Prospective reevaluation of risk factors in mother-to-child transmission of hepatitis C virus: high virus load, vaginal delivery, and negative anti-NS4 antibody

Hepatitis C viral load and mother-to-child transmission: A systematic review and meta-analysis

BACKGROUND AND AIM

We aim to assess the association between maternal hepatitis C virus (HCV) viral load and human immunodeficiency virus (HIV) coinfection and the risk for mother-to-child transmission (MTCT) among pregnant women infected with HCV.

METHODS

A literature search of the Medline, Embase, Central, Science Citation Index Expanded (SCIE), Conference Proceedings Citation Index-Science (CPCIS), Scopus, Literature Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and WHO Global Index Medicus databases, from inception to June 21, 2022, was performed. Studies that reported the incidence HCV-MTCT were included. Pooled effect estimates were calculated using the random-effects model, and Holm-Bonferroni correction was performed for multiple pooled associations.

RESULTS

The present meta-analysis included 26 studies involving 4934 newborns with maternal HCV infection. Pregnant women with HCV viremia exhibited increased risk for MTCT (odds ratio [OR] 8.25 [95% confidence interval (CI) 4.65-14.63]) compared with those negative for HCV-RNA. Multiple subgroup analysis revealed that the HCV viremia/HIV-positive group demonstrated the highest risk for HCV MTCT, followed by the HCV viremia mono-infected group, while HCV-RNA-negative women demonstrated the lowest risk for HCV MTCT. Among females with HCV viremia, elevated risk for MTCT was found among subjects with a viral load ≥ 6 log₁₀ copies/mL compared with those with viral load < 6 log₁₀ copies/mL (OR 4.58 [95% CI: 2.52-8.34]).

CONCLUSION

The incidence of HCV MTCT was increased among pregnant women with detectable HCV viremia and was even higher in those with a viral load ≥ 6 log₁₀ copies/mL. HIV coinfection further increased the risk for HCV MTCT.

The impact of treatment on the psychological burden of mothers of children with chronic hepatitis C virus infection: a multicenter, questionnaire survey

Mothers of children with chronic hepatitis C virus (HCV) infection experience anxiety about the health of their children. In this study we assessed an impact of treating children with chronic HCV infection on the psychological burden of their mothers. This was a multicenter, questionnaire survey conducted at six institutions in Japan. A newly-developed questionnaire for this study was used to assess changes in the mothers' various concerns regarding HCV infection and thoughts about their child's HCV infection. Responses at the time of diagnosis and at the time of the survey were compared between mothers of children who had received treatment and those without treatment. Responses were received from 36 of 37 eligible mothers (11 and 25, non-treatment and treatment groups, respectively). All children in treatment group had successfully eliminated the virus. Mothers in both groups were psychologically stressed in various ways, including concern about their child's health in the present and future at the time of diagnosis, concern about school, employment, and marriage, concern about the behavior of others towards them and infecting others with HCV, and feelings of guilt regarding their child. These concerns were significantly lower in the present compared to at the time of diagnosis in treatment group, and the rate of decrease was significantly higher in treatment group compared to non-treatment group. Successful treatment greatly reduced mothers' concerns about their children's HCV infection, indicating that treatment during childhood is beneficial from the perspective of the mothers' psychological burden.

Viral hepatitis C during pregnancy: prevalence, impact on perinatal outcomes, patient management tactics (literature review)

The article presents modern ideas about the impact of viral hepatitis C on the course of pregnancy, the severity of maternal disease associated with it: methods of delivery and possible vertical transmission. Epidemiological data on the prevalence in the world and the Russian Federation, risk factors for perinatal HCV transmission, and the course of pregnancy in women infected with HCV are shown. The search for the necessary literary sources was carried out in the databases Scopus, PubMed, MedLine, The Cochrane Library, RSCI.

Treatment and prevention of viral hepatitis in pregnancy

Viral hepatitis in pregnancy may be caused by many types of viruses that cause systemic infection or target hepatocytes in their pathogenesis. Because viral hepatitis during pregnancy may represent acute or chronic infection or the reactivation of a prior infection, a high clinical suspicion, medical history review, and awareness of risk factors for the acquisition of infection are important management principles. The route of infection varies widely and ranges from fecal-oral transmission for the hepatitis A and E viruses to vertical transmission for hepatitis B, blood-borne transmission for hepatitis C, and sexual transmission for the herpes simplex virus. For this reason, the exposure details about travel, food preferences, drug use, and sexual contacts are important to elicit. Although routine prenatal screening is recommended for chronic viral hepatitis caused by hepatitis B and C, most other causes of viral hepatitis in pregnancy are detected in the setting of compatible signs and symptoms (fatigue, abdominal discomfort, jaundice, scleral icterus) or incidentally noted transaminitis on routine labs. Serologic testing is helpful for diagnosis with molecular testing as indicated to guide the management of hepatitis B and C. Preventive vaccines for hepatitis A and B with established safety of use in pregnancy are recommended for women who are at risk of acquisition. Postexposure prophylaxis for hepatitis A is a single dose of immunoglobulin and vaccination can be used if immunoglobulin G is not available. Antiviral therapy with tenofovir disoproxil fumarate is recommended as prophylaxis in pregnant women with active hepatitis B and an elevated viral load (>200,000 IU/mL) during the third trimester to prevent vertical transmission. The neonate exposed to hepatitis B at birth should receive immunoglobulin G and a monovalent birth dose vaccine within 12 hours, followed by completion of the 3-dosage vaccine series. The prevalence of hepatitis C in women of reproductive age has increased in the United States, and the role of antiviral therapy during pregnancy is of great interest. Cesarean delivery is not currently recommended for the sole purpose of reducing vertical transmission risk in pregnant women with viral hepatitis. Breastfeeding is recommended in women with hepatitis A, B, and C. New and promising prevention and treatment options for hepatitis B and C are under investigation. Investigators and regulatory authorities should ensure that these clinical trials for promising antivirals and vaccines are designed to include pregnant and lactating women.

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.

