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Musto F, Stracuzzi M, Crivellaro E, Rubinacci V, Cibarelli A, Porro C, Ghidoni E, Zuccotti GV, Giacomet V. Natural History and Management of Hepatitis C in Children: 25 Years Experience of a Reference Center in Northern Italy. Pediatr Infect Dis J 2024:00006454-990000000-00863. [PMID: 38753999 DOI: 10.1097/inf.0000000000004374] [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: 05/18/2024]
Abstract
Hepatitis C virus (HCV) infection natural history and management in the pediatric population are still debated. We retrospectively evaluated the outcome of a HCV pediatric population managed at the Pediatric Infectious Disease Unit of Luigi Sacco Hospital (Milan, Italy) from January 1997 to January 2022 (median follow-up 10 years) and we focused on the role of new drugs and transient elastography. Fifty-seven patients were enrolled: 8 (14%) had a spontaneous clearance, 33 were treated (58%), 7 (12%) were not treated because they were under 12 years old and 9 were lost at follow-up. HCV RNA was undetectable in all treated patients at the end of therapy, after 12 weeks (SVR12) and for the rest of their follow-up. All patients treated underwent elastography before and 1 year after therapy. Median stiffness pretherapy was 5.6 kPa, and 9 patients (16%) had abnormal transient elastography (>7 kPa, median 8.7 kPa). Median stiffness after treatment in the abnormal group was 6.8 kPa. Direct-acting antiviral agents are a safe and effective therapy for HCV chronic infection in the pediatric population. Liver elastography is normal in many vertically infected children before 12 years, but, when abnormal, it shows a significant improvement after direct-acting antiviral agent treatment. Further studies are needed to evaluate the role of elastography at diagnosis and follow-up in children.
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Affiliation(s)
- Francesca Musto
- From the Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital Milan, University of Milan
| | - Marta Stracuzzi
- From the Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital Milan, University of Milan
| | - Elisa Crivellaro
- From the Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital Milan, University of Milan
| | - Valeria Rubinacci
- From the Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital Milan, University of Milan
| | - Alessandro Cibarelli
- From the Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital Milan, University of Milan
| | - Cecilia Porro
- From the Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital Milan, University of Milan
| | - Elena Ghidoni
- From the Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital Milan, University of Milan
| | - Gian Vincenzo Zuccotti
- Pediatric Department, Buzzi Children's Hospital
- Department of Biosciences, Pediatric Clinical Research Center Romeo ed Enrica Invernizzi, University of Milan, Milan, Italy
| | - Vania Giacomet
- From the Paediatric Infectious Disease Unit, Department of Paediatrics, Luigi Sacco Hospital Milan, University of Milan
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2
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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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3
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Morris N, Hunter K, Bhat V, Kushnir A. Hepatitis C Exposure Diagnosis and Testing in Infants Born to Hepatitis C Virus-infected Mothers. Pediatr Infect Dis J 2024:00006454-990000000-00829. [PMID: 38621170 DOI: 10.1097/inf.0000000000004355] [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: 04/17/2024]
Abstract
BACKGROUND There has been a 5-fold increase in the number of cases of hepatitis C virus (HCV) infection among pregnant women, which is potentially associated with the increase in opioid use. METHODS This study was a retrospective review of infants born at a tertiary urban hospital in New Jersey, from January 1, 2011 to January 1, 2021, who were born to mothers with a prenatal diagnosis of HCV. RESULTS Of the 142 mothers with a prenatal diagnosis of HCV, 114 (80%) infants had a diagnosis of HCV exposure in the electronic health records. Of the HCV-exposed infants with follow-up data at 24 months of age, 52 (46%) were tested, with 34 of 52 (65%) receiving adequate testing. Infants documented as HCV exposed were more likely to be born to a mother with nonopioid drug use in pregnancy (P = 0.01) and have a higher birth weight (P = 0.03). Of tested infants, those with a higher number of well-child pediatrician visits (P = 0.01) were more likely to receive adequate testing. Trends showed more polymerase chain reaction testing than antibody testing for those who were inadequately tested. CONCLUSIONS A significant proportion of infants born to HCV-infected mothers were either not identified at birth (20%) or did not receive adequate testing on follow-up (35%). Further work needs to be done to improve documentation of HCV exposure at birth and follow-up testing to avoid missing congenitally acquired HCV.
