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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; 13:445-454. [PMID: 38915257 DOI: 10.1093/jpids/piae066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 06/24/2024] [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 ratio (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 to 7.7% by maternal viral load (VL) status. Infants born to women with active infection were 2.5 times more likely (95% confidence intervals [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 nonbiologic 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, Pennsylvania, USA
| | - Anthony Lentscher
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hui Liu
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Magee Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - Anne-Marie Rick
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Wu J, Wang H, Xiang Z, Jiang C, Xu Y, Zhai G, Ling Z. Role of viral hepatitis in pregnancy and its triggering mechanism. J Transl Int Med 2024; 12:344-354. [PMID: 39360164 PMCID: PMC11444475 DOI: 10.2478/jtim-2024-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024] Open
Abstract
Hepatitis viral infection can cause severe complications, even mortality in pregnant women and their offspring. Multiple studies have shown that vertical transmission can cause viral hepatitis infections in newborns, especially in hepatitis B, C, and E. Screening for hepatitis viral infection in pregnant women is essential. Once infected, pregnant women should be given timely antiviral treatments, which could effectively alleviate the disease progression and reduce adverse outcomes. Besides, the mechanism of viral hepatitis mediating adverse pregnancy outcomes has been a hot topic. Hepatitis B virus has been found to mediate both mother- to-child and parent-child transmission. Liver injury in hepatitis C virus infection is associated with immune-mediated mechanisms, which can be regulated by hormonal factors as well. The mediating mechanism of adverse maternal and infant outcomes caused by hepatitis E virus infection is mainly related to viral replication in the placenta and changes in cytokine and estrogen. Nevertheless, the specific mechanisms related to hepatitis A virus and hepatitis D virus remain unclear, and more research is needed. This review shows that the existence of viral hepatitis during pregnancy can pose certain risks for pregnant women and infants, and different interventions have been used to treat pregnant women infected with viral hepatitis. It may provide deep insight into adverse pregnancy outcomes caused by viral hepatitis and give guidance on treatment.
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Affiliation(s)
- Jian Wu
- Department of Blood Transfusion, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, 242 Guangji Road, Suzhou 215008, Jiangsu Province, China
| | - Huiqing Wang
- Department of Family Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang Province, China
| | - Ze Xiang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, City, Hangzhou 310003, Zhejiang Province, China
| | - Chun Jiang
- Department of Blood Transfusion, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, 242 Guangji Road, Suzhou 215008, Jiangsu Province, China
| | - Yunyang Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, City, Hangzhou 310003, Zhejiang Province, China
| | - Guanghua Zhai
- Department of Blood Transfusion, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, 242 Guangji Road, Suzhou 215008, Jiangsu Province, China
| | - Zongxin Ling
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Rd, City, Hangzhou 310003, Zhejiang Province, China
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Sandul AL, Wester C, Panagiotakopoulos L. Testing Infants and Children With Perinatal Exposure to Hepatitis C Virus. Am Fam Physician 2024; 110:228-229. [PMID: 39283843 PMCID: PMC11457147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Affiliation(s)
- Amy L Sandul
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carolyn Wester
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Kuncio DE, Waterman EJ, Robison SZG, Roberts A. Factors Associated With Perinatal Hepatitis C Screening Among Exposed Children: 2016-2020. Pediatrics 2024; 154:e2023064745. [PMID: 38867693 DOI: 10.1542/peds.2023-064745] [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] [Received: 10/25/2023] [Revised: 04/19/2024] [Accepted: 04/19/2024] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Children perinatally exposed to hepatitis C virus (HCV) should be screened for infection, yet testing rates are low. Clinical perinatal HCV testing recommendations vary and may contribute to poor completion. This study examines pediatric care factors associated with perinatal HCV testing completion. METHODS A cohort of people living with HCV in Philadelphia, Pennsylvania, who delivered a live birth in 2016 to 2020 and their children were followed by the Philadelphia Department of Public Health. The association of completion of HCV screening with pregnant/postpartum person demographics, pediatric care factors, and testing policy were retrospectively explored. χ2 and multivariable logistic regressions were used. RESULTS HCV-positive pregnant people gave birth to 457 children of whom 307 (67.2%) were tested for HCV according to recommendations and 79 (17.2%) were inadequately tested. Children were more likely to be tested if born to a pregnant person with HIV coinfection (P = .007), if they were always on schedule for vaccinations (P < .001), and if they attended the 18-month well visit (P < .001). Completion rates varied significantly by pediatrician's testing policy: 90.9% tested if the policy was for 2 months, 79.6% if 2 to 12 months, 61.9% if 12 months, and 58.5% if 18 months of age (P < .001). CONCLUSIONS Timing of perinatal HCV testing policies was significantly associated with testing completion rates. Testing at 2 months was associated with far better HCV testing completion than other strategies, regardless of birthing person and pediatrician factors. These findings suggest routine HCV testing of children perinatally exposed to HCV is best achieved in the first year of life.
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Affiliation(s)
- Danica E Kuncio
- Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - Emily J Waterman
- Philadelphia Department of Public Health, Philadelphia, Pennsylvania
| | - S Z Ginny Robison
- Philadelphia Department of Public Health Affiliated, Philadelphia, Pennsylvania
| | - Alison Roberts
- Philadelphia Department of Public Health Affiliated, Philadelphia, Pennsylvania
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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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Foley MK, Djerboua M, Kushner T, Biondi MJ, Feld JJ, Terrault NA, Flemming JA. Maternal neighbourhood-level social determinants of health and their association with paediatric hepatitis C screening among children exposed to hepatitis C in pregnancy. Paediatr Perinat Epidemiol 2024; 38:152-160. [PMID: 38273801 PMCID: PMC11299768 DOI: 10.1111/ppe.13042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Current guidelines recommend HCV screening by 18 months of age for those exposed to HCV in utero; yet, screening occurs in the minority of children. OBJECTIVES To evaluate the association between maternal neighbourhood-level social determinants of health (SDOH) and paediatric HCV screening in the general population in a publicly funded healthcare system in Canada. METHODS Retrospective cohort study using administrative healthcare data held at ICES. Children born to individuals positive for HCV RNA in pregnancy from 2000 to 2016 were identified and followed for 2 years. Major SDOH were identified, and the primary outcome was HCV screening in exposed children (HCV antibody and/or RNA). Associations between SDOH and HCV screening were determined using multivariate Poisson regression models adjusting for confounding. RESULTS A total of 1780 children born to persons with +HCV RNA were identified, and 29% (n = 516) were screened for HCV by age two. Most mothers resided in the lowest income quintile (42%), and most vulnerable quintiles for material deprivation (41%), housing instability (38%) and ethnic diversity (26%) with 11% living in rural locations. After adjustment for confounding, maternal rural residence (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.62, 1.07) and living in the highest dependency quintile (RR 0.83, 95% CI 0.65, 1.07) were the SDOH most associated with paediatric HCV screening. Younger maternal age (RR 0.98 per 1-year increase, 95% CI 0.97, 0.99), HIV co-infection (RR 1.69, 95% CI 1.16, 2.48) and GI specialist involvement (RR 1.18, 95% CI 1.00, 1.39) were associated with higher probabilities of screening. CONCLUSIONS Among children exposed to HCV during pregnancy, rural residences and living in highly dependent neighbourhoods showed a potential association with a lower probability of HCV screening by the age of 2. Future work evaluating barriers to paediatric HCV screening among rural residing and dependent residents is needed to enhance the screening.
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Affiliation(s)
- Mary K. Foley
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | | | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine, New York, New York, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, Icahn School of Medicine, New York, New York, USA
| | - Mia J. Biondi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- School of Nursing, Faculty of Health Sciences, York University, Toronto, Ontario, Canada
| | - Jordan J. Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Ontario, Canada
| | - Norah A. Terrault
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine at University of Southern California, Los Angeles, California, USA
| | - Jennifer A. Flemming
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
- ICES Queens, Kingston, Ontario, Canada
- Division of Cancer Care and Epidemiology, Queen’s Cancer Research Institute, Kingston, Ontario, Canada
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Boudova S, Tholey DM, Ferries-Rowe E. Hepatitis C virus detection and management after implementation of universal screening in pregnancy. AJOG GLOBAL REPORTS 2024; 4:100317. [PMID: 38435837 PMCID: PMC10905043 DOI: 10.1016/j.xagr.2024.100317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
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.
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Affiliation(s)
- Sarah Boudova
- Department of Obstetrics and Gynecology Indiana University School of Medicine, Indianapolis, IN (Drs Boudova and Ferries-Rowe)
| | - Danielle M. Tholey
- Division of Gastroenterology and Hepatology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA (Dr Tholey)
| | - Elizabeth Ferries-Rowe
- Department of Obstetrics and Gynecology Indiana University School of Medicine, Indianapolis, IN (Drs Boudova and Ferries-Rowe)
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Thompson LA, Plitt SS, Doucette K, Coffin CS, Klein KB, Robinson JL, Charlton CL. Evaluation and comparison of risk-based and universal prenatal HCV screening programs in Alberta, Canada. J Hepatol 2023; 79:1121-1128. [PMID: 37348788 DOI: 10.1016/j.jhep.2023.05.044] [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: 02/01/2023] [Revised: 05/11/2023] [Accepted: 05/31/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND & AIMS Canadian clinical practice guidelines currently recommend risk-based screening for HCV in pregnant individuals. However, no provinces or territories have ever compared the effectiveness of risk-based vs. universal screening for the prenatal diagnosis of HCV. We aimed to evaluate and compare HCV screening programs after implementing a universal population-level pilot program among prenatal patients in Alberta, Canada. METHODS The Alberta Prenatal Screening Program for Select Communicable Diseases was amended to include universal HCV antibody screening. Cohorts of pregnant individuals screened for HCV through risk-based or universal programs were generated over 1-year periods. HCV screening rates and prevalence were analyzed and compared between cohorts to evaluate the effectiveness of screening methods. Social and demographic risk factors for HCV-positive individuals were compared between screening cohorts to identify which populations may be overlooked with risk-based guidelines. RESULTS HCV antibody screening rates were 11.9% and 99.9% among pregnant individuals in the risk-based and universal cohorts, respectively. HCV prevalence among the cohorts was 0.07% and 0.11% (difference = 0.04%, p = 0.032), with an average of 21 additional HCV-positive pregnant individuals identified annually with universal screening. HCV-positive pregnant patients diagnosed through universal screening were more likely to engage in high-risk sexual behaviours/sex work compared to those diagnosed through risk-based screening (47.6% vs. 12.5%, respectively p = 0.035), suggesting that these high-risk cases are being missed by risk-based screening. CONCLUSIONS Universal HCV screening diagnoses significantly higher numbers of pregnant individuals infected with HCV compared to risk-based screening. Universal HCV screening or amending risk-based guidelines to incorporate more proxy variables for risk factors should be considered to improve prenatal HCV screening guidelines in Canada and help achieve HCV elimination in the next decade. IMPACT AND IMPLICATIONS HCV is a bloodborne pathogen that can cause severe liver disease and be vertically transmitted from a mother to her baby during pregnancy. Pregnant individuals in Alberta are currently only tested for HCV if they disclose engaging in activities that put them at risk of acquiring the infection (risk-based screening). Using a population-wide universal prenatal HCV screening program, our work shows that testing based on patient disclosed risk alone leads to the significant underdiagnosis of HCV in pregnant individuals and suggests individuals engaging in sex work or risky sexual behaviours are being overlooked by the current risk-based program. Our outcomes represent the first province-wide study to evaluate and compare prenatal HCV risk-based and universal screening programs in Canada and provide evidence to support the update of prenatal HCV screening policies across the country and in similar jurisdictions.
