Maternal drug use is a preeminent risk factor for mother-to-child hepatitis C virus transmission: results from a multicenter study of 1372 mother-infant pairs

CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children - United States, 2023

The elimination of hepatitis C is a national priority (https://www.hhs.gov/sites/default/files/Viral-Hepatitis-National-Strategic-Plan-2021-2025.pdf). During 2010-2021, hepatitis C virus (HCV) acute and chronic infections (hereinafter referred to as HCV infections) increased in the United States, consequences of which include cirrhosis, liver cancer, and death. Rates of acute infections more than tripled among reproductive-aged persons during this time (from 0.8 to 2.5 per 100,000 population among persons aged 20-29 years and from 0.6 to 3.5 among persons aged 30-39 years). Because acute HCV infection can lead to chronic infection, this has resulted in increasing rates of HCV infections during pregnancy. Approximately 6%-7% of perinatally exposed (i.e., exposed during pregnancy or delivery) infants and children will acquire HCV infection. Curative direct-acting antiviral therapy is approved by the Food and Drug Administration for persons aged ≥3 years. However, many perinatally infected children are not tested or linked to care. In 2020, because of continued increases in HCV infections in the United States, CDC released universal screening recommendations for adults, which included recommendations for screening for pregnant persons during each pregnancy (Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC recommendations for hepatitis C screening among adults-United States, 2020. MMWR Recomm Rep 2020;69[No. RR-2]:1-17). This report introduces four new CDC recommendations: 1) HCV testing of all perinatally exposed infants with a nucleic acid test (NAT) for detection of HCV RNA at age 2-6 months; 2) consultation with a health care provider with expertise in pediatric hepatitis C management for all infants and children with detectable HCV RNA; 3) perinatally exposed infants and children with an undetectable HCV RNA result at or after age 2 months do not require further follow-up unless clinically warranted; and 4) a NAT for HCV RNA is recommended for perinatally exposed infants and children aged 7-17 months who previously have not been tested, and 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 aged ≥18 months who previously have not been tested. Proper identification of perinatally infected children, referral to care, and curative treatment are critical to achieving the goal of hepatitis C elimination.

Hepatitis C viral load and mother-to-child transmission: A systematic review and meta-analysis

BACKGROUND AND AIM

We aim to assess the association between maternal hepatitis C virus (HCV) viral load and human immunodeficiency virus (HIV) coinfection and the risk for mother-to-child transmission (MTCT) among pregnant women infected with HCV.

METHODS

A literature search of the Medline, Embase, Central, Science Citation Index Expanded (SCIE), Conference Proceedings Citation Index-Science (CPCIS), Scopus, Literature Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and WHO Global Index Medicus databases, from inception to June 21, 2022, was performed. Studies that reported the incidence HCV-MTCT were included. Pooled effect estimates were calculated using the random-effects model, and Holm-Bonferroni correction was performed for multiple pooled associations.

RESULTS

The present meta-analysis included 26 studies involving 4934 newborns with maternal HCV infection. Pregnant women with HCV viremia exhibited increased risk for MTCT (odds ratio [OR] 8.25 [95% confidence interval (CI) 4.65-14.63]) compared with those negative for HCV-RNA. Multiple subgroup analysis revealed that the HCV viremia/HIV-positive group demonstrated the highest risk for HCV MTCT, followed by the HCV viremia mono-infected group, while HCV-RNA-negative women demonstrated the lowest risk for HCV MTCT. Among females with HCV viremia, elevated risk for MTCT was found among subjects with a viral load ≥ 6 log₁₀ copies/mL compared with those with viral load < 6 log₁₀ copies/mL (OR 4.58 [95% CI: 2.52-8.34]).

CONCLUSION

The incidence of HCV MTCT was increased among pregnant women with detectable HCV viremia and was even higher in those with a viral load ≥ 6 log₁₀ copies/mL. HIV coinfection further increased the risk for HCV MTCT.

Clinical practice guidelines for the management of children with mother-to-child transmitted hepatitis C virus infection

BACKGROUND

The first guidelines for care of pregnant women carrying the hepatitis C virus (HCV) and their infants were published in 2005 in Japan. Since then, evidence has gradually accumulated worldwide regarding the natural course and treatment of this condition and, especially in recent years, treatment for chronic hepatitis C in adult patients has made great progress. However, the clinical practice policy for children has not been standardized, and new clinical practice guidelines for children with mother-to-child (MTC) transmitted HCV infection have become necessary.

METHODS

In the development of the current guideline, we requested cooperation from The Japanese Society for Pediatric Infectious Diseases, The Japan Society of Hepatology, and the Japan Society of Obstetrics and Gynecology. The committee members were recommended and approved by each society to participate in developing the guidelines. The guideline was also created in accordance with the Minds Guide for Practice Guideline Development. The statements were prepared by consensus-building using the Delphi method, based on the comprehensively searched academic papers and guidelines. These articles were retrieved through searching the PubMed, Cochrane Library, and the Igaku Chuo Zasshi databases.

RESULTS

Eight clinical questions (CQs) with clinical statements were developed regarding etiology (CQs 1-3), diagnosis (CQs 4 and 5), and treatment (two CQs 6 and 7). In each statement, the consensus rate, evidence level, and recommendation level were determined.

CONCLUSION

The guidelines will be helpful in the management of children with hepatitis C MTC transmission.

Prospective cohort study of children exposed to hepatitis C virus through a pregnancy screening program

Objectives:

Porto Alegre, in south Brazil, has one of the highest Hepatitis C virus (HCV) infections rate in the country (84.4 cases/100,000 in 2018). Prenatal screening of HCV, however, has not been routinely offered.

Methods:

We conducted a longitudinal study of pregnant women with HCV and their infants between January 2014 to December 2018. Screening for HCV antibodies was offered to all women delivering at our tertiary institution. HCV RT-PCR was performed if seropositive. Infants were followed prospectively.

Results:

Among 18,953 pregnant women delivering, 17,810 were screened for HCV antibodies (93.9%) with 130 positive results. (HCV seroprevalence 0.7%). HCV RNA was detectable in 57/117 cases (48.7%). HCV viremia was associated with use of injectable drugs (p=0.03), inhaled/crack drug use (p=0.02), an HCV-seropositive partner, ≥3 lifetime sexual partners (p=<0.01). Genotype 1 was most prevalent (68%) during pregnancy. Among 43 children with follow-up, 6 (13%) were HCV infected (transmission rate 13.9%); genotype 3 infected 50%. Two infants (33%) cleared infection; mothers had genetic polymorphisms associated with clearance.

Conclusion:

HCV vertical transmission was high in our population, with HCV infection during pregnancy being vastly underdiagnosed. Public health efforts must focus on this vulnerable population for disease prevention and early treatment.

Hepatitis C Virus in Neonates and Infants

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.

Evidence for B cell maturation but not trained immunity in uninfected infants exposed to hepatitis C virus

OBJECTIVES

Vertical transmission of hepatitis C virus (HCV) is rare compared with other chronic viral infections, despite that newborns have an immature, and possibly more susceptible, immune system. It further remains unclear to what extent prenatal and perinatal exposure to HCV affects immune system development in neonates.

DESIGN

To address this, we studied B cells, innate immune cells and soluble factors in a cohort of 62 children that were either unexposed, exposed uninfected or infected with HCV. Forty of these infants were followed longitudinally from birth up until 18 months of age.