Estimating paediatric hepatitis C prevalence in the United States

Over 70 million individuals are infected with hepatitis C virus (HCV) worldwide. Yet most prevalence data are in the adult population, with little focus on paediatrics, partially due to the scarcity of public data. The objective of this paper is to examine HCV prevalence in children by estimating prevalence rates among women, given the assumption that most cases are vertically transmitted. Between 2001 and 2017, maternal HCV infection affected ~ 0.24% of all births, with prevalence increasing by at least 261%. On average, approximately 0.01% of the total number of live births were infected with HCV, with a 245% increase in the number of children born with the infection. HCV epidemiology has evolved, with women of childbearing age representing a greater proportion of infected individuals in the United States, and infants born to infected mothers being at risk. We therefore recommend a greater public health focus of HCV on the paediatric population.

Perinatal transmission of hepatitis C virus: an update

Infection with hepatitis C virus (HCV) is a major health problem worldwide. A large proportion of perinatal HCV infections are silent and may present later in adulthood with long-term complications. HCV has no effective immune prophylaxis and hence appropriate follow-up of all infants born to HCV-infected mothers is necessary. Universal antenatal screening for HCV is largely debatable. Intrauterine and partum transmission of HCV are both possible and higher rates are associated with a high maternal serum viral load (> 10⁶ copies per milliliter), concomitant HIV infection, prolonged or difficult delivery, and invasive fetal monitoring during delivery. Infection during pregnancy and infancy needs to be investigated more in order to design management strategies for perinatal transmission of HCV most effectively. The recently approved new-generation, oral, direct-acting antiviral drugs may open a new era in HCV therapy for pregnant women and infected infants if proved to be safe during conception and infancy.

Vertically acquired hepatitis C virus infection: Correlates of transmission and disease progression

The worldwide prevalence of hepatitis C virus (HCV) infection in children is 0.05%-0.4% in developed countries and 2%-5% in resource-limited settings, where inadequately tested blood products or un-sterile medical injections still remain important routes of infection. After the screening of blood donors, mother-to-child transmission (MTCT) of HCV has become the leading cause of pediatric infection, at a rate of 5%. Maternal HIV co-infection is a significant risk factor for MTCT and anti-HIV therapy during pregnancy seemingly can reduce the transmission rate of both viruses. Conversely, a high maternal viral load is an important, but not preventable risk factor, because at present no anti-HCV treatment can be administered to pregnant women to block viral replication. Caution is needed in adopting obstetric procedures, such as amniocentesis or internal fetal monitoring, that can favor fetal exposure to HCV contaminated maternal blood, though evidence is lacking on the real risk of single obstetric practices. Mode of delivery and type of feeding do not represent significant risk factors for MTCT. Therefore, there is no reason to offer elective caesarean section or discourage breast-feeding to HCV infected parturients. Information on the natural history of vertical HCV infection is limited. The primary infection is asymptomatic in infants. At least one quarter of infected children shows a spontaneous viral clearance (SVC) that usually occurs within 6 years of life. IL-28B polymorphims and genotype 3 infection have been associated with greater chances of SVC. In general, HCV progression is mild or moderate in children with chronic infection who grow regularly, though cases with marked liver fibrosis or hepatic failure have been described. Non-organ specific autoantibodies and cryoglobulins are frequently found in children with chronic infection, but autoimmune diseases or HCV associated extrahepatic manifestations are rare.

Risk factors for vertical transmission of hepatitis C virus: a single center experience with 710 HCV-infected mothers

OBJECTIVE

The aim of this study was to analyze the risk factors on the perinatal transmission of hepatitis C virus (HCV).

STUDY DESIGN

A retrospective cohort study with 711 infants born to 710 HCV-infected mothers was conducted at the Hospital La Fe, in Valencia, Spain, from 1986 to 2011. As potential risk factors for transmission we analyzed: maternal age, mode of acquisition of HCV infection, HIV co-infection, antiretroviral treatment against HIV, CD4 cell count, HIV and HCV viral load, liver enzyme levels during pregnancy, smoking habit, gestational age, intrapartum invasive procedures, length of rupture of membranes, length of labor, mode of delivery, episiotomy, birth weight, newborn gender and type of feeding.

RESULTS

Overall perinatal HCV transmission rate was 2.4%. The significant risk factors related with HCV transmission were maternal virus load >615copies/mL (OR 9.3 [95% CI 1.11-78.72]), intrapartum invasive procedures (OR 10.1 [95% CI 2.6-39.02]) and episiotomy (OR 4.2 [95% CI 1.2-14.16]). HIV co-infection and newborn female were near significance (p=0.081 and 0.075, respectively).

CONCLUSIONS

Invasive procedures as fetal scalp blood sampling or internal electrode and episiotomy increase vertical transmission of HCV, especially in patients with positive HCV RNA virus load at delivery.

Mother-to-Child Transmission of Hepatitis C Virus (HCV) Among HIV/HCV-Coinfected Women

BACKGROUND

Maternal human immunodeficiency virus (HIV) coinfection has been associated with increased hepatitis C virus (HCV) mother-to-child transmission (MTCT). We hypothesized that HCV/HIV-coinfected women with well-controlled HIV disease would not have increased HCV MTCT.

METHODS

The NISDI Perinatal and LILAC cohorts enrolled HIV-infected pregnant women and their infants in Latin America and the Caribbean. This substudy evaluated the HCV infection status of mothers at participating sites and their live born, singleton infants who had a 6-month postnatal visit by December 31, 2008. Mothers who were anti-HCV-positive, or who had CD4 counts (cells/mm(3)) <200 with detectable HCV RNA, were considered HCV-infected. All HCV-infected women were tested for HCV RNA. Infants with HCV RNA were considered HCV-infected.