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Affiliation(s)
| | - Krystal Hunter
- Division of Neonatology, Department of Pediatrics, Cooper Children's Regional Hospital
| | - Vishwanath Bhat
- Division of Neonatology, Department of Pediatrics, Cooper University Hospital, Camden, New Jersey
| | - Alla Kushnir
- From the Cooper Medical School of Rowan University
- Division of Neonatology, Department of Pediatrics, Cooper Children's Regional Hospital
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Panagiotakopoulos L, Miele K, Cartwright EJ, Kamili S, Furukawa N, Woodworth K, Tong VT, Kim SY, Wester C, Sandul AL. CDC's New Hepatitis C Virus Testing Recommendations for Perinatally Exposed Infants and Children: A Step Towards Hepatitis C Elimination. J Womens Health (Larchmt) 2024. [PMID: 38476092 DOI: 10.1089/jwh.2023.1114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
New U.S. Centers for Disease Control and Prevention (CDC) guidelines for hepatitis C virus (HCV) testing of perinatally exposed infants and children released in 2023 recommend a nucleic acid test (NAT) for detection of HCV ribonucleic acid (i.e., NAT for HCV RNA) at 2-6 months of age to facilitate early identification and linkage to care for children with perinatally acquired HCV infection. Untreated hepatitis C can lead to cirrhosis, liver cancer, and premature death and is caused by HCV, a blood-borne virus transmitted most often among adults through injection drug use in the United States. Perinatal exposure from a birth parent with HCV infection is the most frequent mode of HCV transmission among infants and children. New HCV infections have been increasing since 2010, with the highest rates of infection among people aged 20-39 years, leading to an increasing prevalence of HCV infection during pregnancy. In 2020, the CDC recommended one-time HCV screening for all adults aged 18 years and older and for all pregnant persons during each pregnancy. Detecting HCV infection during pregnancy is key for the identification of pregnant persons, linkage to care for postpartum treatment, and identification of infants with perinatal exposure for HCV testing. It was previously recommended that children who were exposed to HCV during pregnancy receive an antibody to HCV (anti-HCV) test at 18 months of age; however, most children were lost to follow-up before testing occurred, leaving children with perinatal infection undiagnosed. The new strategy of testing perinatally exposed children at age 2-6 months was found to be cost-effective in increasing the identification of infants who might develop chronic hepatitis C. This report describes the current perinatal HCV testing recommendations and how they advance national hepatitis C elimination efforts by improving the health of pregnant and postpartum people and their children.
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Affiliation(s)
| | - Kathryn Miele
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Emily J Cartwright
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Saleem Kamili
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nathan Furukawa
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kate Woodworth
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Van T Tong
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Shin Y Kim
- Division of Birth Defects and Infant Disorders, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Carolyn Wester
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Amy L Sandul
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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5
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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 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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6
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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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Saleh E, Jhaveri R. Earlier Testing of Infants With Perinatal Hepatitis C Exposure: A Key Step Toward Elimination. Pediatrics 2024; 153:e2023064242. [PMID: 37909208 DOI: 10.1542/peds.2023-064242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 11/02/2023] Open
Affiliation(s)
- Ezzeldin Saleh
- Division of Pediatric Infectious Diseases, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Ravi Jhaveri
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children''s Hospital of Chicago, Chicago, Illinois
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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8
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Newton SM, Woodworth KR, Chang D, Sizemore L, Wingate H, Pinckney L, Osinski A, Orkis L, Reynolds BD, Carpentieri C, Halai UA, Lyu C, Longcore N, Thomas N, Wills A, Akosa A, Olsen EO, Panagiotakopoulos L, Thompson ND, Gilboa SM, Tong VT. Frequency of Children Diagnosed with Perinatal Hepatitis C, United States, 2018-2020. Emerg Infect Dis 2024; 30:202-204. [PMID: 38063079 PMCID: PMC10756376 DOI: 10.3201/eid3001.230315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
We describe hepatitis C testing of 47 (2%) of 2,266 children diagnosed with perinatal hepatitis C who were exposed during 2018-2020 in 7 jurisdictions in the United States. Expected frequency of perinatal transmission is 5.8%, indicating only one third of the cases in this cohort were reported to public health authorities.