RESULTS

As expected, evidence for B cell maturation was observed with increased age in children, whereas few age-related changes were noticed among innate immune cells. HCV-infected children had a high frequency of HCV-specific IgG-secreting B cells. Such a response was also detected in some exposed but uninfected children but not in uninfected controls. Consistent with this, both HCV-exposed uninfected and HCV-infected infants had evidence of early B cell immune maturation with an increased proportion of IgA-positive plasma cells and upregulated CD40 expression. In contrast, actual HCV viraemia, but not mere exposure, led to alterations within myeloid immune cell populations, natural killer (NK) cells and a distinct soluble factor profile with increased levels of inflammatory cytokines and chemokines.

CONCLUSION

Our data reveal that exposure to, and infection with, HCV causes disparate effects on adaptive B cells and innate immune cell such as myeloid cells and NK cells in infants.

Estimating paediatric hepatitis C prevalence in the United States

Over 70 million individuals are infected with hepatitis C virus (HCV) worldwide. Yet most prevalence data are in the adult population, with little focus on paediatrics, partially due to the scarcity of public data. The objective of this paper is to examine HCV prevalence in children by estimating prevalence rates among women, given the assumption that most cases are vertically transmitted. Between 2001 and 2017, maternal HCV infection affected ~ 0.24% of all births, with prevalence increasing by at least 261%. On average, approximately 0.01% of the total number of live births were infected with HCV, with a 245% increase in the number of children born with the infection. HCV epidemiology has evolved, with women of childbearing age representing a greater proportion of infected individuals in the United States, and infants born to infected mothers being at risk. We therefore recommend a greater public health focus of HCV on the paediatric population.

Hepatitis C virus infection in mothers and children

Many unique challenges are associated with hepatitis C infection in mothers and children. The preconception, antenatal, and postnatal phases each offer opportunities to reduce transmission of the virus from mother to infant or to identify the need for treatment. Management of children and youth with hepatitis C is now entering the era of direct-acting antivirals. Improvements are needed in the identification of infected mothers and children and their linkage to appropriate expert care.

Successful sofosbuvir lead-in monotherapy for the treatment of hepatitis C virus (HCV) infection in a pregnant woman living with HIV

A 30-year-old woman living with HIV was diagnosed with genotype 2b hepatitis C virus (HCV) infection during the second trimester of her pregnancy. She had achieved virologic suppression on an HIV protease inhibitor-based regimen and had recurrent genital herpes simplex virus infection managed with antivirals. Given the risk of perinatal transmission of HCV and to avoid performing a caesarean section, after multidisciplinary consultations and consideration of the limited data on safety on HCV direct-acting antivirals (DAAs) in pregnancy, she consented to and was successfully treated with a 6-week lead-in course of sofosbuvir (SOF) alone followed by a 6-week course of SOF and velpatasvir postpartum. This resulted in cure of her HCV infection. The neonate tested negative for HCV at birth and was healthy without birth defects 2 years postdelivery. Our case highlights a successful HCV treatment approach in a pregnant woman with newer DAAs.

The contribution of injection drug use to hepatitis C virus transmission globally, regionally, and at country level: a modelling study

BACKGROUND

WHO aims to eliminate the hepatitis C virus (HCV) as a public health threat by 2030. Injection drug use is an important risk factor for HCV transmission, but its contribution to country-level and global epidemics is unknown. We estimated the contribution of injection drug use to risk for HCV epidemics globally, regionally, and at country level.

METHODS

We developed a dynamic deterministic HCV transmission model to simulate country-level HCV epidemics among people who inject drugs and the general population. Each country's model was calibrated using country-specific data from UN datasets and systematic reviews on the prevalence of HCV and injection drug use. The population attributable fraction of HCV transmission associated with injection drug use was estimated-defined here as the percentage of HCV infections prevented if additional HCV transmission due to injection drug use was removed between 2018 and 2030.

FINDINGS

The model included 88 countries (85% of the global population). The model predicted 0·23% (95% credibility interval [CrI] 0·16-0·31) of the global population were injection drug users in 2017, and 8% (5-12) of prevalent HCV infections were among people who currently inject drugs. Globally, if the increased risk for HCV transmission among people who inject drugs was removed, an estimated 43% (95% CrI 25-67) of incident HCV infections would be prevented from 2018 to 2030, varying regionally. This population attributable fraction was higher in high-income countries (79%, 95% CrI 57-97) than in countries of low and middle income (38%, 24-64) and was associated with the percentage of a country's prevalent HCV infections that are among people who inject drugs.

INTERPRETATION

Unsafe injecting practices among people who inject drugs contribute substantially to incident HCV infections globally. Any intervention that can reduce HCV transmission among people who inject drugs will have a pronounced effect on country-level incidence of HCV.

FUNDING

None.

Unique Challenges of Hepatitis C in Infants, Children, and Adolescents

PURPOSE

Hepatitis C, a chronic disease with deadly consequences, is no longer predominantly a disease of older people.

METHODS

A limited search was conducted of the relevant literature on 2 topics: (1) the impact of hepatitis C on infants exposed by vertical transmission; and (2) the impact of hepatitis C infection on infected children and adolescents. The findings were supplemented by the first-hand experience of the authors.

FINDINGS

Young people, including women of childbearing age, infants, children, and adolescents, are being especially affected by hepatitis C infection secondary to the intravenous drug use and opioid epidemic. Unfortunately, estimates of disease in young populations are all misleading because universal screening has not been implemented.

IMPLICATIONS

Lack of implementation of policies for screening and therapy on most affected populations will be responsible for perpetuation of this infection. In the era of highly effective therapy and a regimen that is approved by the US Food and Drug Administration for children, this outcome is unacceptable.

Hepatitis C Virus Knowledge Among Pregnant Women with Opioid Use Disorder

Objectives To evaluate Hepatitis C virus (HCV) knowledge and awareness among pregnant women with opioid use disorder (OUD). Methods From May through November 2015, a one-time survey was distributed to a convenience sample of pregnant women with OUD to assess their knowledge and awareness of (a) risk factors for HCV infection, (b) HCV transmission prevention strategies, (c) hepatotoxic risk reduction and (d) perinatal transmission and neonatal implications of HCV infection. Chi square and Fisher's exact tests were used to compare demographic characteristics and HCV knowledge between participants who were HCV positive and negative. Results Of 179 pregnant women with OUD approached, 169 (94%) completed the survey. Of these, 153 (90.5%) reported at least one risk factor for HCV infection, 85 (50.3%) were HCV positive and 38 (44.7%) of HCV positive women were diagnosed with HCV for the first time during pregnancy. When HCV knowledge was evaluated, 114 (66.7%) responded that sharing eating utensils could transmit HCV, 69 (55.0%) responded that there is a vaccine to prevent HCV and 56 (32.7%) did not identify intranasal drug use as a risk factor for HCV transmission. Among HCV positive women, 61 (71.8%) associated breastfeeding with an increased risk for HCV transmission, 33 (38.1%) failed to identify the importance of pediatric follow-up for HCV-exposed children and 16 (18.8%) perceived the risk of HCV vertical transmission as "likely" or "very likely." Conclusions for Practice Gaps in HCV knowledge exist among a rapidly growing population of pregnant women with OUD. Healthcare providers have a unique opportunity to provide HCV education and counseling during pregnancy.