RESULTS

Of 1042 enrolled women, 739 (71%) mother-infant pairs met the inclusion criteria. Of the 739 women, 67 (9%) were anti-HCV-positive and 672 anti-HCV-negative [68 (10%) with CD4 counts <200; of these, 3 (4.4%) were HCV RNA-positive]. Therefore, our study population comprised 70 HCV-infected (47 with HCV RNA) and 669 HCV-uninfected women (and their infants). Factors associated with maternal HCV infection included unemployment (odds ratio [OR] = 2.58); tobacco (OR = 1.73) or marijuana (OR = 3.88) use during pregnancy; enrollment HIV viral load ([VL] copies/mL) ≥10 000 (OR = 2.27); HIV clinical disease stage C (OR = 2.12); and abnormal alanine aminotransferase (OR = 4.24) or aspartate aminotransferase (OR = 11.98). Four of 47 infants (8.5%) born to HCV-viremic women were HCV-infected, and all 4 mothers had HIV VL <1000 at hospital discharge after delivery.

CONCLUSIONS

HCV MTCT among HIV/HCV-coinfected women with well-controlled HIV disease may be lower than reported in other coinfected populations. Studies with longer infant follow-up are needed.

The role of co-infections in mother-to-child transmission of HIV

In HIV-infected women, co-infections that target the placenta, fetal membranes, genital tract, and breast tissue, as well as systemic maternal and infant infections, have been shown to increase the risk for mother-to-child transmission of HIV (MTCT). Active co-infection stimulates the release of cytokines and inflammatory agents that enhance HIV replication locally or systemically and increase tissue permeability, which weakens natural defenses to MTCT. Many maternal or infant co-infections can affect MTCT of HIV, and particular ones, such as genital tract infection with herpes simplex virus, or systemic infections such as hepatitis B, can have substantial epidemiologic impact on MTCT. Screening and treatment for co-infections that can make infants susceptible to MTCT in utero, peripartum, or postpartum can help reduce the incidence of HIV infection among infants and improve the health of mothers and infants worldwide.

Risk factors for mother-to-child transmission of hepatitis C virus: Maternal high viral load and fetal exposure in the birth canal

AIM

  Mother-to-child transmission (MTCT) is the major transmission pathway of hepatitis C virus (HCV) in children. However, its risk factors remain unsettled for introduction of putative intervention.

METHODS

  Pregnant women screened for HCV and MTCT in children born to antibody-positive mothers were prospectively studied in Tottori, Japan.

RESULTS

  Among 41 856 screened women, 188 (0.45%) were HCV antibody-positive, of whom 61% had detectable HCV RNA. While 10 of the 34 children (29%) born to high viral load (HVL: ≥6.0 × 10(5)  IU/mL) mothers were infected, none born to RNA-detectable but non-HVL mothers were infected (P < 0.001). MTCT among vaginally delivered children born to HVL mothers was analyzed. Children delivered after 4 h or more of labor were more frequently infected than were those born within 4 h of labor (P = 0.019). Premature rupture of fetal membranes was significantly more common in infected children than in uninfected children (P < 0.001). Durations of membrane rupture and labor were longer in infected children than in uninfected children (P = 0.008 and P = 0.040, respectively). Elective cesarean section that eliminates these risk factors, other than HVL, significantly reduced MTCT from nine of 22 (41%) to none of nine children (0%) (P = 0.032).

CONCLUSION

  Our data suggest that contamination of the fetus in the birth canal with infected maternal blood is a major risk factor for HCV MTCT, in addition to maternal HVL. To rationalize intervention by elective cesarean section, the natural history of infected children should be carefully evaluated.

NASPGHAN practice guidelines: Diagnosis and management of hepatitis C infection in infants, children, and adolescents

Hepatitis C virus (HCV) is an RNA virus that affects >180 million individuals worldwide with a high propensity for chronic infection. Children with HCV infection differ from adults in several ways including some modes of transmission, rates of clearance, progression of fibrosis, and the duration of potential chronic infection when acquired at birth. Since the discovery of HCV in 1989, there have been significant advances in the understanding of the virology and natural history of chronic HCV infection in children. In addition, there are now several treatment options for children with chronic hepatitis C infection and many new therapies on the horizon. As a consequence, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition brought together experts in pediatric hepatology to review the available data in children and provide clinicians with approaches to the diagnosis, management, and prevention of HCV infection in children and adolescents. The guideline details the epidemiology and natural history of HCV infection in children, the diagnostic workup, monitoring and treatment of disease, and provides an update on future treatment options and areas of research.

HCV prevalence and co-infection with HIV among pregnant women in Saint Camille Medical Centre, Ouagadougou

OBJECTIVE

To determine hepatitis C virus (HCV) prevalence and the rate of HCV/human immunodeficiency virus (HIV) co-infection in pregnant women attending Saint Camille medical centre (SCMC) in Ouagadougou.

METHODS

A total of 607 pregnant women, 16-45 years old, with <32 weeks amenorrhoea were screened for HCV and HIV using rapid tests. The majority of the women included in the study were previously known as HIV infected, as the centre is a reference centre for the programme of prevention against mother-to-child HIV transmission in the country. HCV RNA was extracted and quantified using the cDNA polymerase chain reaction with the nested primers at the 5' untranslated region. Transaminases were measured from plasma samples using spectrophotometric method.

RESULTS

Of women, 62.27% were infected with HIV. The prevalence of HCV was 2.14% in the screened pregnant women: 1.75% in HIV-negative women and 2.38% in HIV-positive ones. This prevalence is not significantly different between HIV-positive and HIV-negative pregnant women (P = 0.81). HCV RNA was found in all women with anti-HCV. A significant transaminase increase was noted in women infected with HCV (P = 0.01 and P < 0.01 for glutamic-pyruvic transaminase and glutamic-oxaloacetic transaminase, respectively). Risk factors significantly associated with HCV positivity in pregnant women included transfusion and genital excision. In addition, the infection was linked with the educational level of the women.

CONCLUSION

The issue of this study revealed that effort should be made to promote safe medical practices and fight against women genital excision that are found to be the main risk factors associated with the HCV infection.