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9
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Panagiotakopoulos L, Sandul AL, Conners EE, Foster MA, Nelson NP, Wester C. CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children - United States, 2023. MMWR Recomm Rep 2023; 72:1-21. [PMID: 37906518 PMCID: PMC10683764 DOI: 10.15585/mmwr.rr7204a1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
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.
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Affiliation(s)
| | - Amy L Sandul
- Division
of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB
prevention, CDC; Division of Global Health Protection, Center for Global
Health, CDC
| | - DHSc1
- Division
of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB
prevention, CDC; Division of Global Health Protection, Center for Global
Health, CDC
| | | | | | | | | | - Collaborators
- Division
of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB
prevention, CDC; Division of Global Health Protection, Center for Global
Health, CDC
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10
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Hall EW, Panagiotakopoulos L, Wester C, Nelson N, Sandul AL. Cost-Effectiveness of Strategies to Identify Children with Perinatally Acquired Hepatitis C Infection. J Pediatr 2023; 258:113409. [PMID: 37023948 PMCID: PMC10448738 DOI: 10.1016/j.jpeds.2023.113409] [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: 12/01/2022] [Revised: 02/24/2023] [Accepted: 03/25/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVE To determine the optimal testing strategy to identify children with perinatally acquired hepatitis C virus (HCV) infection. STUDY DESIGN We used a decision-tree framework with a Markov disease progression model to conduct an economic analysis of 4 strategies, based on combinations of type and timing of test: anti-HCV with reflex to HCV RNA at 18 months among children known to be perinatally exposed (ie, baseline comparison strategy); HCV RNA testing at 2-6 months among infants known to be perinatally exposed (test strategy 1); universal anti-HCV with reflex to HCV RNA at 18 months among all children (test strategy 2); and universal HCV RNA testing at 2-6 months among all infants (test strategy 3). We estimated total cost, quality-adjusted life years, and disease sequalae for each strategy. RESULTS Each of the 3 alternative testing strategies resulted in an increased number of children tested and improved health outcomes. HCV RNA testing at 2-6 months (test strategy 1) was cost-saving and resulted in a population-level difference in cost of $469 671. The 2 universal testing strategies resulted in an increase in quality-adjusted life years and an increase in total costs. CONCLUSIONS Testing of perinatally exposed infants at age 2-6 months with a single HCV RNA test will reduce costs and improve health outcomes, preventing morbidity and mortality associated with complications from perinatal HCV infections.
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Affiliation(s)
- Eric W Hall
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR.
| | - Lakshmi Panagiotakopoulos
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Carolyn Wester
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Noele Nelson
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Amy L Sandul
- Division of Viral Hepatitis, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA
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11
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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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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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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] [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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16
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Miyano S, Pathammavong C, Ichimura Y, Sugiyama M, Phounphenghack K, Tengbriacheu C, Khamphaphongphane B, Nouanthong P, Franzel L, Yang TU, Raaijimakers H, Ota T, Funato M, Komada K, Hachiya M. Prevalence of hepatitis B and C virus infections in Lao People's Democratic Republic: The first national population-based cross-sectional survey. PLoS One 2022; 17:e0278933. [PMID: 36584043 PMCID: PMC9803141 DOI: 10.1371/journal.pone.0278933] [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: 05/06/2022] [Accepted: 11/23/2022] [Indexed: 12/31/2022] Open
Abstract
Population-based seroprevalence of chronic hepatitis B and C infections has not been examined in Lao People's Democratic Republic (PDR). Therefore, this study aimed to estimate the seroprevalence of these infections in the general population of Lao PDR and perform subgroup analysis. A nationwide seroprevalence survey was conducted in Lao PDR in June 2019 using the multistage cluster sampling method. Dried blood spot samples were collected onto WhatmanTM 903 filter paper by finger prick. A chemiluminescent microparticle immunoassay was used to measure the levels of hepatitis B surface antigen (HBsAg) and hepatitis C antibody (HCV-Ab). Samples in which the HBsAg level was above 0.05 IU/ml and HCV-Ab was above the signal/cutoff ratio of 1.0 were considered positive based on comparisons with the relative light unit value of a calibration sample. A total of 1,927 samples (male: 47.3%, mean age: 23.0 years) were included in the analysis. The prevalence was estimated to be 4.2% (95% confidence interval [CI]: 2.7-6.3) for HBsAg and 1.6% (95% CI: 0.5-5.3) for HCV-Ab. Multivariable analysis revealed that those aged 20-24 years (adjusted odds ratio (AOR): 2.3, 95% CI: 1.1-4.6), those aged 25-29 years (AOR: 2.7, 95% CI: 1.3-5.6), those