Update on the management of hepatitis B and C infections in the neonatal period

Hepatitis B virus and hepatitis C virus have received a significant amount of attention in recent years, and both viruses share a significant amount of similarities with one another beyond just that they both primarily target the liver. In recent years, cases of both infections have been fueled by a nationwide epidemic of injection drug use. Most relevant to this audience, they are both transmitted from mother to child. The increased cases in young adults combined with mother to child transmission translate into more exposed infants that will need to be managed and followed. Screening of pregnant women for hepatitis B infection coupled with appropriate treatment and prophylaxis measures are incredibly effective to preventing transmission. Prevention of hepatitis C infection is not yet possible, but advances in antiviral therapy make interruption of transmission a future possibility.

Seroconversion rates among health care workers exposed to hepatitis C virus-contaminated body fluids: The University of Pittsburgh 13-year experience

BACKGROUND

Hepatitis C virus (HCV) transmission to health care personnel (HCP) after exposure to a HCV-positive source has been reported to occur at an average rate of 1.8% (range, 0%-10%). We aimed to determine the seroconversion rate after exposure to HCV-contaminated body fluid in a major U.S. academic medical center.

METHODS

A longitudinal analysis of a prospectively maintained database of reported occupational injuries occurring between 2002 and 2015 at the University of Pittsburgh Medical Center was performed. Data collected include type of injury and fluid, injured body part, contamination of sharps, resident physicians' involvement, and patients' hepatitis B virus (HBV), HCV, and HIV status.

RESULTS

A total of 1,361 cases were included in the study. Most exposures were caused by percutaneous injuries (65.0%), followed by mucocutaneous injuries (33.7%). Most (63.3%) were injuries to the hand, followed by the face and neck (27.6%). Blood exposure accounted for 72.7%, and blood-containing saliva accounted for 3.4%. A total of 6.9% and 3.7% of source patients were coinfected with HIV and HBV, respectively. The HCV seroconversion rate was 0.1% (n = 2) because of blood exposure secondary to percutaneous injuries.

CONCLUSIONS

This study provides the largest and most recent cohort from a major U.S. academic medical center. The seroconversion rates among HCP exposed to HCV-contaminated body fluids was found to be lower than most of the data found in the literature.

Update on hepatitis C and implications for pregnancy

Mother-to-child transmission of hepatitis C virus infection occurs in a significant minority of cases and the diagnosis, treatment and cure of hepatitis C virus infection with direct acting antivirals prior to pregnancy can eliminate this risk in almost all cases. Women with hepatitis C virus infection have increased risks of adverse events in pregnancy and poor perinatal outcomes for their children, although the contribution of hepatitis C virus per se is difficult to determine. Altering the mode of delivery does not reduce mother to child transmission of hepatitis C virus infection, although avoidance of fetal scalp electrodes and other potential high risk procedures is recommended during pregnancy and delivery. Breast feeding has not been demonstrated to be a risk for mother-to-child transmission and avoidance of breast feeding is not recommended, although breast feeding with cracked or bleeding nipples is generally avoided. Safety of the currently available hepatitis C virus antivirals in pregnancy and breastfeeding has not yet been established.

Longitudinal Long-term Follow-up Study of Children with Vertically Acquired Hepatitis C Virus Infection

Seventeen children with vertically acquired hepatitis C virus (HCV) infection were followed from birth for a mean of 104 months. Alanine aminotransferase (ALT) levels were increased significantly at 3 and 6 months of age but were stable thereafter. HCV polymerase chain reaction was positive at 3 months in 16 patients and at 12 months in one patient. Viral load remained stable during follow-up at a mean value of 5.4 ± 0.4 log10. Mild chronic hepatitis was the most common histopathological feature on liver biopsy, occurring in six of the seven children biopsied at a mean age of 4.0 ± 2.4 years. Genotype did not seem to be related to the type of liver involvement. The results of this study suggest that vertically acquired HCV infection has a benign course in children, despite the presence of viraemia and persistent alterations in ALT levels.

Vertically acquired hepatitis C virus infection: Correlates of transmission and disease progression

The worldwide prevalence of hepatitis C virus (HCV) infection in children is 0.05%-0.4% in developed countries and 2%-5% in resource-limited settings, where inadequately tested blood products or un-sterile medical injections still remain important routes of infection. After the screening of blood donors, mother-to-child transmission (MTCT) of HCV has become the leading cause of pediatric infection, at a rate of 5%. Maternal HIV co-infection is a significant risk factor for MTCT and anti-HIV therapy during pregnancy seemingly can reduce the transmission rate of both viruses. Conversely, a high maternal viral load is an important, but not preventable risk factor, because at present no anti-HCV treatment can be administered to pregnant women to block viral replication. Caution is needed in adopting obstetric procedures, such as amniocentesis or internal fetal monitoring, that can favor fetal exposure to HCV contaminated maternal blood, though evidence is lacking on the real risk of single obstetric practices. Mode of delivery and type of feeding do not represent significant risk factors for MTCT. Therefore, there is no reason to offer elective caesarean section or discourage breast-feeding to HCV infected parturients. Information on the natural history of vertical HCV infection is limited. The primary infection is asymptomatic in infants. At least one quarter of infected children shows a spontaneous viral clearance (SVC) that usually occurs within 6 years of life. IL-28B polymorphims and genotype 3 infection have been associated with greater chances of SVC. In general, HCV progression is mild or moderate in children with chronic infection who grow regularly, though cases with marked liver fibrosis or hepatic failure have been described. Non-organ specific autoantibodies and cryoglobulins are frequently found in children with chronic infection, but autoimmune diseases or HCV associated extrahepatic manifestations are rare.

Childhood hepatitis C virus infection: An Australian national surveillance study of incident cases over five years

AIM

An estimated 1.1% of Australian adults are infected with hepatitis C virus (HCV). Many develop chronic liver disease, and some develop liver failure or hepatocellular carcinoma. HCV infection in Australian children is poorly defined. We aimed to determine the reported incidence, clinical and epidemiological features of newly diagnosed HCV infection in Australian children presenting to paediatricians.

METHODS

We undertook prospective active national surveillance, using the Australian Paediatric Surveillance Unit, of incident HCV cases in children aged <15 years between 1(st) January 2003, and 31(st) December 2007.

RESULTS

There were 45 confirmed cases of newly diagnosed HCV infection over five years (<1 per 100,000 children aged <15 years per year). Median age at diagnosis was 2.9 years. Positive maternal HCV serostatus was the most frequent reported risk factor for HCV infection in children (40/45). Three children (all aged > 14), were exposed through their own IV drug use. No children were co-infected with HIV and only one child was co-infected with HBV. All children were asymptomatic at diagnosis, although many had minor elevations in liver transaminases. Many clinicians reported difficulties with follow-up.

CONCLUSIONS

Childhood HCV infection is uncommon in Australia, although our data likely underestimate the incidence. Only a small number of children aged <18 months was identified, despite known perinatal exposure. Opportunistic investigation of children at risk for HCV, improved education regarding vertical transmission for health care providers, and increased coordination of childhood HCV services are required to improve recognition and management of children with HCV.