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Affiliation(s)
- L Alexa Thompson
- Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Alberta, Canada
| | - Sabrina S Plitt
- Public Health Agency of Canada, Ottawa, Ontario, Canada; School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Karen Doucette
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Li Ka Shing Institute of Virology, Edmonton, Alberta, Canada
| | - Carla S Coffin
- Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kristin B Klein
- Provincial Population and Public Health, Alberta Health Services, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Joan L Robinson
- Division of Infectious Diseases, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Carmen L Charlton
- Division of Diagnostic and Applied Microbiology, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada; Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Alberta, Canada; Li Ka Shing Institute of Virology, Edmonton, Alberta, Canada; Alberta Precision Laboratories (ProvLab), University of Alberta Hospital, Edmonton, Alberta, Canada.
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Kushner T. A New Look at Perinatal Hepatitis C Virus Transmission: Results From the Maternal-Fetal Medicine Units Network Study. Obstet Gynecol 2023; 142:447-448. [PMID: 37535958 DOI: 10.1097/aog.0000000000005308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Affiliation(s)
- Tatyana Kushner
- Tatyana Kushner is from the Division of Liver Diseases in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the Icahn School of Medicine at Mount Sinai, New York, New York;
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10
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Fogel RS, Chappell CA. Hepatitis C Virus in Pregnancy: An Opportunity to Test and Treat. Obstet Gynecol Clin North Am 2023; 50:363-373. [PMID: 37149316 DOI: 10.1016/j.ogc.2023.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
With the advent of safe and well-tolerated direct-acting antiviral (DAA) medications for hepatitis C virus (HCV), disease eradication is on the horizon. However, as the rate of HCV infection among women of childbearing potential continues to rise due to the ongoing opioid epidemic in the United States, perinatal transmission of HCV presents an increasingly difficult barrier. Without the ability to treat HCV during pregnancy, complete eradication is unlikely. In this review, we discuss the current epidemiology of HCV in the United States, the current management strategy for HCV in pregnancy, as well as the potential for future use of DAAs in pregnancy.
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Affiliation(s)
- Rachel S Fogel
- University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA 15213, USA
| | - Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA; Magee-Womens Research Institute, 204 Craft Avenue, Pittsburgh, PA 15213, USA.
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Ades AE, Gordon F, Scott K, Collins IJ, Thorne C, Pembrey L, Chappell E, Mariné-Barjoan E, Butler K, Indolfi G, Gibb DM, Judd A. Spontaneous Clearance of Vertically Acquired Hepatitis C Infection: Implications for Testing and Treatment. Clin Infect Dis 2023; 76:913-991. [PMID: 35396848 PMCID: PMC9989140 DOI: 10.1093/cid/ciac255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Current guidelines recommend that infants born to women with hepatitis C virus (HCV) viremia be screened for HCV antibody at age 18 months and, if positive, referred for RNA testing at 3 years to confirm chronic infection. This policy is based, in part, on analyses that suggest that 25%-40% of vertically acquired HCV infections clear spontaneously within 4-5 years. METHODS Data on 179 infants with HCV RNA and/or anti-HCV evidence of vertically acquired infection in 3 prospective European cohorts were investigated. Ages at clearance of infection were estimated taking account of interval censoring and delayed entry. We also investigated clearance in initially HCV RNA-negative infants in whom RNA was not detectable until after 6 weeks. RESULTS Clearance rates were initially high then declined slowly. Apparently, many infections clear before they can be confirmed. An estimated 65.9% (95% credible interval [CrI], 50.1-81.6) of confirmed infections cleared by 5 years, at a median 12.4 (CrI, 7.1-18.9) months. If treatment were to begin at age 6 months, 18 months, or 3 years, at least 59.0% (CrI, 42.0-76.9), 39.7% (CrI, 17.9-65.9), and 20.9% (CrI, 4.6-44.8) of those treated would clear without treatment. In 7 (6.6%) confirmed infections, RNA was not detectable until after 6 weeks and not until after 6 months in 2 (1.9%). However, all such cases subsequently cleared. CONCLUSIONS Most confirmed infection cleared by age 3 years. Treatment before age 3, if it was available, would avoid loss to follow-up but would result in substantial overtreatment.
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Affiliation(s)
- A E Ades
- Population Health Sciences, University of Bristol Medical School, Bristol, United Kingdom
| | - Fabiana Gordon
- Population Health Sciences, University of Bristol Medical School, Bristol, United Kingdom
| | - Karen Scott
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Intira Jeannie Collins
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Claire Thorne
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Lucy Pembrey
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth Chappell
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Eugènia Mariné-Barjoan
- Public Health Department, Université Côte d’Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Karina Butler
- Children’s Health Ireland at Crumlin and Temple Street, Dublin, Ireland
| | - Giuseppe Indolfi
- Meyer Children’s Hospital and Department Neurofarba, University of Florence, Firenze, Italy
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Ali Judd
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
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Ades AE, Gordon F, Scott K, Collins IJ, Claire T, Pembrey L, Chappell E, Mariné-Barjoan E, Butler K, Indolfi G, Gibb DM, Judd A. Overall Vertical Transmission of Hepatitis C Virus, Transmission Net of Clearance, and Timing of Transmission. Clin Infect Dis 2023; 76:905-912. [PMID: 35403676 PMCID: PMC9989130 DOI: 10.1093/cid/ciac270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 02/11/2022] [Accepted: 04/05/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND It is widely accepted that the risk of hepatitis C virus (HCV) vertical transmission (VT) is 5%-6% in monoinfected women, and that 25%-40% of HCV infection clears spontaneously within 5 years. However, there is no consensus on how VT rates should be estimated, and there is a lack of information on VT rates "net" of clearance. METHODS We reanalyzed data on 1749 children in 3 prospective cohorts to obtain coherent estimates of overall VT rate and VT rates net of clearance at different ages. Clearance rates were used to impute the proportion of uninfected children who had been infected and then cleared before testing negative. The proportion of transmission early in utero, late in utero, and at delivery was estimated from data on the proportion of HCV RNA positive within 3 days of birth, and differences between elective cesarean and nonelective cesarean deliveries. RESULTS Overall VT rates were 7.2% (95% credible interval [CrI], 5.6%-8.9%) in mothers who were human immunodeficiency virus (HIV) negative and 12.1% (95% CrI, 8.6%-16.8%) in HIV-coinfected women. The corresponding rates net of clearance at 5 years were 2.4% (95% CrI, 1.1%-4.1%), and 4.1% (95% CrI, 1.7%-7.3%). We estimated that 24.8% (95% CrI, 12.1%-40.8%) of infections occur early in utero, 66.0% (95% CrI, 42.5%-83.3%) later in utero, and 9.3% (95% CrI, 0.5%-30.6%) during delivery. CONCLUSIONS Overall VT rates are about 24% higher than previously assumed, but the risk of infection persisting beyond age 5 years is about 38% lower. The results can inform design of trials of interventions to prevent or treat pediatric HCV infection, and strategies to manage children exposed in utero.
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Affiliation(s)
- Anthony E Ades
- Population Health Sciences, University of Bristol Medical School, Bristol, United Kingdom
| | - Fabiana Gordon
- Population Health Sciences, University of Bristol Medical School, Bristol, United Kingdom
| | - Karen Scott
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Intira J Collins
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Thorne Claire
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Lucy Pembrey
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Elizabeth Chappell
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Eugènia Mariné-Barjoan
- Université Côte d’Azur, Public Health Department, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Karina Butler
- Children's Health Ireland at Crumlin and Temple Street, Dublin, Ireland
| | - Giuseppe Indolfi
- Meyer Children's Hospital and Department Neurofarba, University of Florence, Firenze, Italy
| | - Diana M Gibb
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
| | - Ali Judd
- Medical Research Council Clinical Trials Unit, University College London, London, United Kingdom
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13
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Jhaveri R. Elimination Means Everyone: Targeting Hepatitis C in Infants and Pregnant Patients. Clin Infect Dis 2023; 76:920-922. [PMID: 35475916 DOI: 10.1093/cid/ciac330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ravi Jhaveri
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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14
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Pediatric Hepatitis C Quality Improvement Project Improves Healthcare Access. J Pediatr Gastroenterol Nutr 2023; 76:371-378. [PMID: 36728827 DOI: 10.1097/mpg.0000000000003690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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15
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Curtis MR, Chappell C. 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] [MESH Headings] [Grants] [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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Affiliation(s)
- Megan Rose Curtis
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA, USA.
