Increasing Prevalence of Chronic Hepatitis C Virus Infection in a Southern Academic Obstetrical Clinic

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Pediatric Hepatitis C Quality Improvement Project Improves Healthcare Access

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

STUDY DESIGN

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSION

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

Quality improvement to evaluate and provide treatment for chronic hepatitis C postpartum

BACKGROUND

Chronic hepatitis C virus (HCV) infections are increasing among reproductive age individuals. Direct acting antivirals (DAAs) can cure HCV, but the use of DAAs is not currently recommended during pregnancy and breastfeeding. Individuals with HCV commonly have inadequate prenatal and postnatal care.

OBJECTIVES

The purpose of our study was to demonstrate the success of a quality improvement program to increase evaluation during pregnancy and ensuring access to DAA treatment medication during the postpartum period for individuals with chronic HCV to achieve cure 12 weeks after completing therapy. The primary outcome was documented HCV cure rate compared among individuals who received immediate treatment with DAA after delivery or after weaning or a traditional approach of referral to an infectious diseases specialist or hepatologist. The secondary outcome was the proportion of infants exposed to HCV evaluated.

METHODS

An interdisciplinary team developed a program to increase evaluation and HCV treatment for postpartum individuals. Individuals who received prenatal care from March 2017 to May 2021 were eligible. Individuals with chronic HCV had a laboratory evaluation before delivery, and appropriate DAAs were selected for postpartum treatment. The health system specialty pharmacy dispensed DAA prescriptions immediately after delivery to those who were not breastfeeding. Individuals who did breastfeed had the option to begin treatment after weaning. Cure was defined as a sustained viral response or undetectable HCV RNA collected 12 weeks after completing DAA treatment.

RESULTS

We demonstrate the success of an interdisciplinary team to ensure access to therapy for the treatment of postpartum chronic HCV. Only 3 infants (25%) with mothers referred were evaluated at our institution compared with 44% of infants (n = 10) whose mothers were treated after delivery.

CONCLUSION

An interdisciplinary team for HCV treatment improves access to treatment therapy with DAAs leading to the cure of chronic HCV after delivery.

Hepatitis C Virus in Pregnancy: A Systematic Review of the Literature

OBJECTIVE

The aim of this study was to systematically review the literature to summarize recent demographic characteristics of hepatitis C virus (HCV) infection during pregnancy and the efficacy of risk-based versus universal screening.

STUDY DESIGN

PubMed, EMBASE, and Cochrane Library were searched to identify relevant studies. Studies that recognized hepatitis C as a primary or secondary outcome, with pregnant women as the population and written in English, were included. Studies were excluded if they were abstracts only, written in foreign language, or published prior to 1992. Two researchers independently screened all the studies by titles, abstracts, and full text. Conflicts were settled by a third researcher.

RESULTS

A total of 698 studies were identified with 78 fitting inclusion criteria. In total, 69 epidemiologic and 9 comparison studies were found. Identified risk factors for HCV infection include intravenous or illicit drug use, sexually transmitted coinfection, high-risk behaviors in the partners, high parity, and history of miscarriages or abortions. Demographic characteristics associated with HCV include non-Hispanic white race, American Indian or Alaskan Native ethnicity, and increasing age. Providers may fail to adequately screen for each risk factor, and up to two-thirds of women with a known risk factor are not screened under current guidelines. Finally, up to 27% of HCV+ women have no identifiable risk factors for infection.

CONCLUSION

There is evidence that risk-based screening fails to identify a large proportion of HCV positive women in pregnancy and that pregnant women with HCV risk factors and consistent with current screening guidelines fail to be tested. We urge for the adoption of universal screening to identify these women and offer treatment.

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

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