Hepatitis C in Children Co-infected With Human Immunodeficiency Virus

OBJECTIVES

The objective of this systematic review was to summarize evidence regarding hepatitis C in hepatitis C virus/human immunodeficiency virus (HCV/HIV)-co-infected children focusing on mother-to-child transmission, clinical and laboratory features, outcome, and therapies.

METHODS

A literature search was performed using multiple keywords and standardized terminology in MEDLINE, EMBASE, and Cochrane databases dating back to their inception up to April 1, 2015, using the following terms hepatitis C virus, HIV, and child.

RESULTS

Fifty-five of 367 publications were selected for inclusion. In co-infected children, HIV impacted all the different aspects of HCV infection. Maternal HIV infection increased the risk of vertical transmission of hepatitis C. Children with HCV/HIV co-infection presented a lower rate of spontaneous clearance of HCV, were more commonly HCV viraemic, and had higher values of alanine aminotransferase when compared with HCV-monoinfected children. No relevant difference was reported between monoinfection and co-infection with regard to clinical findings. Although the data on the outcome of hepatitis C in the context of co-infection were limited, they were highly suggestive of a more severe outcome in terms of fibrosis in co-infected children. No pediatric data were available on the role of antiretroviral therapy as a cofactor of liver injury in HCV/HIV co-infection. The efficacy of pegylated interferon-α and ribavirin in children with HCV/HIV co-infection was lower than in monoinfected children.

CONCLUSIONS

The effect of HIV co-infection on HCV-related disease was clear with most studies indicating that HIV accelerates HCV progression and reduces the efficacy of the available anti-HCV therapies.

Risk factors for vertical transmission of hepatitis C virus: a single center experience with 710 HCV-infected mothers

OBJECTIVE

The aim of this study was to analyze the risk factors on the perinatal transmission of hepatitis C virus (HCV).

STUDY DESIGN

A retrospective cohort study with 711 infants born to 710 HCV-infected mothers was conducted at the Hospital La Fe, in Valencia, Spain, from 1986 to 2011. As potential risk factors for transmission we analyzed: maternal age, mode of acquisition of HCV infection, HIV co-infection, antiretroviral treatment against HIV, CD4 cell count, HIV and HCV viral load, liver enzyme levels during pregnancy, smoking habit, gestational age, intrapartum invasive procedures, length of rupture of membranes, length of labor, mode of delivery, episiotomy, birth weight, newborn gender and type of feeding.

RESULTS

Overall perinatal HCV transmission rate was 2.4%. The significant risk factors related with HCV transmission were maternal virus load >615copies/mL (OR 9.3 [95% CI 1.11-78.72]), intrapartum invasive procedures (OR 10.1 [95% CI 2.6-39.02]) and episiotomy (OR 4.2 [95% CI 1.2-14.16]). HIV co-infection and newborn female were near significance (p=0.081 and 0.075, respectively).

CONCLUSIONS

Invasive procedures as fetal scalp blood sampling or internal electrode and episiotomy increase vertical transmission of HCV, especially in patients with positive HCV RNA virus load at delivery.

Fertility-related research needs among women at the margins

Fertility-related research encompasses fertility intentions, preconception care, research amongst pregnant women, and post-partum outcomes of mothers and children. However, some women remain under-represented within this domain of study. Women frequently missing within fertility-related research include those who are already the most vulnerable to health disparities, including female sex workers, lesbian, gay, bisexual, and transgender women, women living with HIV, and women who use drugs. Yet characterization of the needs of these women is important, given their unique fertility-related concerns, including risks and barriers to care emanating from social stigmas and discrimination. This synthesis provides an overview of fertility-related evidence, highlighting where there are clear research gaps among marginalized women and the potential implications of these data shortfalls. Overall, research among marginalized women to date has addressed pregnancy prevention and in some cases fertility intentions, but the majority of studies have focused on post-conception pregnancy safety and the well-being of the child. However, among female sex workers specifically, data on pregnancy safety and the well-being of the child are largely unavailable. Within each marginalized group, preconception care and effectiveness of conception methods are consistently understudied. Ultimately, the absence of epidemiologic, clinical and programmatic evidence limits the availability and quality of reproductive health services for all women and prevents social action to address these gaps.

Obstetrical and neonatal outcomes among women infected with hepatitis C and their infants

OBJECTIVES

(1) To describe obstetrical and neonatal outcomes among a cohort of hepatitis C virus (HCV) infected women, comparing HCV RNA positive to HCV RNA negative women; (2) to characterize virologic and hepatic parameters associated with HCV infection during pregnancy; and (3) to describe the rate of HCV vertical transmission.

METHODS

We prospectively enrolled 145 HCV-positive pregnant women across British Columbia between 2000 and 2003. Participating women were monitored during pregnancy and their infants were followed to assess them for HCV infection. Maternal HCV RNA was assessed close to delivery.

RESULTS

Seventy percent of women reported injection drug use as their primary risk factor for HCV acquisition. Observed rates of intrauterine fetal death, preterm delivery, small for gestational age, and low birth weight infants were 3.4%, 17.9%, 11.3%, and 12.5%, respectively, without a significant association with maternal HCV RNA status. The rate of cholestasis was 5.6% in the HCV RNA-positive group (6/108) and 2.8% in the HCV RNA-negative group (1/37) (P = 0.496). Serum alanine aminotransferase levels decreased significantly through pregnancy, and were significantly higher in HCV RNA-positive women than in HCV RNA-negative women after controlling for cholestasis, co-infections, and alcohol consumption. Among the HCV RNA-positive women, the median FIB-4 score was 0.67 (IQR 0.56 to 0.76) in the first trimester, 0.74 (IQR 0.52 to 1.18) in the second trimester, and 0.89 (IQR 0.52 to 1.09) in the third trimester (P = 0.02). The median HCV viral load at delivery was 424 561 IU/mL. The vertical transmission rate was 4.7% in HCV RNA-positive women, with no cases in HCV RNA-negative women.

CONCLUSION

Because of the high rates of poor obstetrical outcomes found in this prospective cohort, population-level screening for HCV in pregnancy should be considered.

Vertical transmission of hepatitis C virus: systematic review and meta-analysis

Updated pooled estimates of vertical hepatitis C (HCV) infection risk to children of HCV RNA–positive mothers ranges between 5.8% and 10.8%, depending on maternal HIV coinfection. Additional risk factors need to be captured and reported by future studies.

Background. We conducted a systematic review of estimates of hepatitis C virus (HCV) vertical transmission risk to update current estimates published more than a decade ago.

Methods. PubMed and Embase were searched and 109 articles were included. Pooled estimates of risk were generated for children born to HCV antibody–positive and viremic women, aged ≥18 months, separately by maternal human immunodeficiency virus (HIV) coinfection.

Results. Meta-analysis of the risk of vertical HCV infection to children of HCV antibody–positive and RNA-positive women was 5.8% (95% confidence interval [CI], 4.2%–7.8%) for children of HIV-negative women and 10.8% (95% CI, 7.6%–15.2%) for children of HIV-positive women. The adjusted meta-regression model explained 51% of the between-study variation in the 25 included risk estimates. Maternal HIV coinfection was the most important determinant of vertical transmission risk (adjusted odds ratio, 2.56 [95% CI, 1.50–4.43]). Additional methodological (follow-up rate and definition of infection in children) and risk factors independently predicted HCV infection and need to be captured and reported by future studies of vertical transmission. Studies assessing the contribution of nonvertical exposures in early childhood to HCV prevalence among children at risk of vertical transmission are needed.