- Boston Medical Center, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Catherine Chappell
- Department of Obstetrics, Gynecology, and Reproductive sciences, University of Pittsburgh, PA, Pittsburgh, USA
- Magee-Women's Research Institute, Pittsburgh, PA, USA
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16
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Dema E, Stander J, Cortina-Borja M, Thorne C, Bailey H. Estimating the number of livebirths to Hepatitis C seropositive women in England in 2013 and 2018 using Bayesian modelling. PLoS One 2022; 17:e0274389. [PMID: 36409689 PMCID: PMC9678281 DOI: 10.1371/journal.pone.0274389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/26/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The UK National Screening Committee currently recommends against antenatal screening for Hepatitis C virus (HCV) infection in England due to lack of HCV prevalence data and treatment licensed for use in pregnancy. We aimed to produce regional and national estimates of the number and proportion of livebirths to HCV seropositive women in England in 2013 and 2018. METHODS A logistic regression model fitted in the Bayesian framework estimated probabilities of HCV seropositivity among 24,599 mothers delivering in the North Thames area of England in 2012 adjusted by maternal age and region of birth. These probabilities were applied to the underlying population structures of women delivering livebirths in England in 2013 and 2018 to estimate the number of livebirths to HCV seropositive women in these years nationally and by region. The Bayesian approach allowed the uncertainty associated with all estimates to be properly quantified. RESULTS Nationally, the estimated number of livebirths to women seropositive for HCV for England was 464 (95% credible interval [CI] 300-692) in 2013 and 481 (95%CI 310-716) in 2018, or 70.0 (95%CI 45.0-104.1) per 100,000 and 76.9 (95%CI 49.5-114.4) per 100,000 in these years respectively. Regions with the highest estimated number of livebirths to HCV seropositive women in 2013 and 2018 included London with 118.5 and 124.4 and the South East with 67.0 and 74.0 per 100,000 livebirths. CONCLUSION Few previous studies have investigated HCV among pregnant women in England. These findings complement and supplement existing research by providing national and regional estimates for the number of livebirths to HCV seropositive women in England. Bayesian modelling allows future national and regional estimates to be produced and the associated uncertainty to be properly quantified.
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Affiliation(s)
- Emily Dema
- Institute for Global Health, University College London, London, United Kingdom
| | - Julian Stander
- Centre for Mathematical Sciences, School of Engineering, Computing and Mathematics, University of Plymouth, Plymouth, United Kingdom
| | - Mario Cortina-Borja
- Population, Policy and Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Claire Thorne
- Population, Policy and Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Heather Bailey
- Institute for Global Health, University College London, London, United Kingdom
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17
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Massih SA, Eke AC. Direct antiviral agents (DAAs) and their use in pregnant women with hepatitis C (HCV). Expert Rev Anti Infect Ther 2022; 20:1413-1424. [PMID: 36111676 PMCID: PMC9588700 DOI: 10.1080/14787210.2022.2125868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/14/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Direct-Acting Antiviral Agents (DAAs) provide safer, efficacious, tolerable, and curative therapy for women with hepatitis C. Their preferred safety and efficacy profile make them potential therapies for the elimination of perinatal transmission of hepatitis C virus (HCV). However, DAAs are not currently recommended for use during pregnancy due to limited pharmacokinetic and safety data. AREAS COVERED This review covers the different DAA drug combinations, the available data on their pharmacodynamic and pharmacokinetic properties, how the physiology in pregnancy can potentially affect DAA drug disposition, known drug-drug interactions with DAAs, and available and planned epidemiological and pharmacokinetic studies on DAA use during pregnancy. Although no large randomized clinical trials or prospective cohort studies involving DAAs have been completed in pregnancy, the currently available studies demonstrate no significant changes in pharmacokinetics, and no major safety concerns in women with hepatitis C. EXPERT OPINION Initial pharmacokinetic and safety data suggest that DAAs have high efficacy and a low risk of adverse events during pregnancy. As more pharmacokinetic and epidemiologic data become available, DAAs could become a preferred option for treating HCV during pregnancy and elimination of perinatal transmission of hepatitis C virus.
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Affiliation(s)
- Sandra Abdul Massih
- Division of Clinical Pharmacology & Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287
| | - Ahizechukwu C. Eke
- Division of Clinical Pharmacology & Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287
- Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 228, Baltimore, MD 21287
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18
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Kushner T, Djerboua M, Biondi MJ, Feld JJ, Terrault N, Flemming JA. Influence of hepatitis C viral parameters on pregnancy complications and risk of mother-to-child transmission. J Hepatol 2022; 77:1256-1264. [PMID: 35643203 DOI: 10.1016/j.jhep.2022.05.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 05/05/2022] [Accepted: 05/16/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS With the World Health Organization plan for hepatitis C elimination by the year 2030, and recent guideline recommendations to screen all women during pregnancy for HCV, data on HCV in pregnancy are needed to determine the association of HCV viremia with adverse pregnancy outcomes and mother-to-child transmission (MTCT). METHODS This retrospective cohort study was performed in Ontario, Canada, using population-based administrative healthcare data. Individuals were stratified based on whether they had active HCV viremia during pregnancy or resolved viremia at time of pregnancy. Peak HCV viral load was determined. Logistic regression was used to determine the association of viremia with adverse pregnancy outcomes; maternal HCV RNA levels were evaluated as a predictor of MTCT. RESULTS We identified a total of 2,170 pregnancies in 1,636 women who were HCV RNA positive prior to pregnancy; 1,780 (82%) pregnancies occurred in women who were HCV RNA positive during pregnancy. Patients who were HCV RNA positive during pregnancy were more likely to have preterm delivery (18% vs. 12%, p = 0.002), intrahepatic cholestasis of pregnancy (4% vs. <2%, p = 0.003), and post-partum hemorrhage (9% vs. 5%, p = 0.013), and less likely to have gestational diabetes (6% vs. 10%, p = 0.008) than those with resolved infection. Only 511 (29%) infants had screening consistent with guidelines after birth; there was an estimated 3.5% risk of MTCT. HCV RNA ≥6.0 log10 IU/ml was significantly associated with MTCT (exact odds ratio 3.4, p = 0.04). CONCLUSION Active HCV viremia among individuals with a history of HCV infection significantly increases adverse pregnancy outcomes. Few infants are screened for MTCT. Higher HCV RNA is associated with increased risk of MTCT. LAY SUMMARY The prevalence of hepatitis C has increased in women of child-bearing age and has important implications for women who become pregnant and their infants. We evaluated the effect that hepatitis C has on pregnancy outcomes as well as the rate of hepatitis C transmission to infants in a large database with linked mother-infant records. We found that active hepatitis C during pregnancy increased the risk of pregnancy complications. We also identified very low rates of testing of infants born to mothers with hepatitis C, but found higher rates of hepatitis C transmission to infants in mothers with higher virus levels.
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Affiliation(s)
- Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine, New York, NY USA; Department of Obstetrics, Gynecology and Reproductive Sciences, Icahn School of Medicine, New York, NY USA.
| | | | - Mia J Biondi
- Toronto Centre for Liver Disease, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON Canada; School of Nursing, Faculty of Health Sciences, York University, Toronto ON Canada
| | - Jordan J Feld
- Toronto Centre for Liver Disease, Sandra Rotman Centre for Global Health, University of Toronto, Toronto, Canada
| | - Norah Terrault
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Jennifer A Flemming
- ICES, Queen's University, Kingston, Ontario, Canada; Departments of Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada
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19
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Honegger JR, Gowda C. Defer no more: advances in the treatment and prevention of chronic hepatitis C virus infection in children. Curr Opin Infect Dis 2022; 35:468-476. [PMID: 35852787 PMCID: PMC9474609 DOI: 10.1097/qco.0000000000000856] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Direct-acting antiviral (DAA) regimens targeting hepatitis C virus (HCV) are now approved for young children. This review examines recent DAA experience in children, current treatment recommendations and challenges, and potential treatment-as-prevention strategies. RECENT FINDINGS In 2021, the US FDA extended approval of two pan-genotypic DAA regimens, glecaprevir/pibrentasvir and sofosbuvir/velpatasvir, to children as young as age 3 years based on high success rates and reassuring safety profiles in registry trials. Similar performance has been replicated with real-world DAA use in thousands of adolescents and in limited reports of children with high-risk conditions, including cirrhosis, cancer, thalassemia and HIV-coinfection. Treatment without delay is now recommended in the USA for viremic children aged 3 years and up to prevent disease progression and future spread. To date, treatment expansion is limited by high rates of undiagnosed paediatric infection. Universal prenatal screening will aid identification of perinatally exposed newborns, but new strategies are needed to boost testing of exposed infants and at-risk adolescents. Postpartum treatment programmes can prevent subsequent vertical transmission but are hampered by low rates of linkage to care and treatment completion. These challenges may be avoided by DAA use in pregnancy, and this warrants continued study. SUMMARY Paediatric HCV is now readily curable. Substantial clinical and public health effort is required to ensure widespread uptake of this therapeutic breakthrough.
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Affiliation(s)
- Jonathan R. Honegger
- Division of Pediatric Infectious Diseases, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Center for Vaccines and Immunity, Abigail Wexner Research Institute, Columbus, Ohio, USA
| | - Charitha Gowda
- Division of Pediatric Infectious Diseases, Nationwide Children’s Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Partners For Kids, Nationwide Children’s Hospital, Columbus, Ohio, USA
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20
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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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21
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Behnke C, Nissim O, Simerlein W, Beeker K, Tarleton JL, Lazenby GB. Quality improvement to evaluate and provide treatment for chronic hepatitis C postpartum. J Am Pharm Assoc (2003) 2021; 62:864-869. [PMID: 34975005 DOI: 10.1016/j.japh.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 11/19/2022]
Abstract
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.
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22
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Gowda C, Smith S, Crim L, Moyer K, Sánchez PJ, Honegger JR. Nucleic Acid Testing for Diagnosis of Perinatally Acquired Hepatitis C Virus Infection in Early Infancy. Clin Infect Dis 2021; 73:e3340-e3346. [PMID: 32640018 PMCID: PMC8563185 DOI: 10.1093/cid/ciaa949] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Most US children with perinatal hepatitis C virus (HCV) exposure fail to receive the recommended anti-HCV antibody test at age ≥18 months. Earlier testing for viral RNA might facilitate increased screening, but sensitivity of this approach has not been established. We hypothesized that modern HCV-RNA RT-PCR platforms would adequately detect infected infants. METHODS Nationwide Children's Hospital electronic health records from 1/1/2008 to 30/6/2018 were reviewed to identify perinatally exposed infants tested by HCV-RNA RT-PCR at age 2-6 months. Diagnostic performance was determined using a composite case definition: (1) infected children had positive repeat HCV-RNA testing or positive anti-HCV at age ≥24 months; (2) uninfected children lacked these criteria and had negative anti-HCV at age ≥18 months. RESULTS 770 perinatally exposed infants underwent HCV-RNA testing at age 2-6 months. Of these, 28 (3.6%) tested positive; viremia was confirmed in all who underwent repeat testing (n = 27). Among 742 infants with negative HCV-RNA results, 226 received follow-up anti-HCV testing at age ≥18 months, of whom 223 tested negative. Three children had low-positive anti-HCV results at age 18-24 months that were negative upon retesting after age 24 months, possibly indicating waning maternal antibodies. Using the composite case definitions, early HCV-RNA screening demonstrated sensitivity of 100% (87.5-100%, Wilson-Brown 95% CI) and specificity of 100% (98.3-100%). CONCLUSIONS Modern HCV-RNA RT-PCR assays have excellent sensitivity for early diagnosis of perinatally acquired infection and could aid HCV surveillance given the substantial loss to follow-up at ≥18 months of age.
