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Morris N, Hunter K, Bhat V, Kushnir A. Hepatitis C Exposure Diagnosis and Testing in Infants Born to Hepatitis C Virus-infected Mothers. Pediatr Infect Dis J 2024; 43:803-808. [PMID: 38621170 DOI: 10.1097/inf.0000000000004355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
BACKGROUND There has been a 5-fold increase in the number of cases of hepatitis C virus (HCV) infection among pregnant women, which is potentially associated with the increase in opioid use. METHODS This study was a retrospective review of infants born at a tertiary urban hospital in New Jersey, from January 1, 2011 to January 1, 2021, who were born to mothers with a prenatal diagnosis of HCV. RESULTS Of the 142 mothers with a prenatal diagnosis of HCV, 114 (80%) infants had a diagnosis of HCV exposure in the electronic health records. Of the HCV-exposed infants with follow-up data at 24 months of age, 52 (46%) were tested, with 34 of 52 (65%) receiving adequate testing. Infants documented as HCV exposed were more likely to be born to a mother with nonopioid drug use in pregnancy ( P = 0.01) and have a higher birth weight ( P = 0.03). Of tested infants, those with a higher number of well-child pediatrician visits ( P = 0.01) were more likely to receive adequate testing. Trends showed more polymerase chain reaction testing than antibody testing for those who were inadequately tested. CONCLUSIONS A significant proportion of infants born to HCV-infected mothers were either not identified at birth (20%) or did not receive adequate testing on follow-up (35%). Further work needs to be done to improve documentation of HCV exposure at birth and follow-up testing to avoid missing congenitally acquired HCV.
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Affiliation(s)
| | - Krystal Hunter
- Division of Neonatology, Department of Pediatrics, Cooper Children's Regional Hospital
| | - Vishwanath Bhat
- Division of Neonatology, Department of Pediatrics, Cooper University Hospital, Camden, New Jersey
| | - Alla Kushnir
- From the Cooper Medical School of Rowan University
- Division of Neonatology, Department of Pediatrics, Cooper Children's Regional Hospital
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2
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DiNicola J, Lentscher A, Liu H, Chappell CA, Rick AM. Pediatric Hepatitis C Screening by Maternal Hepatitis C Infection Status During Pregnancy. J Pediatric Infect Dis Soc 2024:piae066. [PMID: 38915257 DOI: 10.1093/jpids/piae066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Screening for perinatal hepatitis C virus (HCV) infections remains low despite increases in the number of at-risk infants. It is unknown if pediatric screening varies by maternal HCV infection status during pregnancy. METHODS Using a retrospective cohort of mother-infant pairs born from 2015 to 2019, we identified women with HCV and classified their infection status during pregnancy as active, probable or previous based on HCV RNA testing obtained during pregnancy. We used logistic regression to assess odds (OR) of infant screening based on maternal HCV infection status. RESULTS Of the 503 HCV-exposed infants, 137 (27%) were born to women with previous infection, 106 (21%) to women with probable infection, and 260 (52%) to women with active infection. Completion of pediatric screening varied by maternal infection status (43% previous infection; 49% probable infection; 58% active; p=0.014). Pediatric HCV infection ranged from 1.7-7.7% by maternal VL status. Infants born to women with active infection were 2.5 times more likely (95%CI: 1.5-4.4) to have a screening test ordered versus infants of previously infected women; there was no difference for infants of women with probable infection (OR:1.6; 95%CI: 0.9-3.2). Test ordering was also associated with maternal smoking status, a visit at ≥18 months of age and outpatient documentation of HCV exposure. If a test was ordered, there was no difference in test completion by maternal infection status. However, test completion was associated with living with a non-biologic parent and earlier birth year. CONCLUSION Infants born to women with active infection are more likely to be screened for HCV, but many children continue to be unscreened and pediatric HCV infections are going undetected. New Centers for Disease Control and Prevention pediatric HCV screening guidelines recommending earlier screening may improve screening rates.