Establishment of the milk-borne transmission as a key factor for the peculiar endemicity of human T-lymphotropic virus type 1 (HTLV-1): the ATL Prevention Program Nagasaki

In late 2010, the nation-wide screening of pregnant women for human T-lymphotropic virus type 1 (HTLV-1) infection was implemented in Japan to prevent milk-borne transmission of HTLV-1. In the late 1970s, recognition of the adult T-cell leukemia (ATL) cluster in Kyushu, Japan, led to the discovery of the first human retrovirus, HTLV-1. In 1980, we started to investigate mother-to-child transmission (MTCT) for explaining the peculiar endemicity of HTLV-1. Retrospective and prospective epidemiological data revealed the MTCT rate at ∼20%. Cell-mediated transmission of HTLV-1 without prenatal infection suggested a possibility of milk-borne transmission. Common marmosets were successfully infected by oral inoculation of HTLV-1 harboring cells. A prefecture-wide intervention study to refrain from breast-feeding by carrier mothers, the ATL Prevention Program Nagasaki, was commenced in July 1987. It revealed a marked reduction of HTLV-1 MTCT by complete bottle-feeding from 20.3% to 2.5%, and a significantly higher risk of short-term breast-feeding (<6 months) than bottle-feeding (7.4% vs. 2.5%, P < 0.001).

Chronic hepatitis C virus infection in children and adolescents: Epidemiology, natural history, and assessment of the safety and efficacy of combination therapy

Hepatitis C virus (HCV) is the most common cause of chronic liver disease of infectious etiology in children. Most of the children infected with HCV are asymptomatic, and only a few of them develop signs and symptoms of end-stage liver disease early in life. It is not possible to predict either in which patients HCV infection will have a bad outcome or the critical time in early adulthood when disease progression will accelerate. The experiences with therapy in children with chronic hepatitis C are based on earlier and continuing data from adult trials. The currently recommended treatment for chronic HCV infection in adults is the combination of peginterferon-á and ribavirin. The choice of this regimen is based on the results of randomized clinical trials that demonstrated the superiority of this combination treatment over standard interferon-á and ribavirin. Recently, results of pivotal, multicenter, interventional open-label studies on combined treatment with peginterferon-á and ribavirin in children have been published, and the US Food and Drug Administration and the European Medicines Agency have approved the combination therapy in those older than 3 years. The aim of this review is to evaluate critically the available data regarding the safety and efficacy of combination treatment with peginterferon-á and ribavirin in children.

Epidemiological survey of Japanese children infected with hepatitis B and C viruses

AIM

  The lack of a nationwide survey on hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in Japan led us to investigate the epidemiological profiles of these infections among Japanese children.

METHODS

  We conducted a questionnaire survey of children (<20 years of age) infected with either HBV (n = 136) or HCV (n = 114), who visited 636 pediatric institutions in Japan from 2003 through 2005. Most HBV-infected subjects (94%) were born in 1986 or after when a nationwide immunization program for infants born to HBe antigen-positive carriers was initiated. The transmission routes were divided into five groups: maternal, horizontal (subdivided into intrafamilial, iatrogenic and other horizontal), and unknown transmission.

RESULTS

  Comparison of subjects born in 1990 or after and those born in 1989 or before, when anti-HBc and anti-HCV (c100-3) screening tests of blood donors began, showed a shift in the relative proportions of maternal, intrafamilial, iatrogenic, other horizontal, and unknown transmission from 52%, 19%, 4%, 7% and 19% to 70%, 14%, 6%, 1% and 9%, respectively, for HBV, which was statistically insignificant (P = 0.120), and from 14%, 0%, 76%, 4% and 7% to 89%, 2%, 4%, 0% and 5%, respectively, for HCV, which was statistically significant (P < 0.001). HBV horizontal transmission did not decrease in proportion. No transfusion-acquired HCV infection was reported in subjects born in 1993 or after.

CONCLUSION

  Maternal transmission is a prominent source of HCV infection among Japanese children. The implementation of measures to prevent HBV horizontal infection is also essential, and the present system of selective vaccination should be expanded to universal vaccination.

Declining hepatitis C virus (HCV) prevalence in pregnant women: impact of anti-HCV screening of donated blood

BACKGROUND

Screening blood donors for hepatitis C virus (HCV) antibody has effectively mitigated transfusion transmission of HCV. We conducted a post hoc analysis to clarify the impact of donor screening on a general population of reproductive-age females and their offspring.

STUDY DESIGN AND METHODS

Anti-HCV screening in Japan started in late-1989. In a cohort studied between May 1990 and November 2004, a total of 22,664 consecutive serum samples from pregnant women were screened for anti-HCV. Reactive samples were further tested for HCV RNA. Linear structural regression was applied to identify causal relationships.

RESULTS

Anti-HCV-reactive rates declined significantly by two measures. First, among women known to have been transfused, rates fell from 14.8% to 3.1% with the implementation of anti-HCV screening (p < 0.01). Nevertheless, this is 10 times higher than the 0.3% reactive rate seen in a similar cohort of nontransfused women. Second, rates fell from 1.8% among women born in 1955 or before to 0.3% for women born in 1966 or later (p < 0.01). Among 103 anti-HCV-reactive women, 31 (30%) had been transfused and another 17 (17%) had other identifiable risk factors. The remaining 55 (53%) had no clear risk factor. Blood transfusion accounted for 19% of anti-HCV acquisition, by path analysis. Only one infant in this cohort was vertically infected with HCV.

CONCLUSION

Anti-HCV screening of donated blood and hygienic improvements have markedly decreased HCV infection of pregnant women with a transfusion history; however, 70% of anti-HCV-reactive women were deemed to be infected via routes other than transfusion.

Doctor-to-patient transmission of Hepatitis B virus: the potential of antiviral therapy for prevention

Hepatitis B virus (HBV)-infected health-care workers (HCWs) have infected patients during medical procedures. In many countries HBV-infected HCWs are restricted in performing exposure prone procedures based on either HBeAg status or serum HBV DNA level. To prevent loss of skilled HCWs and to minimize transmission risk, highly viraemic HCWs can be offered antiviral therapy. Nucleoside analogues have proven to be effective in reducing transmission of HIV and HBV in the setting of vertical mother-to-infant transmission. Following the same rationale, suppression of viral load in HBV-infected HCWs could minimize the risk of doctor-to-patient transmission to such an extent that job modifications are no longer indicated. To limit the risk of drug resistance, the use of combination therapy is advocated. We describe two chronic HBV-infected HCWs treated with antiviral therapy, eventually leading to well-tolerated and highly effective combination therapy with lamivudine and tenofovir, with continuation of medical practice.