Conclusions. More than 1 in every 20 children delivered by HCV chronically infected women are infected, highlighting that vertical transmission likely constitutes the primary transmission route among children. These updated estimates are a basis for decision making in prioritization of research into risk-reducing measures, and inform case management in clinical settings, especially for HIV-positive women in reproductive age.

Obstetric management does not influence vertical transmission of HCV infection: results of the ALHICE group study

OBJECTIVE

To investigate the impact of variation in obstetric practice during labor and childbirth upon the rate of neonatal transmission of HCV.

METHODS

Pregnant mothers were included in this prospective study from six hospitals in Southern France on the basis of positive HCV serology. Data recorded for the study included maternal factors, delivery details and laboratory data concerning mother and child. Pediatric follow-up was documented for a minimum of 1 year and for up to 2 years for children with circulating HCV RNA.

RESULTS

Two hundred and fourteen mother-child pairs were investigated. HIV/HCV co-infected mothers had a rate of HCV transmission significantly higher (11%) than that observed for mono-infected mothers (3.8%) (odds ratio=3.08 [95% CI:0.95 to 9.99] p=0.05). When the HCV viral load was greater than or equal to 6 log copies/ml, the transmission rate was 14.3% [95% CI:5.4-28.5], this representing a risk of transmission four times higher than for women with a lower viral load (OR=4 [95% CI:1.3-12.4]). Among co-infected mothers, the risk of transmission was significantly increased even when the load was less than 6 log copies/ml (p=0.006). Risk factors were identified related to labor (duration and induction type); the birth process (rupture of the amniotic sac, complete opening of the sac, appearance of the amniotic fluid); fetal characteristics (prematurity) and obstetric maneuvers (instrumental extractions, spontaneous or induced perineal trauma) and none of these factors were associated with an increased rate of HCV maternal-fetal transmission.

CONCLUSIONS

HCV infection does not appear to be a legitimate indication for modifying obstetric practices with regards to type of induction, monitoring of labor, route of delivery, fetal and perineal obstetric maneuvers or care of the newborn in the delivery room.

Mother-to-Child Transmission of Hepatitis C Virus (HCV) Among HIV/HCV-Coinfected Women

BACKGROUND

Maternal human immunodeficiency virus (HIV) coinfection has been associated with increased hepatitis C virus (HCV) mother-to-child transmission (MTCT). We hypothesized that HCV/HIV-coinfected women with well-controlled HIV disease would not have increased HCV MTCT.

METHODS

The NISDI Perinatal and LILAC cohorts enrolled HIV-infected pregnant women and their infants in Latin America and the Caribbean. This substudy evaluated the HCV infection status of mothers at participating sites and their live born, singleton infants who had a 6-month postnatal visit by December 31, 2008. Mothers who were anti-HCV-positive, or who had CD4 counts (cells/mm(3)) <200 with detectable HCV RNA, were considered HCV-infected. All HCV-infected women were tested for HCV RNA. Infants with HCV RNA were considered HCV-infected.

RESULTS

Of 1042 enrolled women, 739 (71%) mother-infant pairs met the inclusion criteria. Of the 739 women, 67 (9%) were anti-HCV-positive and 672 anti-HCV-negative [68 (10%) with CD4 counts <200; of these, 3 (4.4%) were HCV RNA-positive]. Therefore, our study population comprised 70 HCV-infected (47 with HCV RNA) and 669 HCV-uninfected women (and their infants). Factors associated with maternal HCV infection included unemployment (odds ratio [OR] = 2.58); tobacco (OR = 1.73) or marijuana (OR = 3.88) use during pregnancy; enrollment HIV viral load ([VL] copies/mL) ≥10 000 (OR = 2.27); HIV clinical disease stage C (OR = 2.12); and abnormal alanine aminotransferase (OR = 4.24) or aspartate aminotransferase (OR = 11.98). Four of 47 infants (8.5%) born to HCV-viremic women were HCV-infected, and all 4 mothers had HIV VL <1000 at hospital discharge after delivery.

CONCLUSIONS

HCV MTCT among HIV/HCV-coinfected women with well-controlled HIV disease may be lower than reported in other coinfected populations. Studies with longer infant follow-up are needed.

Spontaneous Clearance of Hepatitis C Virus during Pregnancy

Spontaneous clearance of hepatitis C virus (HCV) is expected to be unlikely in pregnancy due to the relative immunosuppression and increase in viraemia that occurs. We report the first case of spontaneous clearance of hepatitis C virus (HCV) occurring in pregnancy.

Hepatitis C virus in pregnancy

Despite recent advances in the pathogenesis, treatment, and public health response to hepatitis C virus (HCV), HCV as it specifically relates to pregnancy has been a neglected condition. HCV-monoinfected pregnant women have a 2-8% risk of viral transmission to their infant, but the mechanism and timing of mother to child transmission (MTCT) are not fully understood, nor is the natural history of the illness in pregnant women and their offspring. Recognition of HCV-infected pregnant women is relevant because of the long-term health implications for the mother, potential adverse effects of infection on pregnancy outcomes, and the possibility of transmission to their infants. Certain risk factors for MTCT of HCV appear similar to those for human immunodeficiency virus (HIV); however, unlike HIV, effective methods for prevention of HCV vertical transmission have not been developed. It is possible that a better understanding of HCV MTCT and pathogenesis in pregnancy will guide development of useful prevention strategies, particularly as we enter an era where interferon-free drug cocktails may emerge as viable treatment options for HCV.

[Hepatitis C and pregnancy: an analysis of factors associated with vertical transmission]

INTRODUCTION

Data concerning hepatitis C virus infection during pregnancy in Brazilian medical services are scarce. This study aimed to verify factors associated with vertical transmission (VT) of HCV in pregnant women.

METHODS

Observational transversal study of pregnant women from Campo Grande, MS, central Brazil, with confirmed reagent serology for HCV infection from 2002 to 2005. Vertical transmission was considered to be positive HCV serology by ELISA, confirmed by PCR, after 18 months of life of the newborn. The factors studied associated with VT were: delivery mode, time of premature rupture of membranes, breastfeeding, blood transfusion history, drug addiction, number of sexual partners and the presence of body tattoos.

RESULTS

Fifty-eight pregnant women with HCV infection were identified, indicating a prevalence rate of 0.2% (58/31,187). Of these 58 pregnant women,23 (39.6%) fulfilled the inclusion criteria. The VT rate was 13% (3/23), and the most frequent HCV viral subtypes were 1a (53%), 1b (30%), 2b (4%) e 3a (13.0%). Two (8.7%) patients were coinfected with HIV. A significant association (p < 0.05) was observed between VT and high maternal serum viremia (> 2.5 x 10(6)) and VT and the use of illicit drugs by the mother.

CONCLUSIONS

The present study demonstrates that high serum maternal viremia for HCV and the use of illicit drugs by the mother are associated with vertical transmission of HCV.

