In updated hepatitis C recommendations, the Centers for Disease Control and Prevention (CDC) is calling for testing of perinatally exposed infants at ages 2-6 months with a single hepatitis C virus (HCV) ribonucleic acid (RNA) test.
All infants and children with detectable HCV RNA should be referred to a health care provider with expertise in hepatitis C management. Further follow-up is not required for those with undetectable HCV RNA at age 2 months or older unless clinically warranted.
The guidance also recommends a nucleic acid test (NAT) for perinatally exposed infants and children up to 17 months if they were not tested already. In addition, a hepatitis C virus antibody (anti-HCV) test followed by a reflex NAT for HCV RNA (when anti-HCV is reactive) is recommended for perinatally exposed children ages 18 months or older who were not tested previously.
“Proper identification of perinatally infected children, referral to care, and curative treatment are critical to achieving the goal of hepatitis C elimination,” according to authors of the guidance in a new Morbidity and Mortality Weekly Report (MMWR).
Perinatal transmission is the most common route of HCV transmission in children. Chronic HCV infection will develop in 5.8% to 7.2% of all infants and children exposed during pregnancy or delivery. Curative antiviral therapy can begin at age 3 years.
However, most perinatally exposed infants and children are not tested or referred for care. Among the possible reasons are lack of awareness of perinatal exposure by pediatric providers, lack of regular pediatric care, changes in providers and challenging social circumstances for families.
A comprehensive systematic literature review was undertaken to examine testing strategies for identifying children with perinatally acquired HCV infection. The new guidance supplements 2020 CDC recommendations, which include universal screening of adults 18 years and older at least once and for all pregnant people during each pregnancy.
The use of highly sensitive and specific NATs for RNA detection among infants and children perinatally exposed to HCV increases the identification of those with HCV in whom substantial morbidity and mortality might develop, the report noted.
HCV causes liver inflammation that can progress to advanced fibrosis, cirrhosis and hepatocellular carcinoma. It is transmitted through percutaneous exposure to infected blood, and rates of infection have risen in conjunction with increases in injection drug use.
Acute and chronic infection rates of HCV have been increasing since 2010, with acute infections more than tripling since 2021 among people of reproductive age. As a result, overall rates of HCV infections during pregnancy have risen by 20% during 2016-’20 and up to 10-fold during 2000-’19.
Perinatal transmission is limited to infants born to pregnant people with detectable HCV RNA. It is more common among pregnant people with poorly controlled coinfection with human immunodeficiency virus and might be more common in pregnant people who inject drugs. After delivery, breastfeeding does not increase HCV transmission unless nipples are cracked or bleeding.
Earlier this year, the CDC updated HCV guidance to call for all blood samples to be collected in a single visit to help increase the percentage of patients linked to care and antiviral therapy. That update followed a report showing only 34% of people diagnosed with hepatitis, including 25% of children and teens, had been cured, despite available treatments.
Historically, all infants with HCV exposure were to be screened for anti-HCV antibodies at 18 months or older. However, most infants with HCV infection are asymptomatic, so diagnosis has depended on subsequent testing to rule out infection. Estimates show that about 70% of children 18 months or older were not being tested with the current strategy.
The new strategy is “both cost-effective and cost-saving,” the report noted, “and will identify more children with perinatal HCV transmission who are eligible for curative treatment beginning at age 3 years.”
The revised recommendation “is a very important step but is only one among many required to achieve comprehensive HCV elimination efforts during pregnancy and early childhood,” authors noted in a related Pediatrics perspective.
“Seamless collaboration between obstetricians, newborn care providers and specialists is required to ensure that pregnant patients are treated ideally during pregnancy… that HCV exposure is documented in the infants’ medical records and communicated to their primary care providers and that parents/caregivers are counseled about perinatal HCV exposure and the plan for infant testing,” the authors wrote.
They said the system already has successful infrastructure in place that performs all of these steps for perinatal human immunodeficiency virus and hepatitis B exposure and screening, which have been successful.
“The elimination of HCV as a public health problem will require us to identify and treat HCV in every subpopulation without exclusion …” they concluded.
Resources
- CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children – United States, 2023
- Information from the AAP Red Book on hepatitis C
- AAP News article “CDC calls for single-visit blood collection when testing for hepatitis C”
- “Earlier Screening of Infants With Perinatal Hepatitis C Exposure: A Key Step Towards Elimination”
- Information for parents from HealthyChildren.org on hepatitis C
The new strategy is “both cost-effective and cost-saving,” the report noted, “and will identify more children with perinatal HCV transmission who are eligible for curative treatment beginning at age 3 years.”
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