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.

Prevalence of antibodies to hepatitis C virus in apparently healthy Port Harcourt blood donors and association with blood groups and other risk indicators

BACKGROUND

Testing for hepatitis C virus (HCV) is not yet mandatory in blood transfusion laboratories in Port Harcourt, Nigeria, so the current prevalence rate of this infection in our locality is unknown. The aim of this study was to determine the prevalence of HCV among apparently healthy blood donors in our area and also to assess some of the risk factors associated with the infection.

MATERIALS AND METHODS

The presence of anti-HCV antibodies was determined in the serum of 300 blood donors in Port Harcourt, Nigeria. A second-generation rapid screening test, the HEP C SPOT HCV assay was used. Initial reactive results were confirmed by repeat testing with UBI HCV EIA 4.0 enzyme immunoassay. The ABO and Rh blood groups of donors were also determined using standard serological procedures.

RESULTS

The majority of our blood donor population was constituted of males (88%) and commercial donors (63%). The blood group distribution of the donors was as follows: O RhD-positive (73%), AB RhD-positive. (4.0%), A RhD-positive (10.0%), B RhD-positive (3.0%), O RhD-negative (4.0%), A RhD-negative (3.0%), AB RhD-negative (1.0%) and B RhD-negative (2.0%). Fifteen of the 300 donors were positive for HCV, giving a prevalence rate of 5.0% in this study population. The age group 21-30 years was identified as the highest risk group with 60% of the subjects with HCV infection being in this group, compared to 20% each in the age groups 31-40 years and 41-50 years old. Twelve of the 15 (80%) HCV-positive subjects were commercial donors. The prevalence of HCV was statistically significantly higher among female donors than among male donors (chi2 = 81.000, p < 0.01). With regards to the distribution of HCV-positivity according to blood group, 4.1% of the O RhD-positive subjects, 10% of the A RhD-positive subjects and 25% of the AB RhD-positive were HCV-positive. No cases of HCV-positivity were found among the donors with other blood groups. No statistically significant relationship was found to exist between blood groups and HCV prevalence (p > 0.05).

CONCLUSION

There was a moderate prevalence of HCV infection (5%) in apparently healthy blood donors in Port Hartcourt, Nigeria. The prevalence was higher among commercial donors and in donors in the age bracket of 21-30 years of age.

Endogenous interferon-alpha level is increased in hepatitis C virus (HCV)-positive pregnant women

BACKGROUND

Mother-to-child transmission of hepatitis C virus (HCV) has been reported in around 5% of cases, and is much more likely to occur in case of coinfection with HIV. However, other cofactors influencing the vertical transmission are still debated.

AIM

To assess the serum concentration of endogenous interferon (IFN) during pregnancy, and its eventual role on the vertical transmission of HCV.

METHODS

Forty-seven HCV-infected pregnant women, and 3 control groups: (1) 75 HCV-negative pregnant women; (2) 29 HCV-positive nonpregnant women; (3) 29 HCV-negative nonpregnant women entered into the study. Endogenous IFN was assayed by enzyme-linked immunosorbent assay. The following parameters were also analyzed: viral load, HIV infection, risk factors for acquiring HCV, parity, gestational age, mode and course of delivery.

RESULTS

Vertical transmission of HCV was observed in 2 cases (4.3%). Plasma levels of IFN were significantly higher in HCV-positive pregnant women compared with either HCV-positive and HCV-negative nonpregnant women. The 2 mothers who transmitted the infection had IFN levels within the same range as the women who did not transmit the infection.

CONCLUSIONS

In HCV-positive pregnant women, there is an increased production of endogenous IFN-alpha. Further studies are warranted for clarifying the mechanisms of this cytokine in the prevention of HCV transmission.

Hepatitis C and pregnancy

Hepatitis C is the most common chronic bloodborne infection in the United States. The diagnosis of vertical transmission is reliably established by a positive serum hepatitis C virus (HCV) RNA on 2 occasions 3 to 4 months apart after the infant is at least 2 months old and/or by the detection of anti-HCV antibodies after the infant is 18 months old. Vertical transmission in HCV RNA-negative pregnant women is approximately 1% to 3% versus approximately 4% to 6% in HCV RNA-positive women. From the standpoint of vertical transmission, no critical HCV RNA titer has been established. Coinfection with HIV has been shown to increase the risk of vertical transmission of HCV, but highly active antiretroviral therapy may decrease the risk significantly. In HIV-negative women, route of delivery does not influence vertical transmission. In HCV/HIV-coinfected women, decisions regarding mode of delivery should be based on HIV status. There is no association between vertical transmission of HCV and gestational age at delivery or the presence of chorioamnionitis. The use of a scalp electrode has been associated with vertical transmission and this practice is discouraged. Data are conflicting regarding duration of ruptured membranes and the risk of vertical transmission of hepatitis C. When the duration of membrane rupture exceeds 6 hours, the risk may be increased. There is no evidence demonstrating an increased risk of HCV transmission in HIV-negative women who breast feed. In HCV/HIV-coinfected women, breast feeding is discouraged in women who have consistent access to safe infant formula.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall that vertical transmission of hepatitis C (HCV) does occur, state that coinfection with HIV increases the transmission rate, and summarize that there is no association between gestational age or presence of chorioamnionitis and no evidence that a cesarean delivery prevents transmission.