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Affiliation(s)
- Charitha Gowda
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital–The Ohio State University College of Medicine, Columbus, Ohio, USA
- Partners For Kids, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Stephanie Smith
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital–The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Linda Crim
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital–The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Katherine Moyer
- Division of Pediatric Infectious Diseases, Inova Children’s Hospital, Falls Church, Virginia USA
| | - Pablo J Sánchez
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital–The Ohio State University College of Medicine, Columbus, Ohio, USA
- Division of Neonatology, Department of Pediatrics, Nationwide Children’s Hospital–The Ohio State University College of Medicine, Columbus, Ohio, USA
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Jonathan R Honegger
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Nationwide Children’s Hospital–The Ohio State University College of Medicine, Columbus, Ohio, USA
- Center for Vaccines and Immunity, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
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Patrick SW, Dupont WD, McNeer E, McPheeters M, Cooper WO, Aronoff DM, Osmundson S, Stein BD. Association of Individual and Community Factors With Hepatitis C Infections Among Pregnant People and Newborns. JAMA HEALTH FORUM 2021; 2:e213470. [PMID: 35977167 PMCID: PMC8727040 DOI: 10.1001/jamahealthforum.2021.3470] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/05/2021] [Indexed: 12/12/2022] Open
Abstract
Importance The opioid crisis has increasingly affected pregnant people and infants. Hepatitis C virus (HCV) infections, a known complication of opioid use, grew in parallel with opioid-related complications; however, the literature informing individual and community risks associated with maternal HCV infection is sparse. Objectives To determine (1) individual and county-level factors associated with HCV among pregnant people and their newborn infants, and (2) how county-level factors influence individual risk among the highest risk individuals. Design Setting and Participants This time-series analysis of retrospective, repeated cross-sectional data included pregnant people in all US counties from 2009 to 2019. We constructed mixed-effects logistic regression models to explore the association between HCV infection and individual and county-level covariates. Analyses were conducted between June 2019 and September 2021. Exposures Individual-level: race and ethnicity, education, marital status, insurance type; county-level: rurality, employment, density of obstetricians. Main Outcomes and Measures Hepatitis C virus as indicated on the newborn's birth certificate. Results Between 2009 and 2019, there were 39 380 122 pregnant people who met inclusion criteria, among whom 138 343 (0.4%) were diagnosed with HCV. People with HCV were more likely to be White (79.9% vs 53.5%), American Indian or Alaska Native (AI/AN) (2.9% vs 0.9%), be without a 4-year degree (93.2% vs 68.6%), and be unmarried (73.7% vs 38.8%). The rate (per 1000 live births) of HCV among pregnant people increased from 1.8 to 5.1. In adjusted analyses, the following factors were associated with higher rates of HCV: individuals identified as White (adjusted odds ratio [aOR], 7.37; 95% CI, 7.20-7.55) and AI/AN (aOR, 7.94; 95% CI, 7.58-8.31) compared with Black individuals, those without a 4-year degree (aOR, 3.19; 95% CI, 3.11-3.28), those with Medicaid vs private insurance (aOR, 3.27; 95% CI, 3.21-3.33), and those who were unmarried (aOR, 2.80; 95% CI, 2.76-2.84); whereas, rural residence, higher rates of employment, and greater density of obstetricians was associated with lower risk of HCV. Among individuals at the highest risk of HCV, higher levels of county employment, accounting for other factors, were associated with less of a rise in HCV infections over time. Conclusions and Relevance In this cross-sectional study, maternal and newborn HCV infections increased substantially between 2009 and 2019, disproportionately among White and AI/AN people without a 4-year degree. County-level factors, including higher levels of employment, were associated with lower individual risks of acquiring the virus.
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Affiliation(s)
- Stephen W. Patrick
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee,RAND Corporation, Pittsburgh, Pennsylvania
| | - William D. Dupont
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth McNeer
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa McPheeters
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William O. Cooper
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David M. Aronoff
- Department of Medicine, Division of Infectious Disease, Vanderbilt University Medical Center, Nashville, Tennessee,Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah Osmundson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley D. Stein
- RAND Corporation, Pittsburgh, Pennsylvania,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Gander S, Morris A, Materniak S. An Evaluation of Hepatitis C Screening in Infants and Children Born to Seropositive Mothers in Saint John, New Brunswick. Cureus 2021; 13:e17377. [PMID: 34584787 PMCID: PMC8457320 DOI: 10.7759/cureus.17377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The primary route of hepatitis C virus (HCV) infection in children is vertical transmission, from mother to fetus in utero. There is a lack of data on the prevalence of pediatric HCV acquired through vertical transmission in Saint John, New Brunswick. Furthermore, what risk factors may be associated with an increased likelihood for a child born to an HCV-seropositive mother should be known to direct screening practices. Methods: A retrospective chart review of the active charts from the local HCV clinic, the Centre for Research, Education & Clinical Care of At-Risk Populations (RECAP), identified HCV-seropositive women who had children at-risk of HCV through vertical transmission. Sociodemographic information and various risk factors were collected, including maternal HCV genotype, non-prescription drug use subcategorized into intravenous drug use and snorting, transfusion history, involvement in opiate substitution therapy, postal code as a proxy for socioeconomic status, and issues of custodianship within the family. A 2 x 2 chi-square analysis was conducted to assess the frequency of HCV screening for children by the presence or absence of familial custodianship issues. Results: In total, data from 62 HCV-seropositive women and 123 infants and children at-risk for HCV were included in this study. HCV status at the time of pregnancy revealed 18 (14.6%) with a positive HCV screen, 14 (11.4%) with a positive viral load, and 91 (74.0%) with unknown status. A total of 30 children (24.4%) had HCV screening performed, of which three (10.0%) were HCV-antibody positive and had a detectable viral load. Results of the chi-square analysis indicated that issues of custodianship had no significant influence on child screening rates. Conclusion: Overall, this study highlighted the inconsistent screening practices of children at-risk for HCV through vertical transmission, as well as the need for improvement in chart documentation and follow-up. Clinicians and researchers should focus their efforts toward proactively identifying children at-risk for HCV through vertical transmission. This could involve screening during pregnancy and subsequent follow-up, or at other points of contact with the healthcare system, such as parental involvement with opioid substitution therapy or well-child visits. Implementation of a targeted screening program could be considered in urban centers similar to the one in this study to connect at-risk populations with essential medical and community services.
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Affiliation(s)
- Sarah Gander
- Pediatrics, Saint John Regional Hospital, Saint John, CAN
| | - Angela Morris
- Pediatrics, Dalhousie Medicine New Brunswick, Saint John, CAN
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Kislovskiy Y, Chappell C, Flaherty E, Hamm ME, Cameron FDA, Krans EE, Chang JC. Experiences and Perspectives From Women Taking Investigational Therapy for Hepatitis C Virus During Pregnancy. Subst Abuse 2021; 15:11782218211046261. [PMID: 34602820 PMCID: PMC8481705 DOI: 10.1177/11782218211046261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 08/19/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Describe the experiences and perspectives among pregnant people with chronic HCV infection receiving ledipasvir/sofosbuvir (LDV/SOF) therapy during pregnancy. METHODS We conducted semi-structured, in-depth interviews within an open-label, phase 1 study of LDV/SOF therapy among pregnant people with chronic HCV infection. Participants took 12 weeks of LDV/SOF and were interviewed at enrollment and again at the end of treatment. We transcribed the interviews verbatim and coded them with NVivo software for subsequent inductive thematic analysis. RESULTS Nine pregnant people completed the study, leading to 18 interview transcripts. All participants identified as women. Eight women acquired HCV through injection drug use, and 1 through perinatal transmission. We identified 3 themes. (1) Treatment for HCV during pregnancy with LDV/SOF was tolerable and convenient. (2) Women described that taking investigational LDV/SOF increased their self-esteem and sense of well-being due to possible cure from HCV, and they felt that the experience of working hard to achieve cure may potentially prevent return to drug abuse in the future. (3) Women appreciated researchers and providers that gave non-judgmental care and communicated honestly, and preferred person-centered care that acknowledges women's individual needs. CONCLUSIONS Women stated that cure from HCV would be "life-changing," and described antepartum treatment for HCV with LDV/SOF as tolerable and desired, when provided by non-judgmental providers. Antepartum treatment was found to be acceptable by study participants and should be further evaluated to combat the increasing HCV epidemic among young persons, including pregnant people.
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Affiliation(s)
- Yasaswi Kislovskiy
- Department of OB/Gyn and Women’s Institute, Allegheny Health Network, Pittsburgh, PA, USA
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Emily Flaherty
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Megan E Hamm
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Flor de Abril Cameron
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Judy C Chang
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
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26
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Jhaveri R, Yee LM, Antala S, Murphy M, Grobman WA, Shah SK. Responsible Inclusion of Pregnant Individuals in Eradicating HCV. Hepatology 2021; 74:1645-1651. [PMID: 33743550 DOI: 10.1002/hep.31825] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 01/08/2023]
Abstract
HCV infections have increased in recent years due to injection drug use and the opioid epidemic. Simultaneously, HCV cure has become a reality, with the advent of direct-acting antivirals (DAAs) and expansion of treatment programs. As a result, HCV screening recommendations now include all adults, including pregnant individuals; and many countries have endorsed widespread DAA access as a strategy to achieve HCV eradication. However, almost universally, pregnant individuals have been systematically excluded from HCV clinical research and treatment programs. This omission runs counter to public health strategies focused on elimination of HCV but is consistent with a historical pattern of exclusion of pregnant individuals from research. Our systematic review of publications on HCV treatment with DAAs in pregnancy revealed only one interventional study, which evaluated sofosbuvir/ledipasvir in 8 pregnant individuals. Given the paucity of research on this issue of great public health importance, we aimed to appraise the current landscape of HCV research/treatment and analyze the ethical considerations for responsibly including pregnant individuals. We propose that pregnancy may be an opportune time to offer HCV treatment given improved access, motivation, and other health care monitoring occurring in the antenatal period. Moreover, treatment of pregnant individuals may support the goal of eliminating perinatal HCV transmission and overcome the established challenges with transitioning care after delivery. The exclusion of pregnant individuals without justification denies them and their offspring access to potential health benefits, raising justice concerns considering growing data on DAA safety and global efforts to promote equitable and comprehensive HCV eradication. Finally, we propose a path forward for research and treatment programs during pregnancy to help advance the goal of HCV elimination.