The effectiveness of outreach testing for hepatitis C in an immigrant Pakistani population

In Scotland, an estimated 1% of the population is infected with hepatitis C virus (HCV). There is ethnic diversity in Scotland, with a large Pakistani sub-population. Our aim was to investigate the prevalence of HCV in an immigrant Pakistani population and effectiveness of an outreach testing intervention. We arranged a series of HCV awareness meetings at the mosques and Pakistani Women's centre in the city of Dundee. Thereafter short-term outreach HCV testing clinics were set up in the same venues. Venous blood samples were obtained and tested for HCV IgG and HbsAg. A short questionnaire was also completed. In total, 177 individuals volunteered for testing, out of an estimated 250 who attended meetings and a total Pakistani population in Dundee of 1723. Of those tested 170 were Scottish Pakistanis (159 first generation, 11 second generation). There were 145 (85·2%) men. The mean age was 45·11 (±s.d. 16·7) years. Seven (4·1%) individuals in the cohort were anti-HCV positive. Five (2·9%) were found to have HCV RNA by PCR. Only one patient had chronic hepatitis B infection. All patients with positive results were seen in the liver clinic for consideration of treatment. We have demonstrated that immigrant Pakistanis retain a higher prevalence of HCV compared to the population of their adopted country. Outreach targeted testing in this group can be achieved using religious and cultural gatherings, with only modest investment in staff time.

Prevalence of hepatitis C virus antibody in newborn infants in southern California in 2003

The prevalence of hepatitis C virus (HCV) antibody in newborn infants in 3 counties in southern California in 2003 was found to be 2.5 per 1000 live births using dried blood spot testing. With advances in HCV antiviral therapy providing decreasing morbidity from chronic HCV infection, prenatal HCV screening to identify both mothers and at-risk infants should be reconsidered.

Vertical transmission of hepatitis C virus in low to middle socio-economic pregnant population of Karachi

PURPOSE

To determine the rate of vertical transmission (transmission from mother to child) of hepatitis C virus in low to middle socio-economic pregnant women.

METHODS

This study was conducted at Sarwar Zuberi Liver Centre (SZLC) in collaboration with the department of Gynaecology and Obstetrics, Civil Hospital Karachi (CHK) and Abbasi Shaheed Hospital (ASH) for a period of 4 years from September 2005 to December 2009. Total 18,000 women seeking antenatal care were screened for hepatitis C antibodies (Anti-HCV) using 4th generation ELISA technique. Positive 1,043 women were further offered HCV ribonucleic acid (RNA) by polymerase chain reaction (PCR). Six hundred and forty women agreed to have PCR done, and 510 PCR positive women were finally included in the study, followed till delivery and treated if required. Newborns of 510 PCR positive mothers were advised HCV-RNA by PCR from 3 to 12 months of age and Anti-HCV at 18 up to 24 months and followed up to 3 years.

RESULTS

1,043/18,000 (5.79%) mothers were Anti-HCV positive, of which PCR results of 640 mothers are available where 510/640 (79.7%) were PCR positive, 357/510 (70%) delivered by spontaneous vaginal delivery (SVD), 33 (6.4%) by forceps delivery, 70 (13.7%) had elective, and 50 (9.8%) had emergency caesarian section. Premature rupture of membranes (PROM) was present in 81 mothers. Data of 510 babies from 3 months to 3 years of age was available of which only 215 had their laboratory tests done (HCV-RNA-PCR in 86 and Anti-HCV in 129). Mean birth weight (kg), height (cm) and OFC (cm) were 2.74 ± 0.43, 52.4 ± 7.5, and 35 ± 4. Apgar score median at 1 and 5 min was 7 (range 2-10), 8 (range 4-10), respectively. Low birth weight was present in 49 (9.6%), 37 (7.2%) had history of Neonatal Intensive Care Unit (NICU) admission. PCR of none of the 86 babies done at 3-12 months was positive. Five babies out of 129 were Anti-HCV positive at 18 months of age. Of this, 3/5 was HCV-RNA-PCR positive. Rate of vertical transmission of HCV was 1.39.

CONCLUSION

In spite of the high hepatitis C positivity in pregnant population, the rate of vertical transmission to the neonate is low.

Prospective study of prevalence and risk factors for hepatitis C in pregnant Egyptian women and its transmission to their infants

AIM

To estimate the hepatitis C virus (HCV) vertical transmission rate, the effect of potential risk factors, and the pattern of HCV antibody response and viremia in HCV-infected infants in Benha, Egypt.

METHODS

A total of 1224 pregnant women who were treated at Benha University Hospital, Egypt, were included in the study. They completed a questionnaire about risk factors for HCV acquisition and suspected risk factors for mother-to-infant transmission and were tested for HCV antibody using a third-generation ELISA test. Women positive for HCV antibody were tested for HCV RNA by polymerase chain reaction. Peripheral blood of infants of positive HCV-RNA women was tested for HCV antibody and HCV-RNA at 1 and after 6 months of age.

RESULTS

Out of 1224 pregnant women, 105 (8.6%; 95% confidence interval, 7.05-10.17) were positive for HCV antibody. Only 83 (6.8%; 5.39-7.21) were positive for HCV-RNA. HCV infection was associated with older age (1.16; 1.1-1.2, P=0.001), blood transfusion (2.69; 1.2-6.0, P=0.016), and HCV infection of the husband (5.47; 1.4-21, P=0.014) or other household members (2.29; 1.2-4.6, P=0.019). Out of 53 infants tested at first month, 43 (81%; 71-92%) were positive for HCV antibody, but only 7 (13%; 4.1-22%) were positive for HCV-RNA. After 6 months, only 2 (3.8%; 0-8.95%) remained positive for HCV RNA.

CONCLUSIONS

The prevalence of HCV in pregnant women in Egypt is lower than previously reported and the potential risk factors associated with HCV infection suggest intra-familial transmission. The frequency of vertical transmission of HCV in Egypt is not substantially different from other countries and does not play a role in the high prevalence of HCV in Egypt.

Chronic hepatitis C virus infection in children and adolescents: Epidemiology, natural history, and assessment of the safety and efficacy of combination therapy

Hepatitis C virus (HCV) is the most common cause of chronic liver disease of infectious etiology in children. Most of the children infected with HCV are asymptomatic, and only a few of them develop signs and symptoms of end-stage liver disease early in life. It is not possible to predict either in which patients HCV infection will have a bad outcome or the critical time in early adulthood when disease progression will accelerate. The experiences with therapy in children with chronic hepatitis C are based on earlier and continuing data from adult trials. The currently recommended treatment for chronic HCV infection in adults is the combination of peginterferon-á and ribavirin. The choice of this regimen is based on the results of randomized clinical trials that demonstrated the superiority of this combination treatment over standard interferon-á and ribavirin. Recently, results of pivotal, multicenter, interventional open-label studies on combined treatment with peginterferon-á and ribavirin in children have been published, and the US Food and Drug Administration and the European Medicines Agency have approved the combination therapy in those older than 3 years. The aim of this review is to evaluate critically the available data regarding the safety and efficacy of combination treatment with peginterferon-á and ribavirin in children.

Treatment of hepatitis C in children

Hepatitis C affects 4-10% of children born to infected mothers, and 80% of them develop chronic infection. Most patients with chronic hepatitis C virus infection are asymptomatic, with persistent or intermittent biochemical abnormalities. Severe liver disease may develop 10 years after onset of infection, with a less than 2% overall risk during the pediatric age. Available therapies have no contraindication in children if otherwise healthy. The US FDA and EMEA have recently approved combined pegylated-IFN-alpha 2b plus ribavirin treatment for children, who should be over 3 years of age in order to avoid severe side effects. Experiences in pilot trials and international studies indicate a response rate of 50% in genotype 1 patients, and more than 90% in genotype 2 or 3 patients, indicating resolution of chronic disease.