Hierarchy of baby-linked immunogenetic risk factors in the vertical transmission of hepatitis C virus

Mother-to-infant transmission of Hepatitis C Virus (HCV) represents the major cause of pediatric HCV infection today. Immunogenetic influence has been poorly investigated and mainly confined to HLA-class II serological polymorphisms. Among 290 parities, 135 from Pavia and 155 from Bergamo, of HCV-RNA-infected Italian women, 21 babies (7.24%) were HCV-RNA positive at birth and steadily positive over 20 months of life. All the 21 infected babies and 44 randomly selected uninfected ones, born to HCV-RNA+ mothers but steadily negative for HCV-RNA during a follow-up of 2 years, and their mothers were investigated for HLA-G, -C, -DRB1, -DQA1 and -DQB1 genomic polymorphisms. Among the different covariates, HLA-Cw*07, -G*010401, -DRB1*0701, -DRB1*1401 and homozygosity for HLA-G 14bp deletion can be considered as risk factors for HCV vertical transmission. On the contrary, protection was conferred by the HLA-DQB1*06, -G*0105N, -Cw*0602, DRB1*1104 and -DRB1*1302 alleles. Our initial question was: has the immunogenetic profile any role in the protection of the fetus growing in an infected milieu and, if so, is it independent from the other non-immunogenetic parameters? The answer to both questions should be yes.

Human T-cell lymphotropic virus type-1 infection and risk of cancer: 15.4 year longitudinal study among atomic bomb survivors in Nagasaki, Japan

The objective of the present study was to investigate the association between human T-lymphotropic virus type-1 (HTLV-1) infection and cancer risk in a longitudinal study. The study population consisted of 2729 atomic bomb survivors in Nagasaki Prefecture, Japan, who had no previous history of cancer at baseline. The baseline survey, including analysis of antibody to HTLV-1, took place during 1985-1987 and follow-up was performed until the end of 2001. There were 553 incident cases of malignant neoplasms during the observation period. After adjustment for sex, age and other variables, HTLV-1 infection was not associated with the risk of developing cancers of all sites, excluding adult T-cell leukemia (rate ratio 1.0, 95% confidence interval [CI] 0.76-1.4), stomach, colon and rectum, lung, female breast or other minor sites, but was associated with increased risk of liver cancer (rate ratio 2.1, 95%CI 1.0-4.6). The point estimate of the rate ratio for thyroid cancer was 3.0, but this was not significantly higher than 1 because of the small number of events (n = 11) and low prevalence of HTLV-1 seropositivity. These findings support the idea that HTLV-1 infection is not associated with an increased general cancer risk. Confounding by hepatitis C virus (HCV) and the interaction between HTLV-1 and HCV may explain the increased risk of liver cancer among HTLV-1 carriers. Further follow-up may be required to determine if HTLV-1 carriers are at increased risk of thyroid cancer.

Alanine transaminase levels in the year before pregnancy predict the risk of hepatitis C virus vertical transmission

Vertical transmission is the most common route of hepatitis C virus (HCV) infection in children. Transmission risk factors have been described, but most risk factors can only be evaluated using expensive laboratory exams. The aim of the present study was to evaluate whether maternal alanine transaminase (ALT) levels before pregnancy correlate with HCV vertical transmission. Seventy-four transmitting and 403 nontransmitting mothers were evaluated. All mothers enrolled had two ALT determinations in the last year before pregnancy, at least 6 months apart. Mothers were divided into two groups: mothers with persistently normal serum ALT levels and mothers with abnormal ALT levels. In the second group both mothers with constantly raised or with fluctuating ALT levels (one normal and one raised determination) were included. ALT was defined as raised if higher than twice the upper limit of normal. Abnormal ALT levels were found in 39/74 (52.7%) HCV transmitting mothers and in 146/403 (32.6%) nontransmitting mothers (P = 0.008; relative risk 1.96; 95% confidence limits 1.19-3.23). The risk of transmission from mothers with constantly raised ALT levels was more evident than that from mothers with fluctuating ALT levels. Increased ALT levels may reflect a more severe liver disease and a higher viral load, factors known to be associated with vertical transmission. ALT determination, a simple, widely available and inexpensive test, may help in identifying mothers with an increased risk of HCV vertical transmission.

Drug abuse, innate immunity and hepatitis C virus

Since its discovery in 1989, hepatitis C virus (HCV) has become a major public health problem. HCV chronically infects an estimated 170 million people worldwide. The seroprevalence of anti-HCV antibody in the United States has been estimated at 1.8%, which corresponds to approximately 4 million people. HCV is the most common chronic blood borne infection in the United States, and the leading cause of liver transplantation in developed countries. Injection drug use is the dominant mode of HCV transmission and accounts for up to 90% of current infections. Opiates and other drug abuse, such as alcohol, have been implicated as cofactors in the pathogenesis of HCV disease. Injection drug use has been the most common risk factor identified in alcoholics with HCV infection. Both opiates and alcohol contribute significantly to morbidity and mortality from HCV disease. These drugs most likely act synergistically to promote the development and progression of HCV disease. However, there is limited information available concerning the interaction of the drug abuse with the host cell innate immunity against HCV infection, which is a major barrier to fundamental understanding of the immunopathogenesis of HCV disease. Therefore, defining the role of the drug abuse in the development of chronic HCV infection is of crucial importance and should provide practical guidance toward the reduction of risk factors that interfere with therapeutic approaches for HCV infection and disease. This review paper focuses on the interplay between drug abuse (opiates and alcohol), innate immunity and HCV in the context of the development of HCV disease.