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Affiliation(s)
- Julia DiNicola
- University of Pittsburgh School of Medicine, Pittsburgh, USA
| | | | - Hui Liu
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences University of Pittsburgh School of Medicine, Pittsburgh, USA
- Magee Womens Research Institute, Pittsburgh, USA
| | - Anne-Marie Rick
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
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3
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Wiese AD, Phillippi JC, Muhar A, Polic A, Liu G, Loch SF, Ong HH, Su WC, Leech AA, Reese T, Wei WQ, Patrick SW. Performance of Phenotype Algorithms for the Identification of Opioid-Exposed Infants. Hosp Pediatr 2024; 14:438-447. [PMID: 38804051 PMCID: PMC11137624 DOI: 10.1542/hpeds.2023-007546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/23/2024] [Accepted: 02/03/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Observational studies examining outcomes among opioid-exposed infants are limited by phenotype algorithms that may under identify opioid-exposed infants without neonatal opioid withdrawal syndrome (NOWS). We developed and validated the performance of different phenotype algorithms to identify opioid-exposed infants using electronic health record data. METHODS We developed phenotype algorithms for the identification of opioid-exposed infants among a population of birthing person-infant dyads from an academic health care system (2010-2022). We derived phenotype algorithms from combinations of 6 unique indicators of in utero opioid exposure, including those from the infant record (NOWS or opioid-exposure diagnosis, positive toxicology) and birthing person record (opioid use disorder diagnosis, opioid drug exposure record, opioid listed on medication reconciliation, positive toxicology). We determined the positive predictive value (PPV) and 95% confidence interval for each phenotype algorithm using medical record review as the gold standard. RESULTS Among 41 047 dyads meeting exclusion criteria, we identified 1558 infants (3.80%) with evidence of at least 1 indicator for opioid exposure and 32 (0.08%) meeting all 6 indicators of the phenotype algorithm. Among the sample of dyads randomly selected for review (n = 600), the PPV for the phenotype requiring only a single indicator was 95.4% (confidence interval: 93.3-96.8) with varying PPVs for the other phenotype algorithms derived from a combination of infant and birthing person indicators (PPV range: 95.4-100.0). CONCLUSIONS Opioid-exposed infants can be accurately identified using electronic health record data. Our publicly available phenotype algorithms can be used to conduct research examining outcomes among opioid-exposed infants with and without NOWS.
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Affiliation(s)
- Andrew D. Wiese
- Departments of Health Policy
- Vanderbilt Center for Child Health Policy
| | - Julia C. Phillippi
- Vanderbilt Center for Child Health Policy
- School of Nursing, Vanderbilt University, Nashville, Tennessee
| | | | | | - Ge Liu
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Henry H. Ong
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wu-Chen Su
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashley A. Leech
- Departments of Health Policy
- Vanderbilt Center for Child Health Policy
| | | | - Wei-Qi Wei
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen W. Patrick
- Departments of Health Policy
- Pediatrics
- Vanderbilt Center for Child Health Policy
- Mildred Stahlman Division of Neonatology
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4
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Curtis MR, Epstein RL, Pei P, Linas BP, Ciaranello AL. Cost-Effectiveness of Strategies for Treatment Timing for Perinatally Acquired Hepatitis C Virus. JAMA Pediatr 2024; 178:489-496. [PMID: 38466273 PMCID: PMC10928541 DOI: 10.1001/jamapediatrics.2024.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/10/2024] [Indexed: 03/12/2024]
Abstract
Importance Prevalence of chronic hepatitis C virus (HCV) infection among pregnant people is increasing in the US. HCV is transmitted vertically in 7% to 8% of births. Direct-acting antiviral (DAA) therapy was recently approved for children with HCV who are 3 years or older. The clinical and economic impacts of early DAA therapy for young children with HCV, compared with treating at older ages, are unknown. Objective To develop a state-transition model to project clinical and economic outcomes for children with perinatally acquired HCV to investigate the cost-effectiveness of treating at various ages. Design, Setting, and Participants The study team modeled the natural history of perinatally acquired HCV to simulate disease progression and costs of a simulated a cohort of 1000 US children with HCV from 3 years old through death. Added data were analyzed January 5, 2021, through July 1, 2022. Interventions The study compared strategies offering 8 weeks of DAA therapy at 3, 6, 12, or 18 years old, as well as a comparator of never treating HCV. Main Outcomes and Measures Outcomes of interest include life expectancy from 3 years and average lifetime per-person health care costs. Other clinical outcomes include cases of cirrhosis, decompensated cirrhosis, and hepatocellular carcinoma (HCC). Results The study team projected that treating HCV at 3 years old was associated with lower mean lifetime per-person health care costs ($148 162) than deferring treatment until 6 years old ($164 292), 12 years old ($171 909), or 18 years old ($195 374). Projected life expectancy was longest when treating at 3 years old (78.36 life years [LYs]) and decreased with treatment deferral until 6 years old (76.10 LYs), 12 years old (75.99 LYs), and 18 years old (75.46 LYs). In a cohort of 1000 children with perinatally acquired HCV, treating at 3 years old prevented 89 projected cases of cirrhosis, 27 cases of HCC, and 74 liver-related deaths compared with deferring treatment until 6 years old. In sensitivity analyses, increasing loss to follow-up led to even greater clinical benefits and cost savings with earlier treatment. Conclusions and Relevance These study results showed that DAA therapy for 3-year-old children was projected to reduce health care costs and increase survival compared with deferral until age 6 years or older. Measures to increase DAA access for young children will be important to realizing these benefits.