Prevalence and risk factors for Hepatitis C and HIV-1 infections among pregnant women in Central Brazil

BACKGROUND

Hepatitis C (HCV) and human immunodeficiency virus (HIV) infections are a major burden to public health worldwide. Routine antenatal HIV-1 screening to prevent maternal-infant transmission is universally recommended. Our objectives were to evaluate the prevalence of and potential risk factors for HCV and HIV infection among pregnant women who attended prenatal care under the coverage of public health in Central Brazil.

METHODS

Screening and counselling for HIV and HCV infections was offered free of charge to all pregnant women attending antenatal clinic (ANC) in the public health system, in Goiania city (~1.1 million inhabitants) during 2004-2005. Initial screening was performed on a dried blood spot collected onto standard filter paper; positive or indeterminate results were confirmed by a second blood sample. HCV infection was defined as a positive or indeterminate sample (EIA test) and confirmed HCV-RNA technique. HIV infection was defined according to standard criteria. Factors associated with HIV and HCV infections were identified with logistic regression. The number needed to screen (NNS) to prevent one case of infant HIV infection was calculated using the Monte Carlo simulation method.

RESULTS

A total of 28,561 pregnant women were screened for HCV and HIV-1 in ANC. Mean maternal age was 23.9 years (SD = 5.6), with 45% of the women experiencing their first pregnancy. Prevalence of HCV infection was 0.15% (95% CI 0.11%-0.20%), and the risk increased with age (p < 0.01). The prevalence of anti-HIV infection was 0.09% (95% CI 0.06%-0.14%). Black women had a 4.9-fold (95% CI 1.42-16.95) greater risk of HIV-1 infection compared to non-black women. NNS to prevent one case of infant HIV infection ranged from 4,141 to 13,928.

CONCLUSION

The prevalence of HIV and HCV infections were low among pregnant women, with high acceptability rates in the opt-in strategy in primary care. Older maternal age was a risk factor for HCV and antenatal HCV testing does not fulfill the requirements for screening recommendation. The finding of higher risk of HIV-1 infection among black women despite being in consonance with the HIV-1 ethnic pattern in some American regions cannot be ruled out to be a surrogate marker of socio-economic condition.

Prospective cohort study of mother-to-infant infection and clearance of hepatitis C in rural Egyptian villages

Although persistent transmission of hepatitis C virus (HCV) from infected mothers to their infants is reported in 4-8%, transient HCV perinatal infection also occurs. This prospective cohort study determined perinatal HCV infection- and early and late clearance-rates in 1,863 mother-infant pairs in rural Egyptian villages. This study found 15.7% and 10.9% of pregnant women had HCV antibodies (anti-HCV) and HCV-RNA, respectively. Among 329 infants born of these mothers, 33 (10.0%) tested positive for both anti-HCV and HCV-RNA 2 months following birth-29 (12.5%) having HCV-RNA positive mothers and 4 (with transient infections) having mothers with only anti-HCV. Fifteen remained HCV-RNA positive at one and/or 2 years (persistent infections), while 18 cleared both virus and antibody by 1 year (transient infections). Among the 15 persistent cases, 7 cleared their infections by 2 or 3 years. At 2- to 6- and at 10- to 12-month maternally acquired anti-HCV was observed in 80% and 5% of infants, respectively. Four perinatally infected and one transiently infected infant were confirmed to be infected by their mothers by the sequence similarity of their viruses. Viremia was 155-fold greater in mothers of infants with persistent than mothers of infants with transient infections. Maternal-infant transmission of HCV is more frequent than generally reported. However, both early and late clearance of infection frequently occurs and only 15 (4.6%) and 8 (2.4%) infants born of HCV-RNA positive mothers had detectable HCV-RNA at one and 2-3 years of age. Investigating how infants clear infection may provide important information about protective immunity to HCV.

Perinatal transmission of hepatitis C virus infection

In industrialized countries, hepatitis C virus (HCV) is the most common cause of chronic liver disease in children. Perinatal transmission is the leading cause of infection. Perinatal transmission is confined almost always to women with detectable HCV ribonucleic acid (RNA) in the peripheral blood by the polymerase chain reaction but all children born to women with anti-HCV antibodies should be tested for HCV. Some but not all studies found that a high concentration of serum HCV RNA is associated with a higher risk of transmission. Maternal peripheral blood mononuclear cell infection by HCV, membrane rupture of longer than 6 hr before delivery, and procedures exposing the infant to maternal blood infected with HCV during vaginal delivery are associated with an increased risk of transmission. Maternal coinfection with HCV and human immunodeficiency virus, maternal history of intravenous drug use and of HCV infection of the sexual partner of the mother predict the risk of perinatal transmission and are dependent on the peripheral blood mononuclear cell infection by HCV. Delivery by Cesarean section is not recommended in pregnant women infected with HCV. Infected mothers can breast feed safely their infants if the nipples are not damaged. A previous delivery of a child infected perinatally with HCV does not increase the risk of transmission in subsequent pregnancies. Immunogenetic factors and HCV genotypes are not related to HCV perinatal transmission. Despite an increased understanding of the risk factors involved in perinatal transmission of HCV, to date little is known about the transmission mechanisms and timing.

Age-related lymphocyte and neutrophil levels in children of hepatitis C-infected women

BACKGROUND

Investigation of immunologic values in children vertically exposed to hepatitis C virus (HCV) infection could help explain the higher risk of infection in girls and indicate mechanisms of spontaneous viral clearance and possible long-term immunologic effects.

METHODS

Prospective study of children born to HCV-infected women. Lymphocyte and neutrophil measurements were age-standardized using the LMS method (this summarizes the changing age distribution of a variable). Associations between maternal and infant characteristics and lymphocyte and neutrophil z-scores were quantified using linear regression allowing for repeated measures.

RESULTS

HCV-infected children, girls, and those born to HCV/human immunodeficiency virus (HIV)-coinfected women had significantly higher lymphocyte z-scores than HCV-uninfected children, boys, and children born to HCV-only-infected women, respectively. Peak absolute lymphocytes were significantly lower for infected children with evidence of viral clearance than for persistently infected children. Girls also had significantly higher neutrophil z-scores than boys but HCV-infected children had significantly lower neutrophil z-scores than uninfected children.

CONCLUSIONS

The gender associations are in line with those observed among children born to HIV-infected women, suggesting general gender-based differences in response to infection. Age-related standards for uninfected children could be used to assess immune function in other pediatric diseases and these results suggest that gender-specific reference values should be used at least for the first 2 years of life.