from the Northern region (AOR: 2.8, 95% CI: 1.2-6.6), and those who were Khmu (AOR: 3.6, 95% CI: 2.0-6.8) or Hmong (AOR: 5.0, 95% CI: 3.3-7.5) were significantly more likely to be positive for HBsAg. Although there were no statistically significant differences in the HCV-Ab prevalence according to each variable, males (2.9%, 95% CI: 0.7-10.7), those aged ≥40 years (6.1%, 95% CI: 2.1-16.8), and those from the Southern region (3.3%, 95% CI: 0.6-15.3) tended to have a higher prevalence. This novel population-based survey found differences in the prevalence of chronic hepatitis B and hepatitis C virus infections in Lao PDR according to sex, age group, region, and ethnicity; however, the results of this study should be confirmed in future studies, and relevant responses tailored for each target also need to be determined to control the transmission of hepatitis B and C infections.
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Affiliation(s)
- Shinsuke Miyano
- Bureau of International Health Cooperation and WHO Collaborating Center for Health Systems Development, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
- * E-mail:
| | - Chansay Pathammavong
- National Immunization Program, Mother and Child Health Center, Ministry of Health, Lao People’s Democratic Republic (Lao PDR), Vientiane Capital, Lao PDR
| | - Yasunori Ichimura
- Bureau of International Health Cooperation and WHO Collaborating Center for Health Systems Development, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Masaya Sugiyama
- Genome Medical Science Project, The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikwa, Chiba, Japan
| | - Kongxay Phounphenghack
- National Immunization Program, Mother and Child Health Center, Ministry of Health, Lao People’s Democratic Republic (Lao PDR), Vientiane Capital, Lao PDR
| | | | | | - Phonethipsavanh Nouanthong
- Institute Pasteur du Laos, National Immunization Technical Advisory Group, Ministry of Health, Vientiane Capital, Lao PDR
| | - Lauren Franzel
- Vaccine-Preventable Diseases and Immunization Team, WHO Lao PDR, Vientiane Capital, Lao PDR
| | - Tae Un Yang
- Vaccine-Preventable Diseases and Immunization Team, WHO Lao PDR, Vientiane Capital, Lao PDR
| | | | - Tomomi Ota
- Bureau of International Health Cooperation and WHO Collaborating Center for Health Systems Development, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Masafumi Funato
- Bureau of International Health Cooperation and WHO Collaborating Center for Health Systems Development, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Kenichi Komada
- Bureau of International Health Cooperation and WHO Collaborating Center for Health Systems Development, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
| | - Masahiko Hachiya
- Bureau of International Health Cooperation and WHO Collaborating Center for Health Systems Development, National Center for Global Health and Medicine, Shinjuku, Tokyo, Japan
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17
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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
- * E-mail:
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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: 0] [Impact Index Per Article: 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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Feld JJ, Matthews GV. Don't Wait: The Benefits of Early Diagnosis in Perinatal Hepatitis C Virus Transmission. Clin Infect Dis 2021; 73:e3347-e3348. [PMID: 32640029 DOI: 10.1093/cid/ciaa942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jordan J Feld
- Toronto Centre for Liver Disease, University Health Network, University of Toronto, Toronto, Canada
| | - Gail V Matthews
- Kirby Institute, University of New South Wales, Sydney, Australia
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23
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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: 11] [Impact Index Per Article: 3.7] [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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24
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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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25
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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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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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27
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Pinto RB, Ramos ARL, Padua LT, Swayze EJ, Cambou MC, Fiorini M, Melo M, Santos BR, Canti ICT, Silveira MLR, Solari MIG, de Correa JF, Chew K, Dos Santos Varella IR, Nielsen-Saines K. Prospective cohort study of children exposed to hepatitis C virus through a pregnancy screening program. Int J Infect Dis 2021; 110:62-68. [PMID: 34273517 PMCID: PMC8478836 DOI: 10.1016/j.ijid.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/03/2021] [Accepted: 07/05/2021] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Leidy Tovar Padua
- University of San Diego School of Medicine, University of California, San Diego, California, USA
| | - Emma Jane Swayze
- Western Michigan University, Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - Mary Catherine Cambou
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Maristela Fiorini
- Communicable Disease Surveillance Team, Municipal Health Secretariat of Porto Alegre, RS, Brazil
| | - Marineide Melo
- Hospital Nossa Senhora da Conceição, Porto Alegre, RS, Brazil
| | | | | | | | | | | | - Kara Chew
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Karin Nielsen-Saines
- David Geffen School of Medicine, University of California, Los Angeles, California, USA.
