncertain, especially the course in the first year of life when some infants appear to have spontaneous resolution.

Maternal-infant transmission of hepatitis C virus infection

Mother-to-infant transmission of hepatitis C virus (HCV) is comparatively uncommon. The prevalence of antibody to HCV (anti-HCV) in pregnant women is 0.1% to 2.4%, although in some endemic areas it is much higher. The proportion of women with anti-HCV who have active infection with viremia is 60% to 70%. Transmission of HCV occurs only when serum HCV RNA is detectable and may be related to higher levels (above 10(6) copies per mL). The rate of mother-to-infant transmission is 4% to 7% per pregnancy in women with HCV viremia. Co-infection with human immunodeficiency virus (HIV) increases the rate of transmission 4 to 5 fold. The actual time and mode of transmission are not known. Elective Cesarean section is not recommended for women with chronic HCV infection alone. The role of treatment to prevent transmission is limited by the fetal toxicity of currently available medications for hepatitis C. Breast feeding poses no important risk of HCV transmission if nipples are not traumatized and maternal hepatitis C is quiescent. Pregnant women at high risk for HCV infection should be screened for anti-HCV, and HCV RNA testing should be performed if anti-HCV is positive. Infants of women with hepatitis C should be tested for HCV RNA on two occasions, between the ages of 2 and 6 months and again at 18 to 24 months, along with serum anti-HCV. The natural history of mother-to-infant hepatitis C remains uncertain, especially the course in the first year of life when some infants appear to have spontaneous resolution.

Hepatitis C and the skin

Hepatitis C is an important and common cause of chronic hepatitis and cirrhosis. Cutaneous manifestations are often the first signs of infection. Dermatologists must be aware of these manifestations, because early diagnosis is the best treatment. HCV Ab by ELISA should be ordered in patients with LCV-urticarial vasculitis, cryoglobulinemia, lichen planus, Sjögren's syndrome, unexplained pruritus, PCT, PAN, chronic urticaria, patients starting methotrexate, unexplained pruritus, and any patient initiating therapy with a potentially hepatotoxic drug.

Mother-to-infant transmission of hepatitis C virus: rate of infection and assessment of viral load and IgM anti-HCV as risk factors

One hundred twenty-six mother-infant couples were studied and 105 exposed babies were monitored for at least 12 months to define the risk of mother-to-infant HCV transmission. Infection occurred in 5 out of 76 infants (6.6%) born to 69 viraemic mothers and in none of 29 born to 26 non-viraemic mothers. Only one child was HCV RNA positive one month after birth, while the remaining children became positive at the 3rd to 4th month. HCV genotypes of the babies matched those of their mothers. No difference was found between women who transmitted the virus and those who did not with regard to age, history of drug abuse, HIV infection, ALT abnormal values, HCV genotype, type of delivery, and breast-feeding. Four out of 5 infected infants were born to mothers with IgM anti-HCV (P = 0.04). The mean viral titre in transmitting women (10(7.2)) was higher than in non-transmitting (10(6.5)), and the proportion of mothers with viral load > or = 10(7) was statistically higher in transmitting than non-transmitting women (P = 0.03). These data show that HCV perinatal infection is a rare event and suggest that IgM positivity and high viral load (> or = 10(7)) in the mother are independent variables correlated with HCV transmission (O.R. = 14.5; 95% CI: 1.3-160.7 and O.R. = 16.3; 95% CI: 1.5-179.9, respectively).

Hepatitis C in childhood

The approach of a pediatric hepatologist in managing children with hepatitis C virus (HCV) differs from adult practice, because the pediatric hepatologist is dealing with the beginning of a chronic illness in which long-term outcomes will not occur for 20 or 40 years, and it is not possible to predict in the early stages of the infection which patients have a more sinister prognosis. The prevalence of chronic HCV in children is low, but varies between different countries in the Asia-Pacific region. In most countries, screening of blood products for HCV has virtually eliminated the risk of post-transfusion HCV, so that in Australia children aged less than 11 years will not have acquired HCV from blood transfusion or extracorporeal membrane oxygenation. The risk of perinatal transmission of this virus is only about 6%, but this remains virtually the only source of HCV transmission for children in most countries. While available data are limited, mild histological changes are present in the majority of children with hepatitis C, and cirrhosis is rare. Unfortunately, long-term natural history studies of the course of HCV infection in children have not been reported. Individual decisions on antiviral treatment are more difficult in childhood, not because the treatment is any less effective or because of the severity of side-effects (which tend to be less severe than for adults), but because the long-term outcome of infection is unclear. At present, treatment should be confined to those with significant hepatic fibrosis and continued moderate to severe necroinflammatory change. Measures to prevent HCV infection in childhood center on whether, as recently suggested, elective cesarean section may reduce the risk of transmission. Despite the presence of HCV-RNA in some breast milk samples, there is no evidence that breast-feeding confers any risk of HCV infection.

[Hepatitis C and pregnancy]

PURPOSE

Today, the natural course of hepatitis C virus (HCV) infection during pregnancy and the prevalence of mother-to-child transmission are better known.

CURRENT KNOWLEDGE AND KEY POINTS

Antenatal screening for HCV infection needs to be proposed to women with risk factors. Viral replication needs to be confirmed by PCR in pregnant women with antibodies against HCV. To date, the clinical course of pregnancy and the mode of delivery have not been changed by HCV infection. Rates of vertical transmission of HCV are about 6% in women with HCV alone and 15% in women co-infected with HIV. A screening for HCV markers is required 18 months after delivery for infants born to HCV mothers. Because of the relatively low rate of HCV vertical transmission, pregnancy can be allowed in infected women. However, taking into account the efficacy of new antiviral strategies, treatment of HCV infection could be proposed before pregnancy.

FUTURE PROSPECTS AND PROJECTS

In case of HCV infection, a careful follow-up of both mother and newborns is required. Long-term follow-up of infected infants is needed to assess the consequences of perinatal HCV infection.

Challenges in the treatment of hepatitis C in children

Hepatitis C infection in children is associated with a unique set of challenges for clinicians and investigators. Although the prevalence of HCV infection is lower in children than in adults, it is important to identify infected children to monitor progression of liver disease and to make appropriate interventions to minimize factors that may exacerbate progression. Identification requires understanding of risk factors important in children, primarily exposure at or near the time of birth. The natural history of this infection in most children is either more benign or significantly prolonged than that of infection acquired in adulthood. Reasons for this difference in natural history must be explored and possibly even exploited in the care of adult patients with HCV infection. Identification of appropriate pediatric candidates for treatment and definition of optimal therapy for these children require ongoing study. Lastly, as perinatal transmission becomes the primary mode of acquisition for new pediatric infections, factors that increase or decrease the likelihood of this transmission must be identified, and effective preventive interventions must be put into practice. There are important differences in the clinical features, natural history, and response to therapy between pediatric and adult patients with HCV infection. Understanding of these differences will allow optimal care for affected children and perhaps better understanding of the pathophysiology and pure natural history of this disease.