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Affiliation(s)
- Megan Rose Curtis
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts
- Boston Medical Center, Massachusetts
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
| | - Rachel L. Epstein
- Boston Medical Center, Massachusetts
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
- Department of Pediatrics, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
| | - Pamela Pei
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Benjamin P. Linas
- Boston Medical Center, Massachusetts
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Massachusetts
| | - Andrea L. Ciaranello
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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5
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Panagiotakopoulos L, Sandul AL, Conners EE, Foster MA, Nelson NP, Wester C. CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children - United States, 2023. MMWR Recomm Rep 2023; 72:1-21. [PMID: 37906518 PMCID: PMC10683764 DOI: 10.15585/mmwr.rr7204a1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
The elimination of hepatitis C is a national priority (https://www.hhs.gov/sites/default/files/Viral-Hepatitis-National-Strategic-Plan-2021-2025.pdf). During 2010-2021, hepatitis C virus (HCV) acute and chronic infections (hereinafter referred to as HCV infections) increased in the United States, consequences of which include cirrhosis, liver cancer, and death. Rates of acute infections more than tripled among reproductive-aged persons during this time (from 0.8 to 2.5 per 100,000 population among persons aged 20-29 years and from 0.6 to 3.5 among persons aged 30-39 years). Because acute HCV infection can lead to chronic infection, this has resulted in increasing rates of HCV infections during pregnancy. Approximately 6%-7% of perinatally exposed (i.e., exposed during pregnancy or delivery) infants and children will acquire HCV infection. Curative direct-acting antiviral therapy is approved by the Food and Drug Administration for persons aged ≥3 years. However, many perinatally infected children are not tested or linked to care. In 2020, because of continued increases in HCV infections in the United States, CDC released universal screening recommendations for adults, which included recommendations for screening for pregnant persons during each pregnancy (Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC recommendations for hepatitis C screening among adults-United States, 2020. MMWR Recomm Rep 2020;69[No. RR-2]:1-17). This report introduces four new CDC recommendations: 1) HCV testing of all perinatally exposed infants with a nucleic acid test (NAT) for detection of HCV RNA at age 2-6 months; 2) consultation with a health care provider with expertise in pediatric hepatitis C management for all infants and children with detectable HCV RNA; 3) perinatally exposed infants and children with an undetectable HCV RNA result at or after age 2 months do not require further follow-up unless clinically warranted; and 4) a NAT for HCV RNA is recommended for perinatally exposed infants and children aged 7-17 months who previously have not been tested, and a hepatitis C virus antibody (anti-HCV) test followed by a reflex NAT for HCV RNA (when anti-HCV is reactive) is recommended for perinatally exposed children aged ≥18 months who previously have not been tested. Proper identification of perinatally infected children, referral to care, and curative treatment are critical to achieving the goal of hepatitis C elimination.
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Affiliation(s)
| | - Amy L Sandul
- Division
of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB
prevention, CDC; Division of Global Health Protection, Center for Global
Health, CDC
| | - DHSc1
- Division
of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB
prevention, CDC; Division of Global Health Protection, Center for Global
Health, CDC
| | | | | | | | | | - Collaborators
- Division
of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB
prevention, CDC; Division of Global Health Protection, Center for Global
Health, CDC
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6
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Evidence for Implementation: HIV/HCV Coinfection and Pregnancy. Curr HIV/AIDS Rep 2023; 20:1-8. [PMID: 36652107 PMCID: PMC9846668 DOI: 10.1007/s11904-022-00643-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW In the context of the opioid epidemic, hepatitis C virus (HCV) infection prevalence is increasing among women of reproductive age. Pregnant people with HIV/HCV coinfection may be at increased risk of adverse pregnancy and neonatal outcomes, although research in this key population is lacking. RECENT FINDINGS Treatment with directly acting antivirals (DAAs) has transformed the clinical care for most patients with HCV. However, pregnant people were excluded from trials of these medications. A recent phase I study has shown promise with excellent safety profile for ledipasvir-sofosbuvir; demonstrating no episodes of perinatal transmission, 100% sustained virologic response, and no safety concerns. Pregnancy represents a time of maximal interaction with the healthcare system and therefore an ideal window of opportunity to cure HCV. Current observational data regarding pregnant people who are co-infected with HCV and HIV suggest poor outcomes such as increased risk of preterm birth; however, there are no prospective and well-controlled studies to fully understand the impact of HIV/HCV coinfection on pregnancy. Phase 1 studies suggest that DAAs are well-tolerated and effective during pregnancy. Only through large, prospective clinical trials will we be able to understand the interaction of HCV and HIV during pregnancy and to evaluate safety and efficacy of DAAs in this key population.