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28
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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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29
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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: 7] [Impact Index Per Article: 2.3] [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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30
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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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31
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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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32
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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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33
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Cost-effectiveness of Universal Hepatitis C Screening in Pregnant Women: A Systematic Review. J Clin Gastroenterol 2021; 55:250-257. [PMID: 32324677 DOI: 10.1097/mcg.0000000000001360] [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] [Received: 01/24/2020] [Accepted: 03/21/2020] [Indexed: 12/10/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) epidemiology has shifted from the baby-boomer generation to young women of childbearing age. The health benefits and cost-effectiveness (CE) of screening pregnant women remain controversial. AIM To systematically review published studies evaluating the CE of screening pregnant women for HCV in the era of direct-acting antivirals (DAAs). MATERIALS AND METHODS We conducted a systematic literature search of CE studies evaluating the costs and benefits of screening pregnant women for HCV. Pertinent information including antiviral agent, drug costs, incremental cost-effective ratio (ICER), and infant care was collected. The authors' definition of the threshold price at which screening was deemed CE was also recorded. The quality of studies was assessed using the Consolidated Health Economic Evaluation Reports Standards (CHEERS) checklist. RESULTS We identified 5 studies that evaluated the ICER of screening pregnant women for HCV. Of these, 2 utilized all oral DAAs, with universal screening CE. The ICER of these 2 studies was $3000 and $41,000 per quality of life-years gained. The remaining studies were interferon-based regimens. Most studies did not include screening of infants. CONCLUSIONS Universally screening pregnant women for HCV was CE in studies that utilized oral DAAs. Most pharmacoeconomic studies failed to incorporate the impact of vertical transmission on infants.
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34
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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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35
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Bhardwaj AM, Mhanna MJ, Abughali NF. Maternal risk factors associated with inadequate testing and loss to follow-up in infants with perinatal hepatitis C virus exposure. J Neonatal Perinatal Med 2021; 14:123-129. [PMID: 32039866 DOI: 10.3233/npm-190264] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Inadequate testing (IT) and follow-up in infants with perinatal hepatitis C virus (HCV) exposure are challenging. We sought to identify maternal clinical and demographic risk factors that are associated with inadequate testing (IT) and follow-up of perinatally HCV-exposed infants. METHODS In a retrospective cohort study spanning a period of 23 years, medical records of HCV-infected women and their perinatally exposed infants were reviewed for maternal characteristics that could be associated with their infants' IT and loss to follow-up. RESULTS A total of 27% (108/407) of HCV-exposed infants were adequately tested (AT) for HCV perinatal transmission. Among AT infants, HCV transmission rate was 11% (12/108). History of maternal intravenous drug use (IVDU) was significantly higher in IT vs. AT infants [88% (193/218) vs. 76% (70/92); p = 0.005]. The percentage of mothers on methadone maintenance treatment during pregnancy was higher in AT vs. IT infants [53% (35/66) vs. 34% (65/186); p = 0.010]. The percentage of mothers with HCV medical care was higher among AT than IT infants [54% (56/102) vs. 41% (106/255); p = 0.022]. CONCLUSIONS Infants born to HCV-infected mothers have suboptimal testing, possibly leading to an underestimation of the rate of HCV vertical transmission. Infants of mothers receiving HCV medical care and methadone treatment have improved testing. Infants of HCV-positive mothers with history of IVDU have lower rates of testing. Screening HCV-infected pregnant women for history of IVDU and linking them to drug treatment programs, and HCV medical care may improve testing and follow-up in their infants.