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Affiliation(s)
- Ravi Jhaveri
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Lynn M Yee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Swati Antala
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Division of Gastroenterology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Margaret Murphy
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - William A Grobman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Seema K Shah
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Advanced General Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021; 70:1-187. [PMID: 34292926 PMCID: PMC8344968 DOI: 10.15585/mmwr.rr7004a1] [Citation(s) in RCA: 829] [Impact Index Per Article: 276.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.
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28
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Wilson RD. Guideline No. 409: Intrauterine Fetal Diagnostic Testing in Women with Chronic Viral Infections. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 42:1555-1562.e1. [PMID: 33308791 DOI: 10.1016/j.jogc.2020.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This revised guideline provides updated information for the care of women with chronic viral infections who require intrauterine fetal diagnostic testing. TARGET POPULATION Women with chronic viral infections who are pregnant or planning a pregnancy. OPTIONS Non-invasive screening tests for diagnosis: maternal serum placental analytes with or without nuchal translucency, sonography, maternal serum cell-free placental DNA; and intrauterine fetal diagnostic testing: amniocentesis, chorionic villus sampling, cordocentesis. OUTCOMES The recommendations in this guideline have the potential to decrease or eliminate morbidity and mortality in women with chronic viral infections and their infants, which is associated with significant health and economic outcomes. EVIDENCE Published literature was retrieved through searches of PubMed, guidelines of national societies (Society of Obstetricians and Gynaecologists of Canada, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, other international societies), and the Cochrane Library using appropriate controlled vocabulary (amniocentesis, chorionic villus sampling, cordocentesis, procedure pregnancy loss risk, viral vertical transmission, fetal and neonatal infection) and keywords (maternal infection or exposure, hepatitis B, hepatitis C, human immunodeficiency virus). Results were restricted to systematic reviews, randomized controlled trials or controlled clinical trials (if available), and observational case-control studies or case series from 2012 to 2019 published in English or French. Studies from 1966 to 2002 were previously reviewed in the SOGC guideline No. 123: Amniocentesis and Women with Hepatitis B, Hepatitis C, or Human Immunodeficiency Virus, and those from 2002 to 2012 were previously reviewed in the SOGC guideline No. 309: Prenatal Invasive Procedures in Women With Hepatitis B, Hepatitis C, and/or Human Immunodeficiency Virus Infections. Updated literature searches were completed regularly through August 2019 and were incorporated into this guideline. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE The intended users are maternity care providers and women with chronic viral infections. This guideline provides information to educate and counsel these women, and to offer them reproductive options. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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29
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Auriti C, De Rose DU, Santisi A, Martini L, Piersigilli F, Bersani I, Ronchetti MP, Caforio L. Pregnancy and viral infections: Mechanisms of fetal damage, diagnosis and prevention of neonatal adverse outcomes from cytomegalovirus to SARS-CoV-2 and Zika virus. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166198. [PMID: 34118406 PMCID: PMC8883330 DOI: 10.1016/j.bbadis.2021.166198] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/07/2021] [Accepted: 06/03/2021] [Indexed: 02/07/2023]
Abstract
Some maternal infections, contracted before or during pregnancy, can be transmitted to the fetus, during gestation (congenital infection), during labor and childbirth (perinatal infection) and through breastfeeding (postnatal infection). The agents responsible for these infections can be viruses, bacteria, protozoa, fungi. Among the viruses most frequently responsible for congenital infections are Cytomegalovirus (CMV), Herpes simplex 1–2, Herpes virus 6, Varicella zoster. Moreover Hepatitis B and C virus, HIV, Parvovirus B19 and non-polio Enteroviruses when contracted during pregnancy may involve the fetus or newborn at birth. Recently, new viruses have emerged, SARS-Cov-2 and Zika virus, of which we do not yet fully know the characteristics and pathogenic power when contracted during pregnancy. Viral infections in pregnancy can damage the fetus (spontaneous abortion, fetal death, intrauterine growth retardation) or the newborn (congenital anomalies, organ diseases with sequelae of different severity). Some risk factors specifically influence the incidence of transmission to the fetus: the timing of the infection in pregnancy, the order of the infection, primary or reinfection or chronic, the duration of membrane rupture, type of delivery, socio-economic conditions and breastfeeding. Frequently infected neonates, symptomatic at birth, have worse outcomes than asymptomatic. Many asymptomatic babies develop long term neurosensory outcomes. The way in which the virus interacts with the maternal immune system, the maternal-fetal interface and the placenta explain these results and also the differences that are observed from time to time in the fetal‑neonatal outcomes of maternal infections. The maternal immune system undergoes functional adaptation during pregnancy, once thought as physiological immunosuppression. This adaptation, crucial for generating a balance between maternal immunity and fetus, is necessary to promote and support the pregnancy itself and the growth of the fetus. When this adaptation is upset by the viral infection, the balance is broken, and the infection can spread and lead to the adverse outcomes previously described. In this review we will describe the main viral harmful infections in pregnancy and the potential mechanisms of the damages on the fetus and newborn.
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Affiliation(s)
- Cinzia Auriti
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
| | - Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
| | - Alessandra Santisi
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
| | - Ludovica Martini
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
| | - Fiammetta Piersigilli
- Department of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium.
| | - Iliana Bersani
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
| | - Maria Paola Ronchetti
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus, Newborn and Infant - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
| | - Leonardo Caforio
- Fetal and Perinatal Medicine and Surgery Unit, Medical and Surgical Department of Fetus, Newborn and Infant - "Bambino Gesù" Children's Hospital IRCCS, Rome, Italy.
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Abstract
Infectious hepatitis in pregnancy is clinically significant in both the acute and chronic phases. Here, we review the perinatal implications of chronic hepatitis B and C and acute hepatitis A and E. Familiarity with screening, transmission, diagnosis, and management of infectious hepatitis is of ongoing importance during obstetric care, as these diseases are endemic in much of the world. Pregnancy and interpregnancy care provide opportunities to prevent infection and transmission of hepatitis.
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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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Malik F, Bailey H, Chan P, Collins IJ, Mozalevskis A, Thorne C, Easterbrook P. Where are the children in national hepatitis C policies? A global review of national strategic plans and guidelines. JHEP Rep 2021; 3:100227. [PMID: 33665586 PMCID: PMC7898178 DOI: 10.1016/j.jhepr.2021.100227] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND & AIMS It is estimated that 3.26 million children and adolescents worldwide have chronic HCV infection. To date, the global response has focused on the adult population, but direct-acting antiviral (DAA) regimens are now approved for children aged ≥3 years. This global review describes the current status of policies on HCV testing and treatment in children, adolescents, and pregnant women in WHO Member States. METHODS We identified national strategic plans and/or clinical practice guidelines (CPGs) for HCV infection from a World Health Organization (WHO) database of national policies from Member States as of August 2019. A standardised proforma was used to abstract data on polices or recommendations on testing and treatment in children, adolescents and pregnant women. Analysis was stratified according to the country-income status and results were validated through WHO regional focal points through August 2020. RESULTS National HCV policies were available for 122 of the 194 WHO Member States. Of these, the majority (n = 71/122, 58%) contained no policy recommendations for either testing or treatment in children or adolescents. Of the 51 countries with policies, 24 had specific policies for both testing and treatment, and were mainly from the European region; 18 countries for HCV testing only (12 from high- or upper-middle income); and 9 countries for treatment only (7 high- or upper-middle income). Twenty-one countries provided specific treatment recommendations: 13 recommended DAA-based regimens for adolescents ≥12 years and 6 still recommended interferon/ribavirin-based regimens. CONCLUSIONS There are significant gaps in policies for HCV-infected children and adolescents. Updated guidance on testing and treatment with newly approved DAA regimens for younger age groups is needed, especially in most affected countries. LAY SUMMARY To date, the predominant focus of the global response towards elimination of hepatitis C has been on the testing and treatment of adults. Much less attention has been paid to testing and treatment among children and adolescents, although in 2018 an estimated 3.26 million were infected with HCV. Our review shows that many countries have no national guidance on HCV testing and treatment in children and adolescents. It highlights the urgent need for advocacy and updated policies and guidelines specific for children and adolescents.
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Key Words
- AASLD, American Association for the Study of Liver Diseases
- APASL, Asian Pacific Association for the Study of the Liver
- Adolescents
- CPGs, clinical practice guidelines
- Children
- Clinical practice guidelines
- DAAs, direct-acting antivirals
- EASL, European Association for the Study of the Liver
- ESPGHAN, European Society for Paediatric Gastroenterology Hepatology and Nutrition
- GHSS, Global Health Sector Strategy
- GLE, glecaprevir
- GT, genotype
- Hepatitis C
- IDU, injecting drug use
- IFN, interferon
- LED, ledipasvir
- LMICs, low- and middle-income countries
- MoH, ministries of health
- NASPGHAN, North American Society for Pediatric Gastroenterology Hepatology and Nutrition
- NSPs, national strategic plans
- National strategic plans
- PIB, pibrentasvir
- Policies
- Policy review
- Pregnancy
- RBV, ribavirin
- SOF, sofosbuvir
- VEL, velpatasvir
- WHO, World Health Organization
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Affiliation(s)
- Farihah Malik
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Heather Bailey
- UCL Institute for Global Health, University College London, London, UK
| | - Polin Chan
- World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - Intira Jeannie Collins
- Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | | | - Claire Thorne
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Philippa Easterbrook
- Department of Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
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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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Perfect C, Jhaveri R. Hepatitis C Virus in Children: Trying to Overcome the Domestic and Global Challenges of Cases and Cost. J Pediatric Infect Dis Soc 2021; 10:71-74. [PMID: 31616918 DOI: 10.1093/jpids/piz069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/16/2019] [Indexed: 12/23/2022]
Abstract
Over the last decade, Hepatitis C virus has persisted and evolved as a domestic and global health challenge for adults and children. The challenges involve both increased cases in the United States and cost of treatment both in the US and globally.