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Varol M, Licka Dieye N, Zang M, Handa D, C Zorich S, Millen AE, Gomez-Duarte OG. Hepatitis C Virus Exposure and Infection in the Perinatal Period. Curr Pediatr Rev 2022; 19:21-33. [PMID: 35440312 DOI: 10.2174/1573396318666220417235358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/09/2022] [Accepted: 01/24/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hepatitis C virus infection is a leading cause of blood-borne hepatitis disease worldwide. Hepatitis C is a silent liver disease that, without treatment, leads to late-onset complications, including chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma, in 10-40% of patients. OBJECTIVE This study aimed to review the epidemiology, clinical features, diagnosis, treatment, and prevention of hepatitis C among perinatally exposed children. METHODS Public databases, including MEDLINE and PubMed, and websites from the Centers for Disease Control and Prevention, the Food and Drug Administration, the World Health Organization, and the National Institutes of Health were searched for relevant articles published between 2006 and 2021. RESULTS The prevalence of hepatitis C has increased among women of childbearing age in the United States and is associated with risk factors, such as intravenous drug use, health inequities, and low socioeconomic background. Infants born to hepatitis C virus-infected mothers have a 6% risk of vertical transmission, and among those infected, 75% will develop chronic hepatitis C and late complications. However, hepatitis C-exposed infants are frequently lost to follow-up, and those infected have delayed diagnosis and treatment and are at high risk for late-onset complications. Direct- acting antivirals and the establishment of effective treatment guidelines cure hepatitis C virus infections. CONCLUSION Hepatitis C predominantly affects underserved communities. Early screening of mothers and infants is critical for the diagnosis, treatment, and prevention of chronic infections and lateonset complications. New policies are needed to address hepatitis C health care inequities affecting mothers and infants in the United States.
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Affiliation(s)
- Mine Varol
- Department of Pediatrics, Division of Pediatric Infectious Diseases, International Enteric Vaccine Research Program (IEVRP), University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Ndeye Licka Dieye
- Department of Pediatrics, Division of Pediatric Infectious Diseases, International Enteric Vaccine Research Program (IEVRP), University at Buffalo, State University of New York, Buffalo, NY, USA.,Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Michael Zang
- Sisters of Charity Hospital, Catholic Health System, Buffalo, NY, USA
| | - Deepali Handa
- Department of Pediatrics, Division of Neonatology, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Shauna C Zorich
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Amy E Millen
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, NY, USA
| | - Oscar G Gomez-Duarte
- Department of Pediatrics, Division of Pediatric Infectious Diseases, International Enteric Vaccine Research Program (IEVRP), University at Buffalo, State University of New York, Buffalo, NY, USA
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Abstract
Hepatitis C virus prevalence has steeply risen among pregnant women in association with the opioid epidemic and the major national infectious diseases and liver society guidelines recommend universal hepatitis C virus testing in pregnancy. All infants born to mothers with hepatitis C virus infection should be evaluated. Many children spontaneously clear hepatitis C virus or remain minimally symptomatic, but some develop significant liver disease if untreated. With hepatitis C virus cure available starting at age 3, we must improve programs to identify and cure hepatitis C virus-infected women and infants with the goal of eliminating mother-to-child transmission.
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Affiliation(s)
- Rachel L Epstein
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, 801 Massachusetts Avenue, Crosstown Center 2nd Floor, Boston, MA 02118, USA.
| | - Claudia Espinosa
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Morsani College of Medicine, University of South Florida, 12901 Bruce B Downs Boulevard, Tampa, FL 33612, USA
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Rogers ME, Balistreri WF. Cascade of care for children and adolescents with chronic hepatitis C. World J Gastroenterol 2021; 27:1117-1131. [PMID: 33828389 PMCID: PMC8006101 DOI: 10.3748/wjg.v27.i12.1117] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/19/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic hepatitis C virus (HCV) infection presents a significant global public health burden. In 2015, over 400000 deaths worldwide were attributed to HCV infection. This led the World Health Organization (WHO) in 2016 to set the ambitious goal of eliminating HCV by 2030. Adult-centered guidelines have been established in order to provide direction for healthcare professionals, allowing integration of the newest screening policies and therapeutic strategies into their practices. However, for children and adolescents, HCV is a significant, unrecognized public health problem. HCV infection rates in the United States in women of childbearing age and those who are pregnant have increased in parallel with the rising opioid epidemic. An estimated 29000 women with HCV infection gave birth each year from 2011 to 2014 in the United States, with approximately 1700 of their infants being infected with HCV. Newer HCV-specific therapeutics, namely direct acting antivirals (DAA), has brought a new and highly successful approach to treatment of hepatitis C. Recent studies have confirmed similar levels of effectiveness and safety of DAA therapies in the pediatric population. Thus, an enhanced cascade of care, which should include the population under 18 years of age, can help achieve the WHO goal by focusing on elimination in the youngest populations. This review will present an overview of the natural history, clinical features, and management of HCV in children and adolescents.
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Affiliation(s)
- Michael Evan Rogers
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
| | - William F Balistreri
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, United States
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