Over the last decade, hepatitis C virus (HCV) infections nationwide have been on the rise. Primarily driven by widespread injection drug use, the epidemiology of HCV is now dramatically different compared with 10 years ago.1 An infection that was mostly prevalent among adults born between 1945 and 1965 (baby boomers) is now just as common, if not more so, among young adults, including women of childbearing age.2,3 These women with HCV infection get pregnant and ultimately deliver infants with perinatal exposure.4 Because there are few systems in place to track and subsequently test these infants, several studies have demonstrated that most exposed infants never receive HCV testing of any kind.5,6 These data have largely come from single institutions, single health systems, or city public health systems.6–9 In this issue of Pediatrics, Lopata et al10 were able to use the Tennessee Medicaid database to demonstrate on a state level that >75% of infants with HCV exposure are never tested. The advantages of this particular study are the availability of data over a 10-year time span across an entire state, particularly one that touches the Appalachian region, where HCV has been identified at high rates because of opioid use. They also report dramatic regional differences in HCV prevalence and testing, which highlights some of the challenges associated with implementing HCV screening programs at the state or regional level.
What do we conclude from the results of this study? The obvious answer is that we need better systems to identify, track, and test infants with HCV exposure. However, this conclusion is too narrowly focused. The issue at hand is that our current system for HCV screening is fragmented and outdated. Historically, baby boomers were a high-prevalence group for HCV because they came of age at a time when injection drug use was becoming more prevalent and sexual practices were becoming more liberal, before the ability to protect the blood supply with a screening test of any kind existed. For all groups except baby boomers, a risk-based HCV screening strategy is recommended.11 However, studies have demonstrated that risk-based HCV screening misses cases when compared with universal screening.12 As a result of this and because baby boomers were a high-prevalence population, in 2012 the US Public Health Service changed the recommendation to universal screening for this age cohort.11 Overall, this strategy has worked and served to identify many more individuals with HCV infection.13 The problem now is that baby boomers are no longer the only high-prevalence group, and recent data suggest that young adults, including adolescents, have HCV rates that equal or exceed those of baby boomers in many parts of the country.2 Despite these changes in HCV infections, the US Public Health Service recommendation for risk-based screening for young adults has not changed.
We need a new national strategy for HCV screening that endorses one-time, universal screening of young adults at any health care encounter, universal screening of pregnant women, and a system that integrates follow-up of infants with HCV exposure by using a model similar to HIV mother-to-child transmission prevention programs. Individual institutions or entire states, such as Kentucky, have implemented these measures and made great strides in improving their identification of patients with HCV infection and screening of infants with HCV exposure.14,15 Each of these strategies would be cost-effective, particularly when associated with access to highly effective HCV antiviral therapy for all parties.16–18 With our current policies in place for risk-based screening and intermittent access to HCV therapy, the United States will never achieve the goals set by the World Health Organization for HCV elimination by 2030.19 Of note, the US Preventive Services Task Force has drafted new guidance for HCV screening that recommends expanding testing to all adults 18 to 79 years old and includes pregnant women, and this was available from public comment at the time of writing this article.20
What can pediatricians do in the meantime to improve testing and outcomes for infants with HCV exposure? First, be familiar with the latest American Association for the Study of Liver Diseases–Infectious Diseases Society of America guidance on the timing and test type of HCV screening21 and seize every opportunity to screen patients. Of note, the American Academy of Pediatrics Committee on Infectious Diseases Red Book recommendations will be updated in the next edition to be consistent with the American Association for the Study of Liver Diseases–Infectious Diseases Society of America guidance. Second, work with obstetricians and local public health colleagues to improve HCV screening practices for pregnant women and subsequent tracking of infants with HCV exposure. Third, know that treatment will likely be available for children as young as 3 years old in the near future, so infants who are identified now can be managed for prompt initiation of therapy and cure once they are eligible.15 Lastly, engage in advocacy efforts at the state and national levels to support access to health services that help reduce the adverse impact of HCV: universal screening, unfettered access to HCV therapy, and expansion of harm-reduction efforts for those at risk for HCV acquisition.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-2482.
POTENTIAL CONFLICTS OF INTEREST: Dr Jhaveri has received research funding for clinical trials participation from AbbVie, Gilead Sciences, and Merck and serves on the American Association for the Study of Liver Diseases–Infectious Diseases Society of America Hepatitis C Vaccine Guidance Panel and the American Association for the Study of Liver Diseases Program for Viral Hepatitis Elimination Task Force for Global Health.
FINANCIAL DISCLOSURE: Dr Jhaveri has indicated he has no financial relationships relevant to this article beyond the items already listed under Potential Conflicts of Interest.