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Affiliation(s)
| | - Ravi Jhaveri
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Chappell CA, Jonas MM. Hepatitis C Virus in Pregnancy: Are We Ready for Test and Treat? J Infect Dis 2021; 222:S789-S793. [PMID: 33245353 DOI: 10.1093/infdis/jiaa181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Catherine A Chappell
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Maureen M Jonas
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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Kushner T, Reau N. Changing epidemiology, implications, and recommendations for hepatitis C in women of childbearing age and during pregnancy. J Hepatol 2021; 74:734-741. [PMID: 33248169 DOI: 10.1016/j.jhep.2020.11.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/10/2020] [Accepted: 11/19/2020] [Indexed: 02/08/2023]
Abstract
Despite the remarkable advances in HCV treatment brought about by the advent of direct-acting antivirals, HCV remains a global public health concern. One particular concern relates to the rising prevalence of HCV in women of childbearing age. Active HCV during pregnancy is associated with cholestasis of pregnancy as well as the risk of mother-to-child transmission. Guidelines are increasingly recommending universal screening during pregnancy, while the treatment of HCV during pregnancy is an area of ongoing research.
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Affiliation(s)
- Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Nancy Reau
- Hepatology Services, Rush University Medical Center, Chicago, IL, United States.
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Terrault NA, Levy MT, Cheung KW, Jourdain G. Viral hepatitis and pregnancy. Nat Rev Gastroenterol Hepatol 2021; 18:117-130. [PMID: 33046891 DOI: 10.1038/s41575-020-00361-w] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2020] [Indexed: 02/06/2023]
Abstract
The management of viral hepatitis in the setting of pregnancy requires special consideration. There are five liver-specific viruses (hepatitis A, B, C, D, E), each with unique epidemiology, tendency to chronicity, risk of liver complications and response to antiviral therapies. In the setting of pregnancy, the liver health of the mother, the influence of pregnancy on the clinical course of the viral infection and the effect of the virus or liver disease on the developing infant must be considered. Although all hepatitis viruses can harm the mother and the child, the greatest risk to maternal health and subsequently the fetus is seen with acute hepatitis A virus or hepatitis E virus infection during pregnancy. By contrast, the primary risks for hepatitis B virus (HBV), hepatitis C virus (HCV) and hepatitis D virus are related to the severity of the underlying liver disease in the mother and the risk of mother-to-child transmission (MTCT) for HBV and HCV. The prevention of MTCT is key to reducing the global burden of chronic viral hepatitis, and prevention strategies must take into consideration local health-care and socioeconomic challenges. This Review presents the epidemiology of acute and chronic viral hepatitis infection in pregnancy, the effect of pregnancy on the course of viral infection and, conversely, the influence of the viral infection on maternal and infant outcomes, including MTCT.
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Affiliation(s)
- Norah A Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, USA.
| | - Miriam T Levy
- Department of Gastroenterology and Liver, Liverpool Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Ka Wang Cheung
- Department of Obstetrics and Gynaecology, Queen Mary Hospital, University of Hong Kong, Hong Kong, Hong Kong
| | - Gonzague Jourdain
- French National Research Institute for Sustainable Development (IRD), Marseille, France.,Chiang Mai University, Chiang Mai, Thailand
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Chen SH, Lai HC, Chiang IP, Su WP, Lin CH, Kao JT, Chuang PH, Hsu WF, Wang HW, Chen HY, Huang GT, Peng CY. Performance of Acoustic Radiation Force Impulse Elastography for Staging Liver Fibrosis in Patients With Chronic Hepatitis C After Viral Eradication. Clin Infect Dis 2021; 70:114-122. [PMID: 30816416 DOI: 10.1093/cid/ciz161] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 02/22/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Data on noninvasive liver fibrosis staging after viral eradication are unclear. This histology-based study validated the performance of liver stiffness (LS) measurements after viral eradication. METHODS Consecutive participants with chronic hepatitis C (CHC) who received concomitant LS measurements through acoustic radiation force impulse (ARFI) elastography and percutaneous liver biopsy were prospectively screened and analyzed. RESULTS Of the 644 patients, 521 (80.9%) underwent a biopsy at treatment baseline, and the remaining 123 (19.1%) underwent a biopsy at 3 years (median; interquartile range, 0.1) after the sustained virological response (SVR) to pegylated interferon-based and direct-acting antiviral treatments. The proportions of histological fibrosis stages did not differ significantly between the pretreatment and post-SVR groups (P = .0615). However, the LS values differed significantly (P < .0001). The median LS values (presented as shear wave velocities in meters per second) were 1.51 (0.92) for the pretreatment group and 1.22 (0.77) for the post-SVR group. The cutoffs (areas under the receiver operating characteristic curve, obtained using the bootstrap method) to dichotomize between METAVIR fibrosis stage F1 versus stages F2-F4, F1-F2 versus F3-F4, and F1-F3 versus F4 were 1.47 (0.8333, 95% confidence interval [CI] 0.7981-0.8663), 1.81 (0.8763, 95% CI 0.8376-0.9107), and 1.86 (0.8811, 95% CI 0.8378-0.9179) in the pretreatment group, respectively, and 1.22 (0.7872, 95% CI 0.7001-0.8624), 1.59 (0.8808, 95% CI 0.8034-0.9422), and 1.75 (0.9018, 95% CI 0.8201-0.9644) in the post-SVR group, respectively. CONCLUSIONS The performance of LS measurements through ARFI elastography is promising to determine the liver fibrosis stage on necroinflammation-resolved histology in CHC after viral eradication.
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Affiliation(s)
- Sheng-Hung Chen
- Graduate Institute of Clinical Medical Science, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan.,Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hsueh-Chou Lai
- Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.,College of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - I-Ping Chiang
- Department of Pathology, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Pang Su
- Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hsin Lin
- Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Jung-Ta Kao
- School of Medicine, China Medical University, Taichung, Taiwan.,Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Po-Heng Chuang
- Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wei-Fan Hsu
- Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Wei Wang
- Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Yao Chen
- Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Guan-Tarn Huang
- School of Medicine, China Medical University, Taichung, Taiwan.,Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Yuan Peng
- School of Medicine, China Medical University, Taichung, Taiwan.,Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
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Woodworth KR, Reynolds MR, Burkel V, Gates C, Eckert V, McDermott C, Barton J, Wilburn A, Halai UA, Brown CM, Bocour A, Longcore N, Orkis L, Lopez CD, Sizemore L, Ellis EM, Schillie S, Gupta N, Bowen VB, Torrone E, Ellington SR, Delaney A, Olson SM, Roth NM, Whitehill F, Zambrano LD, Meaney-Delman D, Fehrenbach SN, Honein MA, Tong VT, Gilboa SM. A Preparedness Model for Mother-Baby Linked Longitudinal Surveillance for Emerging Threats. Matern Child Health J 2021; 25:198-206. [PMID: 33394275 PMCID: PMC7780211 DOI: 10.1007/s10995-020-03106-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 02/07/2023]
Abstract
Introduction Public health responses often lack the infrastructure to capture the impact of public health emergencies on pregnant women and infants, with limited mechanisms for linking pregnant women with their infants nationally to monitor long-term effects. In 2019, the Centers for Disease Control and Prevention (CDC), in close collaboration with state, local, and territorial health departments, began a 5-year initiative to establish population-based mother–baby linked longitudinal surveillance, the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET). Objectives The objective of this report is to describe an expanded surveillance approach that leverages and modernizes existing surveillance systems to address the impact of emerging health threats during pregnancy on pregnant women and their infants. Methods Mother–baby pairs are identified through prospective identification during pregnancy and/or identification of an infant with retrospective linking to maternal information. All data are obtained from existing data sources (e.g., electronic medical records, vital statistics, laboratory reports, and health department investigations and case reporting). Results Variables were selected for inclusion to address key surveillance questions proposed by CDC and health department subject matter experts. General variables include maternal demographics and health history, pregnancy and infant outcomes, maternal and infant laboratory results, and child health outcomes up to the second birthday. Exposure-specific modular variables are included for hepatitis C, syphilis, and Coronavirus Disease 2019 (COVID-19). The system is structured into four relational datasets (maternal, pregnancy outcomes and birth, infant/child follow-up, and laboratory testing). Discussion SET-NET provides a population-based mother–baby linked longitudinal surveillance approach and has already demonstrated rapid adaptation to COVID-19. This innovative approach leverages existing data sources and rapidly collects data and informs clinical guidance and practice. These data can help to reduce exposure risk and adverse outcomes among pregnant women and their infants, direct public health action, and strengthen public health systems.
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Affiliation(s)
- Kate R Woodworth
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA.