Prevalence and risk factors for hepatitis C virus infection in Mongolian children: Findings from a nationwide survey

Although the hepatitis C virus (HCV) infection is one of the major causes of chronic hepatitis and hepatocellular carcinoma (HCC) in Mongolia, its prevalence among children and routes of transmission are largely unknown. The aim of the study was to determine the prevalence of anti-HCV antibodies and the possible risk factors for transmission among school children using representative national data. A nationwide cross-sectional survey among elementary school children was conducted in four main geographical regions and the metropolitan area of Mongolia, through multistage, stratified, random cluster sampling. Serum samples from 1,145 children (response rate, 93%; 592 boys and 553 girls; age range, 7-12 years), which represented nearly 2% of the second grade population in Mongolia, were tested for HCV antibodies with a third-generation immunoradiometric assay (IRMA). Positive samples were further evaluated by a third-generation immunoblot assay (RIBA). A standardized questionnaire concerning the socio-demographic characteristics and potential risk factors was used. Overall, seven subjects were confirmed to be anti-HCV seropositive, giving a prevalence of 0.6% (95% CI: 0.15-1.0%). The prevalence of anti-HCV increased with age. In the multivariate logistic regression analysis, adjusted for age, sex, and residence, the history of dental manipulation (odds ratio [OR] = 15.4; 95% CI: 1.4-164.8) and surgery (OR = 8.3; 95% CI: 1.5-45.6) were associated independently with the presence of anti-HCV. These findings suggest that contaminated equipment used in the dental and surgical manipulations probably played a predominant role in HCV transmission among Mongolian children. Strict guidelines on disinfection and sterilization procedures of medical instruments have to be introduced and should be followed to improve the control of HCV infection in Mongolia.

Hepatitis B and C viruses in infants and young children

Advances during the past 20 years have led to a better understanding of the prevention, diagnosis, and treatment of acute and chronic hepatitis B (HBV) and hepatitis C (HCV) infections in the pediatric population. Universal vaccination and prenatal testing for HBV have decreased the incidence rate of acute HBV infections from more than 3/100,000 to 0.34/100,000 in all children. Diagnosis of chronic HBV is confirmed with positive serologic testing on two occasions at least 6 months apart. Current approved therapies with interferon alpha and lamivudine for children with chronic HBV infection have shown some efficacy, but results have been variable. In contrast, the lack of an effective HCV vaccine and the risk of mother-to-child transmission may increase the number of children with vertically acquired HCV that ultimately go on to develop liver fibrosis or cirrhosis. Diagnosis of HCV in the neonate should be postponed until after the child reaches 1 year of age because infants may have transient viremia. Treatment for HCV infected children has not been studied extensively. Peginterferon alpha-2a and Ribavirin are not currently approved for pediatric use; however, recent studies in children have shown potential benefit. More effective and less toxic therapies for young patients with HBV and HCV are needed, as are methods to interrupt perinatal transmission of HBV and HCV.

Risk factors for hepatitis C virus transmission to health care workers after occupational exposure: a European case-control study

BACKGROUND

Additional studies are required to identify risk factors for hepatitis C virus (HCV) transmission to health care workers after occupational exposure to HCV.

METHODS

We conducted a matched case-control study in 5 European countries from 1 January 1991 through 31 December 2002. Case patients were health care workers who experienced seroconversion after percutaneous or mucocutaneous exposure to HCV. Control subjects were HCV-exposed health care workers who did not experience seroconversion and were matched with case patients for center and period of exposure.

RESULTS

Sixty case patients and 204 control subjects were included in the study. All case patients were exposed to HCV-infected fluids through percutaneous injuries. The 37 case patients for whom information was available were exposed to viremic source patients. As risk factors for HCV infection, multivariate analysis identified needle placement in a source patient's vein or artery (odds ratio [OR], 100.1; 95% confidence interval [CI], 7.3-1365.7), deep injury (OR, 155.2; 95% CI, 7.1-3417.2), and sex of the health care worker (OR for male vs. female, 3.1; 95% CI, 1.0-10.0). Source patient HCV load was not introduced in the multivariate model. In unmatched univariate analysis, the risk of HCV transmission increased 11-fold for health care workers exposed to source patients with a viral load >6 log(10) copies/mL (95% CI, 1.1-114.1), compared with exposures to source patients with a viral load < or =4 log10 copies/mL.

CONCLUSION

In this study, HCV occupational transmission was found to occur after percutaneous exposures. The risk of HCV transmission after percutaneous exposure increased with deep injuries and procedures involving hollow-bore needle placement in the source patient's vein or artery. These results highlight the need for widespread adoption of needlestick-prevention devices in health care settings, together with other preventive measures.

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.

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HCV viremia is associated with drug use in young HIV-1 and HCV coinfected pregnant and non-pregnant women

AIMS

Vertical transmission of HCV is increased among HIV-1/HCV coinfected women and is related to HCV viral load. In this study we assessed clinical and demographic factors associated with HCV viremia in a cohort of young pregnant and non-pregnant mothers coinfected with HIV-1.

DESIGN

A cross-sectional clinic-based study nested within a prospective cohort study.

METHODS

From 1988 to 2000, HIV-1 + pregnant and non-pregnant women with children followed in a large maternal, child and adolescent HIV-1 clinic were evaluated for HCV infection using EIA 3.0. HCV RNA levels were determined for HCV antibody + women using polymerase chain reaction. Demographic and clinical characteristics between HCV-RNA(+) and HCV-RNA(-) women and between pregnant and non-pregnant HIV-1/HCV coinfected women were compared using univariate and multivariate analyses.

FINDINGS

Among 359 HIV-1(+) women, 84 (23%) were HCV-ab + and 49/84 (58%) had detectable HCV-RNA in plasma. Median age was 31. CD4 counts, HIV-1 RNA levels and demographic characteristics were similar for viremic and non-viremic women and pregnant and non-pregnant women. However, viremic women were more likely to report a history of (88% versus 43%; P < 0.001) or active injection drug use (AIDU) (83% versus 29%; P < 0.001). Logistic regression analysis showed that HCV viremia was associated significantly with AIDU (adjusted OR: 15.17; 95% CI: 3.56, 64.56) after adjusting for age, race, number of sexual partners, pregnancy status, CD4 counts and HIV-1 viral load.

CONCLUSION

In this cohort of young HIV-1 and HCV coinfected women, HCV viremia was associated strongly with active injection drug use, perhaps due to reinfection or reactivation of HCV. Thus, careful evaluation for HCV infection and counseling related to drug use may be necessary.

Routine hepatitis C virus screening in pregnancy: a cost-effectiveness analysis

OBJECTIVE

The purpose of this study was to determine whether routine hepatitis C virus screening in pregnancy is cost-effective.