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Affiliation(s)
- A M Bhardwaj
- Department of Pediatric Critical Care, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - M J Mhanna
- Department of Pediatrics, Case Western Reserve University at Metro Health Medical Center, Cleveland, OH, USA
| | - N F Abughali
- Department of Pediatrics, Case Western Reserve University at Metro Health Medical Center, Cleveland, OH, USA
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36
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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: 49] [Impact Index Per Article: 16.3] [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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37
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Statler VA, Espinosa C. Management of Hepatitis C in Children and Adolescents. J Pediatric Infect Dis Soc 2020; 9:785-790. [PMID: 33043957 DOI: 10.1093/jpids/piaa114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/10/2020] [Indexed: 12/09/2022]
Abstract
The management of hepatitis C virus (HCV) infections has changed dramatically in recent years with the use of direct antiviral agents (AADs). New AADs have excellent safety profile and demonstrated to be highly effective. Interferon free regimens are now recommended for children and adolescents but significant barriers for treatment exist. Overcoming those barriers will facilitate HCV elimination. This review covers varied topics to familiarize providers with the current status of pediatric HCV management in light of newly available DAAs medications.
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Affiliation(s)
| | - Claudia Espinosa
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, USA
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38
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Rahal H, Boutros S, Farhat M, Kullar R, Rahal K, Saab S. Estimating paediatric hepatitis C prevalence in the United States. J Viral Hepat 2020; 27:1455-1461. [PMID: 32810350 DOI: 10.1111/jvh.13377] [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: 05/22/2020] [Accepted: 08/07/2020] [Indexed: 12/09/2022]
Abstract
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.
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Affiliation(s)
- Harman Rahal
- Department of Internal Medicine, UCLA Medical Center, Los Angeles, CA, USA
| | - Sandra Boutros
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Mohamad Farhat
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Kabir Rahal
- Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
| | - Sammy Saab
- Department of Internal Medicine, UCLA Medical Center, Los Angeles, CA, USA.,Department of Surgery, University of California at Los Angeles, Los Angeles, CA, USA
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39
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Using Preventive Health Alerts in the Electronic Health Record Improves Hepatitis C Virus Testing Among Infants Perinatally Exposed to Hepatitis C. Pediatr Infect Dis J 2020; 39:920-924. [PMID: 32453202 DOI: 10.1097/inf.0000000000002757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Perinatal exposure to hepatitis C virus (HCV) is a major public health issue, and poor testing rates leave many children with infection unidentified. We sought to use the electronic health record (EHR) to promote guideline-directed HCV testing among infants born to mothers with HCV infection in an urban, safety-net hospital system. METHODS Our study population was identified using our EHR database, Epic. Children were included in the study if they had perinatal HCV exposure, were 18 months to 18 years of age and had at least 1 encounter in a primary or urgent care clinic during the study period. Our study included retrospective (October 2011 to February 2015) and prospective (February 2015 to May 2018) arms. Our EHR-based intervention was initiated in the prospective arm and recommended a one-time HCV antibody test at or after the age of 18 months using a health maintenance reminder. The health maintenance reminder activated a point-of-care alert and a linked HCV testing order set in all prespecified encounters during the intervention period. RESULTS Median time to appropriate HCV testing decreased from 96.2 months preintervention to 9.1 months postintervention (P < 0.0001), and rate of completed antibody testing increased from 14% to 61% (P < 0.0001). CONCLUSIONS Among children with perinatal HCV exposure, using a point-of-care alert within the EHR significantly increased the HCV antibody testing rate in accordance with American Academy of Pediatrics (AAP) recommendations. More effective EHR-based interventions combined with increased provider awareness of appropriate HCV testing in perinatally exposed infants is imperative.