| | - Megan R Reynolds
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Veronica Burkel
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA.,Eagle Medical Services and Eagle Global Scientific, LLC, Atlanta, USA
| | - Cymone Gates
- Arizona Department of Health Services, Phoenix, USA
| | | | | | | | | | - Umme-Aiman Halai
- Los Angeles County Department of Public Health, Los Angeles, USA
| | | | - Angelica Bocour
- New York City Department of Health & Mental Hygiene, Long Island City, USA
| | | | - Lauren Orkis
- Pennsylvania Department of Health, Pittsburgh, USA
| | | | | | - Esther M Ellis
- U.S. Virgin Islands Department of Health, Christiansted, USA
| | - Sarah Schillie
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, USA
| | - Neil Gupta
- Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, USA
| | - Virginia B Bowen
- Division of STD Prevention, National Center for HIV, Hepatitis, STD, and TB Prevention, CDC, Atlanta, USA
| | - Elizabeth Torrone
- Division of STD Prevention, National Center for HIV, Hepatitis, STD, and TB Prevention, CDC, Atlanta, USA
| | - Sascha R Ellington
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, USA
| | - Augustina Delaney
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA.,Eagle Medical Services and Eagle Global Scientific, LLC, Atlanta, USA
| | - Samantha M Olson
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA.,G2S Corporation, San Antonio, USA
| | - Nicole M Roth
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA.,Eagle Medical Services and Eagle Global Scientific, LLC, Atlanta, USA
| | - Florence Whitehill
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, USA
| | - Laura D Zambrano
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Dana Meaney-Delman
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - S Nicole Fehrenbach
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Margaret A Honein
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Van T Tong
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA
| | - Suzanne M Gilboa
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention (CDC), 4770 Buford Highway NE, Atlanta, GA, 30341, USA
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Pearce ME, Yu A, Alvarez M, Bartlett SR, Binka M, Jeong D, Clementi E, Adu P, Wilton J, Yoshida EM, Pick N, Buxton JA, Wong J, Jassem A, Krajden M, Janjua NZ. Prenatal hepatitis C screening, diagnoses, and follow-up testing in British Columbia, 2008-2019. PLoS One 2020; 15:e0244575. [PMID: 33382774 PMCID: PMC7775094 DOI: 10.1371/journal.pone.0244575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/11/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Current guidelines in British Columbia recommend prenatal screening for hepatitis C antibodies (anti-HCV) if risk factors are present. We aimed to estimate frequency of prenatal anti-HCV testing, new diagnoses, repeated and follow-up testing among BC women. METHODS BC Centre for Disease Control Public Health Laboratory data estimated the number of BC women (assigned female at birth or unknown sex) aged 13-49 who received routine prenatal serological screening (HIV, hepatitis B, syphilis and rubella) from 2008-2019. Anti-HCV tests ordered the same day as routine prenatal screens were considered prenatal anti-HCV tests. Assessment of follow-up was based on HCV RNA and/or genotype testing within one year of new prenatal anti-HCV diagnoses. RESULTS In 2019, 55,202 routine prenatal screens were carried out for 50,392 BC women. Prenatal anti-HCV tests increased significantly, from 19.6% (9,704/49,515) in 2008 to 54.6% (27,516/50,392) in 2019 (p<0.001). New prenatal anti-HCV diagnoses (HCV positive diagnoses at first test or seroconversions) declined from 14.3% in 2008 to 10.1% in 2019. The proportion of women with new prenatal anti-HCV diagnoses that were a result of a first HCV test declined from 0.3% (29/9,701) in 2008 to 0.03% (8/27,500) in 2019. For women known to be anti-HCV positive at the time of prenatal screening, the proportion who had a prenatal anti-HCV test increased from 35.6% in 2008 to 50.8% in 2019. CONCLUSION Prenatal anti-HCV testing increased substantially over the study period. However, new HCV diagnoses remained relatively stable, suggesting that a considerable proportion of BC women with low or no risk are being screened as part of prenatal care. The vast majority of women with new HCV diagnoses receive appropriate follow-up HCV RNA and genotype testing, which may indicate interest in HCV treatment. These findings contribute to the discussion around potential for prenatal anti-HCV screening in an effort to eliminate HCV.
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Affiliation(s)
- Margo E. Pearce
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
| | - Amanda Yu
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Maria Alvarez
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Sofia R. Bartlett
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mawuena Binka
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Dahn Jeong
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emilia Clementi
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Prince Adu
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - James Wilton
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Eric M. Yoshida
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, British Columbia, Canada
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Neora Pick
- Department of Medicine, Division of Infectious Diseases, University of British Columbia Vancouver, British Columbia, Canada
- British Columbia Women’s Hospital, Vancouver, British Columbia, Canada
| | - Jane A. Buxton
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Agatha Jassem
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Naveed Z. Janjua
- British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Wilson RD. Directive clinique n o 409 : Tests diagnostiques fœtaux intra-utérins en cas d'infection virale chronique maternelle. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1563-1570.e1. [PMID: 33308792 DOI: 10.1016/j.jogc.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIF La présente directive clinique révisée met à jour les renseignements sur la prestation de soins aux femmes atteintes d'une infection virale chronique devant se soumettre à un test diagnostique fœtal intra-utérin. POPULATION CIBLE Femmes atteintes d'une infection virale chronique qui sont enceintes ou prévoient le devenir. OPTIONS Tests de dépistage non invasifs à des fins diagnostiques : marqueurs placentaires sériques maternels avec ou sans mesure de la clarté nucale, échographie, ADN fœtal libre circulant dans le sang maternel; et tests diagnostiques fœtaux intra-utérins : amniocentèse, biopsie choriale (choriocentèse), cordocentèse. ISSUES Les recommandations de la présente directive clinique pourraient réduire ou éliminer la morbi-mortalité chez les femmes atteintes d'une infection virale chronique et leurs nourrissons, ce qui est associé à d'importantes conséquences sur les plans de la santé et de l'économie. DONNéES PROBANTES: La littérature publiée a été recueillie au moyen de recherches dans les bases de données PubMed et Cochrane Library ainsi que dans les directives cliniques de sociétés médicales nationales et internationales (Société des obstétriciens et gynécologues du Canada, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine et d'autres sociétés internationales) en utilisant un vocabulaire (amniocentesis, chorionic villus sampling, cordocentesis, procedure pregnancy loss risk, viral vertical transmission, fetal and neonatal infection) et des mots clés (maternal infection or exposure, hepatitis B, hepatitis C, human immunodeficiency virus) contrôlés et appropriés. Les résultats retenus se limitent aux revues systématiques, aux essais cliniques randomisés ou aux essais cliniques comparatifs (si disponibles) et aux études cas-témoins observationnelles ou études de série de cas publiées entre 2012 et 2019 en anglais ou en français. Les études publiées entre 1966 et 2002 ont déjà été examinées dans la directive clinique de la SOGC no 123, L'amniocentèse chez les femmes infectées par l'hépatite B, l'hépatite C ou le virus de l'immunodéficience humaine; les études publiées entre 2002 et 2012 ont quant à elles été examinées dans la directive clinique de la SOGC no 309, Interventions effractives prénatales chez les femmes qui présentent des infections par le virus de l'hépatite B, le virus de l'hépatite C et/ou le virus de l'immunodéficience humaine. De nouvelles recherches ont été effectuées dans la littérature jusqu'en août 2019, puis ont été intégrées à la présente directive clinique. MéTHODES DE VALIDATION: L'auteur a évalué la qualité des données probantes et la solidité des recommandations au moyen du cadre méthodologique GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Consulter l'annexe A en ligne (le tableau A1 pour les définitions et le tableau A2 pour les interprétations des recommandations fortes et faibles). PUBLIC VISé: Les utilisateurs prévus sont des fournisseurs de soins de maternité et les femmes atteintes d'une infection virale chronique. Cette directive fournit des renseignements pour renseigner et conseiller ces femmes et leur offrir des options de procréation. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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Abstract
The opioid crisis has grown to affect pregnant women and infants across the United States, as evidenced by rising rates of opioid use disorder among pregnant women and neonatal opioid withdrawal syndrome among infants. Across the country, pregnant women lack access to evidence-based therapies, including medications for opioid use disorder, and infants with opioid exposure frequently receive variable care. In addition, public systems, such as child welfare and early intervention, are increasingly stretched by increasing numbers of children affected by the crisis. Systematic, enduring, coordinated, and holistic approaches are needed to improve care for the mother-infant dyad. In this statement, we provide an overview of the effect of the opioid crisis on the mother-infant dyad and provide recommendations for management of the infant with opioid exposure, including clinical presentation, assessment, treatment, and discharge.
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Affiliation(s)
- Stephen W Patrick
- Division of Neonatology, Department of Pediatrics and Health Policy, School of Medicine, Vanderbilt University and Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee;
| | - Wanda D Barfield
- Centers for Disease Control and Prevention, Atlanta, Georgia; and
| | - Brenda B Poindexter
- Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Medical Hospital Center, Cincinnati, Ohio
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Gross MS, Ruth AR, Rasmussen SA. Respect women, promote health and reduce stigma: ethical arguments for universal hepatitis C screening in pregnancy. JOURNAL OF MEDICAL ETHICS 2020; 46:674-677. [PMID: 32054774 DOI: 10.1136/medethics-2019-105692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 01/03/2020] [Accepted: 01/13/2020] [Indexed: 05/25/2023]
Abstract
In the USA, there are missed opportunities to diagnose hepatitis C virus (HCV) in pregnancy because screening is currently risk-stratified and thus primarily limited to individuals who disclose history of injection drug use or sexually transmitted infection risks. Over the past decade, the opioid epidemic has dramatically increased incidence of HCV and a feasible, well-tolerated cure was introduced. Considering these developments, recent evidence suggests universal HCV screening in pregnancy would be cost-effective and several professional organisations have called for updated national policy. Historically, universal screening has been financially disincentivised on the healthcare system level, particularly since new diagnoses may generate an obligation to provide expensive treatments to a population largely reliant on public health resources. Here, we provide ethical arguments supporting universal HCV screening in pregnancy grounded in obligations to respect for persons, beneficence and justice. First, universal prenatal HCV screening respects pregnant women as persons by promoting their long-term health outside of pregnancy. Additionally, universal screening would optimise health outcomes within current treatment guidelines and may support research on treatment during pregnancy. Finally, universal screening would avoid potential harms of risk-stratifying pregnant women by highly stigmatised substance use and sexual behaviours.
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Affiliation(s)
- Marielle S Gross
- Berman Institute of Bioethics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Alexandra R Ruth
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sonja A Rasmussen
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
- Department of Epidemiology, University of Florida College of Public Health and Health Professions, Gainesville, Florida, USA
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Hepatitis C Virus Antibody Screening in a Cohort of Pregnant Women: Identifying Seroprevalence and Risk Factors. Obstet Gynecol 2020; 135:778-788. [PMID: 32168224 DOI: 10.1097/aog.0000000000003754] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To describe the prevalence of hepatitis C virus (HCV) antibody, evaluate current risk factors associated with HCV antibody positivity, and identify novel composite risk factors for identification of groups most likely to demonstrate HCV antibody seropositivity in an obstetric population from 2012 to 2015. METHODS The Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network initiated an observational study of mother-to-child transmission of HCV in 2012 that included offering HCV antibody screening to their entire obstetric population. Women presenting for prenatal care before 23 weeks of gestation without a known multifetal gestation were eligible. For each woman who was HCV antibody-positive, two women at similar gestational age who were HCV antibody-negative were identified and included for comparison. Risk factors were evaluated by patient interview and chart review. Women in the case group were identified to have a signal-to-cutoff value of at least 5 on the Abbott ARCHITECT platform. RNA status was evaluated for women in the case group. RESULTS Of 106,842 women screened for the HCV antibody, 254 had positive results. The HCV antibody seroprevalence rate was 2.4 cases per 1,000 women (95% CI 2.1-2.7). One hundred thirty-one women in the case group and 251 women in the control group were included in the case-control analysis. Factors associated with HCV antibody positivity included injection drug use (adjusted odds ratio [aOR] 22.9, 95% CI 8.2-64.0), blood transfusion (aOR 3.7, 95% CI 1.3-10.4), having a partner with HCV (aOR 6.3, 95% CI 1.8-22.6), more than three lifetime sexual partners (aOR 5.3, 95% CI 1.4-19.8), and smoking (aOR 2.4, 95% CI 1.2-4.6). A composite of any of these potential risk factors provided the highest sensitivity for detecting HCV antibody (75/82 cases, 91%). CONCLUSION In this cohort, the seroprevalence of HCV antibody was low, and the current risk factors for HCV screening were not identified. These findings may be useful in defining new strategies for identifying mothers with the HCV antibody and the neonates susceptible to maternal transmission of HCV. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT01959321.
