In a recently released issue of Pediatrics, Dr. Susan M Lopata and colleagues (10.1542/peds.2019-2482) report on screening rates for Hepatitis C among infants exposed prenatally to the virus. The prevalence of Hepatitis C among adults in the United States, including among expectant women, has risen over the past decade, with an estimated 2.4 million people now living with Hepatitis C.1 Screening is recommended for all exposed infants, and treatments are now available for children ages 3 years and up, so this work is highly relevant to pediatricians. The authors investigated mother-infant dyads (2005-2014) living in Tennessee and receiving TennCare (Tennessee’s Medicaid Program). They identified those expectant women who were HCV-infected and included their infants who could be followed through age 2 years, since screening is formally recommended either by Hepatitis C antibody testing at age 18 months or by Hepatitis C RNA PCR beginning at age 1-2 months. Of 384,837 mother-infant pairs, 4,072 (1.1%) were HCV-infected and could be followed to determine whether the recommended screening occurred.
Their findings are disconcerting and serve as an important wake-up call. Overall barely one fourth (23%) of infants were screened as recommended. Interestingly, infants who were screened were more likely to have HIV positive mothers and mothers who smoked cigarettes, which suggests practitioner awareness of some but not all Hepatitis C risk factors. Adults at greatest risk for Hepatitis C include current or former injection drug users, people with HIV, those who have had a needle stick event, those who undergo hemodialysis or received blood products or clotting factors prior to improved screening techniques, and anyone born 1945-1965.1 Universal screening of expectant women is cost effective, and is recommended by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Disease Society of America (IDSA) partly because of the breadth of these Hepatitis C risk factors and the availability of treatment.2 However, the Centers for Disease Control and Prevention (CDC) does not recommend this strategy yet, and instead endorses risk-based screening of expectant women, which is what Tennessee uses.1 Relevant to this study then, even more infants were potentially missed due to failure to identify their mothers’ exposure.
I was not aware that treatment is available for Hepatitis C infected infants, and this is the best reason for active screening of all exposed infants. Active monitoring of liver disease is also recommended. Guidelines for treatment from the AASLD and IDSA state clearly, “Direct-acting antiviral (DAA) treatment with an approved regimen is recommended for all children and adolescents with HCV infection aged ≥3 years as they will benefit from antiviral therapy, regardless of disease severity.”2 Since the optimal timing for screening exposed infants with RNA PCR is not known, testing for Hepatitis C antibody at or after 18 months appears to be a best practice.2 We have a chance to make a big difference for the long-term health of infants exposed to Hepatitis C prenatally, and this article brings home for me the rationale and importance of the recommended screening.
1. Hepatitis C Information. Centers for Disease Control and Prevention. https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#a1 Updated January 13, 2020, Accessed February 4, 2020.
2. Recommendations for testing, managing, and treating hepatitis C. Accessed February 4, 2020, at https://www.hcvguidelines.org/