STUDY DESIGN

A decision tree with Markov analysis was developed to compare 3 approaches to asymptomatic hepatitis C virus infection in low-risk pregnant women: (1) no hepatitis C virus screening, (2) hepatitis C virus screening and subsequent treatment for progressive disease, and (3) hepatitis C virus screening, subsequent treatment for progressive disease, and elective cesarean delivery to avert perinatal transmission. Lifetime costs and quality-adjusted life years were evaluated for mother and child.

RESULTS

In our base case, hepatitis C virus screening and subsequent treatment of progressive disease was dominated (more costly and less effective) by no screening, with an incremental cost of 108 US dollars and a decreased incremental effectiveness of 0.00011 quality-adjusted life years. When compared with no screening, the marginal cost and effectiveness of screening, treatment, and cesarean delivery was 117 US dollars and 0.00010 quality-adjusted life years, respectively, which yields a cost-effectiveness ratio of 1,170,000 US dollars per quality-adjusted life year.

CONCLUSION

The screening of asymptomatic pregnant women for hepatitis C virus infection is not cost-effective.

Elective cesarean delivery to prevent perinatal transmission of hepatitis C virus: a cost-effectiveness analysis

OBJECTIVE

This study was undertaken to determine whether elective cesarean delivery to avert perinatal hepatitis C virus (HCV) transmission is cost-effective.

STUDY DESIGN

Using decision analysis, we compared 2 approaches: (1) offering elective cesarean delivery to avert perinatal HCV transmission, (2) performing a cesarean delivery only for obstetric indications. Lifetime cost and quality-adjusted-life-years (QALYs) for HCV-infected neonates were evaluated with Markov analysis. We assumed elective cesarean delivery reduces perinatal HCV transmission, and we varied both the risk reduction caused by elective cesarean delivery and the background risk of perinatal HCV infection.

RESULTS

When elective cesarean section prevents all perinatal HCV transmission, 18 elective cesarean deliveries are necessary to avert 1 neonatal infection with a cost-effectiveness ratio of 34,812 dollars/QALY. At a background perinatal transmission rate of 7.7% elective cesarean deliveries is cost-effective only if it reduces the risk of perinatal transmission by more than 77%.

CONCLUSION

Elective cesarean delivery is cost-effective only if it substantially reduces the risk of perinatal HCV transmission.

Vertical transmission of hepatitis C virus in a hospital in southern Brazil

BACKGROUND: There still are controversies concerning the vertical transmission of hepatitis C virus. AIM: To evaluate the prevalence of antibodies against hepatitis C virus in pregnant women, as well as the rate of vertical transmission of this virus. PATIENTS AND METHODS: Between August 1998 and November 1999, 1,090 consecutive pregnant women were screened for anti-hepatitis C virus; positive results were confirmed by the polymerase chain reaction assay. Patient's viral load was evaluated by the branched deoxyribonucleic acid assay. Hepatitis C virus genotype was identified by direct sequencing of the polymerase chain reaction amplification products. The same tests were performed in the children born from infected mothers at the 1st and 6th month of life. RESULTS: Of the 1,090 mothers surveyed, 29 were positive for anti-hepatitis C virus (prevalence of 2.66%). Twenty-five patients presented with hepatitis C virus RNA, with a median hepatitis C virus viral load of 3.132 ± 5.891 MEq/mL. Twenty-two patients (six human immunodeficiency virus-coinfected) were followed and gave birth to 23 children; 18 of them had blood samples tested at the 1st month of life, and 22, at the 6th month. Vertical transmission rate was 5.56%; it affected a girl who had hepatitis C virus RNA detectable only in the 1st month sample (41.570 MEq/mL). The mother who transmitted hepatitis C virus was coinfected with human immunodeficiency virus and presented with an hepatitis C virus viral load of 3.765 MEq/mL, with 100% homology with her daughter's hepatitis C virus genotype. CONCLUSION: These results suggest that the prevalence of hepatitis C virus infection in pregnant women should not be neglected, and early diagnosis of vertical transmission and the follow up of infected children should be emphasized.

Risk factors for hepatitis C infection among sexually transmitted disease-infected, inner city obstetric patients

Objective: To test the hypothesis that our inner city obstetric patients who have been infected with sexually transmitted diseases (STDs) will have a higher prevalence of hepatitis C virus infection than the general population and to identify specific risk factors and high-risk groups.

Methods: All patients in our prenatal clinic (July 1997–April 1999) who tested positive for one or more STDs were asked to return for hepatitis C antibody testing. Medical charts of all patients who returned for hepatitis C testing were reviewed.

Results: A total of 106 patients with STDs were tested for hepatitis C. Positive screening tests for anti-hepatitis C antibody were found in 6.6% (7/106) of the patients (95% CI = 2.7–13.1%). This frequency is significantly higher than the hepatitis C prevalence (1.8%) in the general United States population (p = 0.006). Multiple logistic regression analysis confirmed only older age (p = 0.016) and positive HIV status (p = 0.023) to be significant predictors of hepatitis C infection.

Conclusions: Inner city STD-infected obstetric patients are at high risk for hepatitis C infection compared with the general population. Increasing age and HIV-positive status are risk factors which are significantly associated with hepatitis C infection.

La transmission materno-fœtale du virus de l’hépatite C : actualités sur l’intérêt de la césarienne

The rate of mother-to-infant transmission for hepatitis C virus is estimated to be around 5% of viraemic mothers and represents an important route of HCV infection among children. Transmission is possible in utero but the highest risk of infection is at or near the time of delivery because of an important blood transmission of hepatitis C virus. Mothers with high levels of HCV-RNA and co-infected for human immunodeficiency virus are documented to have risk factors for vertical transmission of HCV. Thus, for these, the mode of delivery must be discussed even if there are no precise recommendations. Among obstetrical risk factors, the results of literature fail to prove a benefit of elective caesarean delivery in the aim to reduce the vertical transmission of HCV. However, obstetrical situations with a high risk of blood contact between mother and foetus must be considered and if possible evicted.

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.