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Hepatitis C in 2020: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper. J Pediatr Gastroenterol Nutr 2020; 71:407-417. [PMID: 32826718 DOI: 10.1097/mpg.0000000000002814] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In 1989, a collaboration between the Centers for Disease Control (CDC) and a California biotechnology company identified the hepatitis C virus (HCV, formerly known as non-A, non-B hepatitis virus) as the causative agent in the epidemic of silent posttransfusion hepatitis resulting in cirrhosis. We now know that, the HCV genome is a 9.6 kb positive, single-stranded RNA. A single open reading frame encodes a 3011 amino acid residue polyprotein that undergoes proteolysis to yield 10 individual gene products, consisting of 3 structural proteins (core and envelope glycoproteins E1 and E2) and 7 nonstructural (NS) proteins (p7, NS2, NS3, NS4A, NS4B, NS5A, and NS5B), which participate in posttranslational proteolytic processing and replication of HCV genetic material. Less than 25 years later, a new class of medications, known as direct-acting antivirals (DAAs) which target these proteins, were introduced to treat HCV infection. These highly effective antiviral agents are now approved for use in children as young as 3 years of age and have demonstrated sustained virologic responses exceeding 90% in most genotypes. Although tremendous scientific progress has been made, the incidence of acute HCV infections has increased by 4-fold since 2005, compounded in the last decade by a surge in opioid and intravenous drug use. Unfortunately, awareness of this deadly hepatotropic virus among members of the lay public remains limited. Patient education, advocacy, and counseling must, therefore, complement the availability of curative treatments against HCV infection if this virus is to be eradicated.
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El-Sayed MH, Indolfi G. Hepatitis C Virus Treatment in Children: A Challenge for Hepatitis C Virus Elimination. Semin Liver Dis 2020; 40:213-224. [PMID: 32526785 DOI: 10.1055/s-0040-1708812] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Hepatitis C is a global public health threat. The introduction of direct-acting antivirals (DAAs) brings the prospect of curing the 71 million people living with the disease, dramatically changing the landscape of hepatitis C. The World Health Organization developed a roadmap for the elimination and cure of hepatitis C by 2030 with a clear goal with measurable targets. However, there is a lack of a well-defined strategy to tackle the hepatitis C virus (HCV) problem in children and adolescents vis-à-vis the adult population. Hepatitis C in children and adolescents can be addressed as part of a national policy for elimination in the whole population, namely macroelimination, or could be fragmented into a microelimination approach targeting the high-risk population groups. Children born to HCV-infected mothers, adolescents who are injecting drugs, migrants, and those suffering from inherited blood diseases are important target populations. After the U.S. Food and Drug Administration approval for the use of DAAs in children aged 3 years and above, evidence from clinical trials and real-world experience was accumulated using brand and generic medicines, with sustained virological response rates exceeding 95%. The evidence created should guide policies on the management of hepatitis C in children and adolescents. There are many challenges in managing HCV in this left-behind marginalized population. The lack of awareness and epidemiological data, consent age, prohibitive prices of medicines, and absence of policies on access to diagnostics, treatment, and linkage to care are among the many barriers to service delivery that should be addressed to achieve the elimination goal by 2030.
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Affiliation(s)
- Manal H El-Sayed
- Department of Pediatrics, Faculty of Medicine, Clinical Research Center, Ain Shams University, Cairo, Egypt
| | - Giuseppe Indolfi
- Pediatric and Liver Unit, Meyer Children's University Hospital and Department NEUROFARBA, University of Florence, Florence, Italy
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Chappell CA, Scarsi KK, Kirby BJ, Suri V, Gaggar A, Bogen DL, Macio IS, Meyn LA, Bunge KE, Krans EE, Hillier SL. Ledipasvir plus sofosbuvir in pregnant women with hepatitis C virus infection: a phase 1 pharmacokinetic study. LANCET MICROBE 2020; 1:e200-e208. [PMID: 32939459 PMCID: PMC7491553 DOI: 10.1016/s2666-5247(20)30062-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Hepatitis C virus (HCV) infection is increasing among pregnant women because of the opioid epidemic, yet there are no interventions to reduce perinatal HCV transmission or to treat HCV during pregnancy. Physiological changes in pregnancy alter the pharmacokinetics of some medications; thus, our aim was to compare the pharmacokinetic parameters of ledipasvir 90 mg plus sofosbuvir 400 mg during pregnancy with non-pregnant women. Methods This was an open-label, phase 1 study of pregnant women with genotype 1 HCV infection and their infants. A reference group of women who had participated in pharmacokinetic studies of ledipasvir–sofosbuvir during phase 2 and 3 trials was used. Participants were enrolled at Magee-Womens Hospital (Pittsburgh, PA, USA) between 23 and 24 weeks’ gestation and had a 12-week course of oral ledipasvir–sofosbuvir (daily 90 mg ledipasvir plus 400 mg sofosbuvir). Three 12-h intensive pharmacokinetic visits were done at 25–26, 29–30, and 33–34 weeks’ gestation and individual pharmacokinetics were summarised by geometric mean across the three visits. The primary outcome, analysed in all participants without suspected dosing errors, was the ledipasvir–sofosbuvir area under the concentration–time curve of the dosing interval (AUCtau) during pregnancy compared with the reference group by geometric mean ratio. This study is registered with ClinicalTrials.gov, NCT02683005. Findings From Oct 1, 2016, to Sept 30, 2018, 29 pregnant women were screened and nine (31%) were enrolled. Eight (89%) women were included in the primary analysis. Ledipasvir and sofosbuvir exposures were similar in the pregnant women versus the non-pregnant reference group (geometric mean ratio of AUCtau ledipasvir 89·3% [90% CI 68·7–116·1]; sofosbuvir 91·1% [78·0–106·3]). Interpretation Ledipasvir–sofosbuvir was safe and effective without clinically meaningful differences in drug exposure among pregnant versus non-pregnant women. Funding National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health/Office of Research on Women’s Health, and Gilead Sciences.
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Affiliation(s)
- Catherine A Chappell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Kimberly K Scarsi
- College of Pharmacy, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | | | - Debra L Bogen
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Leslie A Meyn
- Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Katherine E Bunge
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Sharon L Hillier
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
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Jhaveri R. Screening for Hepatitis C Virus: How Universal Is Universal? Clin Ther 2020; 42:1434-1441. [PMID: 32712026 PMCID: PMC7376340 DOI: 10.1016/j.clinthera.2020.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/21/2020] [Indexed: 12/19/2022]
Abstract
In March and April of 2020, public health authorities issued major updates to screening recommendations for hepatitis C virus infection. With the rise in cases driven by injection drug use coupled with access to highly effective therapies promising a cure, all adults aged ≥18 years should receive one-time hepatitis C virus antibody screening in any health care setting. Although the recommendation is dubbed "universal," this commentary reviews the details of the recommendations and discusses the high-risk populations not entirely captured with these changes.
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Affiliation(s)
- Ravi Jhaveri
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Box 20, Chicago, IL, USA.
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Mostafa A, Ebeid FSE, Khaled B, Ahmed RHM, El-Sayed MH. Micro-elimination of hepatitis C through testing of Egyptian pregnant women presenting at delivery: implications for screening policies. Trop Med Int Health 2020; 25:850-860. [PMID: 32306545 DOI: 10.1111/tmi.13404] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Despite the high burden of hepatitis C virus (HCV) infection in Egypt, screening of pregnant women is not yet universal, making national and global elimination unlikely. This study assessed the proportion of pregnant women who were screened for HCV infection at delivery, the prevalence and risk factors for HCV infection, the associated adverse neonatal outcomes, and the real-life linkage to care of infected women and follow-up of their infants' HCV status and timing of testing. METHODS Data were collected from medical records of a retrospective cohort of all pregnant women who were admitted to a university hospital in Cairo for delivery between January and June 2018 (n = 6734). HCV antibody- and RNA-positive women and their infants were prospectively followed-up by phone interviews till September 2019. RESULTS 2177 (32.3%) pregnant women were screened for HCV infection. 19 (0.9%) tested HCV antibody- and RNA-positive. Being ≥ 30 years old (ORa 3.6, 95% CI: 1.4-9.2; P = 0.009), history of abortion (ORa 3.5, 95% CI: 1.2-10.3; P = 0.022) and blood transfusion (ORa 29.1, 95% CI: 9.6-88.4; P < 0.001) were independent risk factors for infection. Adverse neonatal outcomes did not vary significantly among HCV antibody-positive and antibody-negative women. Only 13 (68.4%) HCV antibody- and RNA-positive women started treatment with direct-acting antivirals (DAAs) post-breastfeeding (two completed the treatment course and were cured). Four (21.1%) did not start treatment, and two (10.5%) were lost to follow-up. All infants of the 13 HCV antibody- and RNA-positive women who started DAA therapy tested HCV RNA-negative within their first year of life. CONCLUSION Extending screening services to all pregnant women and better linkage to care are essential for the national elimination of HCV infection.
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Affiliation(s)
- Aya Mostafa
- Department of Community, Environmental, and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Fatma S E Ebeid
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Clinical Research Center, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Belal Khaled
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rania H M Ahmed
- Department of Gynecology and Obstetrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Manal H El-Sayed
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Clinical Research Center, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Squires JE, Balistreri WF. Treatment of Hepatitis C: A New Paradigm toward Viral Eradication. J Pediatr 2020; 221:12-22.e1. [PMID: 32446469 DOI: 10.1016/j.jpeds.2020.02.082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/27/2020] [Accepted: 02/28/2020] [Indexed: 12/18/2022]
Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh PA.
| | - William F Balistreri
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital, Cincinnati, OH
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