Higher risk of hepatitis C virus perinatal transmission from drug user mothers is mediated by peripheral blood mononuclear cell infection

Maternal injection drug use and peripheral blood mononuclear cell infection by hepatitis C virus are important risk factors for perinatal transmission of the virus. The aim of present study was to evaluate the independent association of these two factors on perinatal transmission. Forty-eight consecutive mothers who transmitted infection to their offspring and 122 consecutive mothers who did not, together with their children, were examined. Both maternal injection drug use and peripheral blood mononuclear cell infection were significantly more frequent in infected than in uninfected children (respectively P = 0.04; odds ratio 2.33, 95% confidence intervals 1.02-5.42 and P < 10(-6); odds ratio and 95% confidence intervals not calculable due to zero values). Multivariate analysis confirmed the link between maternal peripheral blood mononuclear cell infection and perinatal transmission (P < 10(-6); odds ratio and 95% confidence intervals not calculable due to zero values) but no association was found with maternal injection drug use. The high risk of perinatal transmission found in injection drug use mothers is dependent on maternal peripheral blood mononuclear cell infection by hepatitis C virus. Peripheral blood mononuclear cell infection represents one of the most important risk factors for hepatitis C virus perinatal transmission.

Endogenous interferon-alpha level is increased in hepatitis C virus (HCV)-positive pregnant women

BACKGROUND

Mother-to-child transmission of hepatitis C virus (HCV) has been reported in around 5% of cases, and is much more likely to occur in case of coinfection with HIV. However, other cofactors influencing the vertical transmission are still debated.

AIM

To assess the serum concentration of endogenous interferon (IFN) during pregnancy, and its eventual role on the vertical transmission of HCV.

METHODS

Forty-seven HCV-infected pregnant women, and 3 control groups: (1) 75 HCV-negative pregnant women; (2) 29 HCV-positive nonpregnant women; (3) 29 HCV-negative nonpregnant women entered into the study. Endogenous IFN was assayed by enzyme-linked immunosorbent assay. The following parameters were also analyzed: viral load, HIV infection, risk factors for acquiring HCV, parity, gestational age, mode and course of delivery.

RESULTS

Vertical transmission of HCV was observed in 2 cases (4.3%). Plasma levels of IFN were significantly higher in HCV-positive pregnant women compared with either HCV-positive and HCV-negative nonpregnant women. The 2 mothers who transmitted the infection had IFN levels within the same range as the women who did not transmit the infection.

CONCLUSIONS

In HCV-positive pregnant women, there is an increased production of endogenous IFN-alpha. Further studies are warranted for clarifying the mechanisms of this cytokine in the prevention of HCV transmission.

Re-evaluation of the true rate of hepatitis C virus mother-to-child transmission and its novel risk factors based on our two prospective studies

OBJECTIVE

To re-evaluate the true hepatitis C virus (HCV) mother-to-child transmission (MTCT) rate and its novel risk factors.

STUDY DESIGN

A comparative study based on our own two prospective studies done during the two periods, 'early' (1989-1994) and 'recent' (1995-2004).

RESULTS

All carrier infants became HCV RNA-positive within 3 months after birth. The MTCT and de-carrier rates were, respectively, higher (14.2%) and lower (16.7%) in the recent period, although liver dysfunction of carrier infants was found very frequently (66.7%) in both groups. MTCT occurred significantly when the maternal viral load, serum alanine aminotransferase (sALT) levels and blood loss at delivery were, respectively, more than 10(5) copies/mL, 110 IU/L, and 500 g. No MTCT was found when elective cesarean section was done.

CONCLUSIONS

The true HCV MTCT and de-carrier rates were found to be much higher and lower than those reported previously. The maternal liver dysfunction (sALT >or=110 IU/mL) and blood loss (>or=500 g) at delivery are the next risk factors to maternal viral load (>or=10(5) copies/mL) for MTCT.

Hepatitis C virus infection

The prevalence of chronic hepatitis C infection in the general paediatric population varies between 0.1 and 15% around the world, with the highest numbers noted in endemic areas of Africa. The risk of viral transmission from an infected mother to her child is approximately 5% and there are currently no effective preventative measures to lower it. All children born to infected mothers should be tested for hepatitis C. The progression to liver damage in infected children is slow. However, in the perspective of 15-20 years of infection or in the presence of other risk factors, such as concomitant chronic disease, a progression to more severe liver damage can be seen. Thus, the use of antiviral treatment may be of importance. Treatment combinations of interferon and ribavirin seem to be at least as effective in children as in adults. However, the negative effect on growth of interferon requires specific attention by paediatricians.

Improving the treatment of hepatitis C infection in the UK

The UK lags behind its European neighbours in the identification and treatment of hepatitis C virus infection. Having recognised this problem, national guidelines are evolving based on detailed examination of clinical evidence. This article reviews recommended treatments for hepatitis C virus infection in the UK, recent advances in the understanding of how to use these treatments and new developments.

Caesarean section versus vaginal delivery for preventing mother to infant hepatitis C virus transmission

BACKGROUND

Observational studies have generally not provided evidence that delivery by caesarean section reduces perinatal hepatitis C virus (HCV) transmission. However, these studies have methodological weaknesses with potential for bias and their findings should be interpreted with caution.

OBJECTIVES

To assess the evidence from randomised controlled trials that a policy of delivery by planned caesarean section versus vaginal delivery reduces mother to infant HCV transmission.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2006) and the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2).

SELECTION CRITERIA

Controlled trials using random or quasi-random participant allocation that compared a policy of planned elective caesarean section versus vaginal birth for mothers with HCV infection.

DATA COLLECTION AND ANALYSIS

We did not identify any randomised controlled trials.

MAIN RESULTS

We did not identify any randomised controlled trials.

AUTHORS' CONCLUSIONS

Currently, there is no evidence from randomised controlled trials upon which to base any practice recommendations regarding planned caesarean section versus vaginal delivery for preventing mother to infant hepatitis C virus transmission. In the absence of trial data, evidence to inform women and carers is only available from observational studies that are subject to biases. Systematic review of these studies is needed. There is a need to determine whether women and healthcare providers would support a large pragmatic randomised controlled trial to provide evidence regarding the benefits and harms of planned elective caesarean section versus planned vaginal birth for women with HCV infection.

Treatment of hepatitis C virus infection in intravenous drug users

BACKGROUND

Hepatitis C virus (HCV) infection is common among intravenous drug users, and because of the long latent period, HCV liver disease is set to increase.

OBJECTIVES

We sought to examine practice guidelines regarding treatment of HCV in drug users and to review the evidence for current practices.

METHODS

A structured search of the Pubmed database, websites of the National Institute for Clinical Excellence and national and international expert groups and opinion of independent experts in the field.

RESULTS AND CONCLUSIONS

All those infected with HCV need to be assessed to ascertain whether they have active ongoing viral replication and the extent of liver damage. HCV-infected individuals should be educated about the modes of transmission and means of reducing the risk of infecting others. They should also be advised to avoid cofactors (especially alcohol) that accelerate the progression of liver disease. Specific treatment with antivirals can cause viral clearance and prevent the progression of liver disease. Therapy is effective in those on opiate-replacement treatments and also in motivated individuals who continue to use intravenous drugs. The decision whether to treat drug users should be made jointly by specialists in the management of viral hepatitis and addiction on a case-by-case basis. Current combination drug regimens are expensive but are claimed to be cost-effective, and are certainly much less costly than managing end-stage liver disease. In addition to satisfactory sustained viral response rates, other benefits such as a beneficial effect on drug habit, self-esteem and rehabilitation have been reported. Encouraging suitable drug users to take-up and comply with treatment seems to be more easily achieved in supportive drug dependency unit settings (rather than the more formal surroundings of a hospital clinic).