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40
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McCauley M, Egbe T, Parris A, Rosenberg S, Carmicheal‐Kusy C, Goldberg D. Screening Adult Children of Hepatitis C-Infected Baby Boomers: Barriers to Testing and Prevalence Estimates. Clin Liver Dis (Hoboken) 2020; 16:77-82. [PMID: 32922755 PMCID: PMC7474142 DOI: 10.1002/cld.985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/10/2020] [Accepted: 04/22/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Maureen McCauley
- Center for Clinical Epidemiology and BiostatisticsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA
| | - Teniola Egbe
- Center for Clinical Epidemiology and BiostatisticsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA,Center for Pediatric Clinical EffectivenessChildren’s Hospital of PhiladelphiaPhiladelphiaPA
| | - Alexandra Parris
- Division of GastroenterologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Samantha Rosenberg
- Division of GastroenterologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | | | - David Goldberg
- Center for Clinical Epidemiology and BiostatisticsUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPA,Division of GastroenterologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPA,Division of Digestive Health and Liver DiseasesUniversity of Miami Miller School of MedicineMiamiFL
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41
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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: 62] [Impact Index Per Article: 15.5] [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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42
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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: 5] [Impact Index Per Article: 1.3] [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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43
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Millbourn C, Lybeck C, Psaros Einberg A, Nordin M, Lindh G, Hökeberg I, Fredlund H, Fischler B, Fadl H, Duberg AS, Lindahl K. Anti-HCV prevalence and risk factor-based screening for hepatitis C in pregnant women and their partners in Sweden. Infect Dis (Lond) 2020; 52:776-785. [PMID: 32654571 DOI: 10.1080/23744235.2020.1784456] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The hepatitis C virus (HCV) prevalence in Sweden is estimated to be <0.5%, but unclear in pregnant women. The dominating route of transmission is drug use (DU), blood transfusions constituted a risk before 1992. The aim was to examine the anti-HCV prevalence and risk factors for HCV among pregnant women and their partners to evaluate screening strategies. METHODS Pregnant women and partners in Örebro County and in southern Stockholm were offered HCV-screening when visiting an antenatal clinic in 2013-2016, and completed a questionnaire concerning the country of birth, knowledge of HCV-status and HCV risk factors. RESULTS In Örebro 2,827 pregnant women and 707 partners, and in Stockholm 1,281 pregnant women and 320 partners participated. Anti-HCV was positive in 34 (0.7%) (25 pregnant women) and the associated risk factors were DU (n = 27), partner with HCV (n = 24) and not born in Sweden (n = 8). HCV RNA was positive in 23 (0.4%), 4 previously unknown and 10 who had been lost to follow-up. The most effective risk factor-based screening model for pregnant women included DU, blood transfusions, born in high prevalence country, partner with HCV, resulting in 538 (13%) pregnant women tested with 96% sensitivity, 87% specificity. CONCLUSIONS In this study of expecting parents in two Swedish regions, the anti-HCV prevalence was 0.7% and 0.4% were viraemic, of which about 60% were previously unknown or lost to follow-up. Awaiting more studies, including cost-benefit analysis evaluating universal screening, we recommend this improved risk factor-based screening model to identify HCV-infected individuals who need follow-up and therapy.
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Affiliation(s)
- Charlotta Millbourn
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Huddinge, Sweden.,Department of Infectious Diseases, Danderyd Hospital, Stockholm, Sweden
| | - Charlotte Lybeck
- Department of Infectious Diseases, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Afrodite Psaros Einberg
- Department of Clinical Science, Intervention and Technology, CLINTEC, Stockholm, Sweden.,Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Margareta Nordin
- Department of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden
| | - Gudrun Lindh
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Ingegerd Hökeberg
- Department of Communicable Disease Prevention and Control, Stockholm County Council, Stockholm, Sweden
| | - Hans Fredlund
- Department of Microbiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Björn Fischler
- Department of Clinical Science, Intervention and Technology, CLINTEC, Stockholm, Sweden.,Department of Pediatrics, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Fadl
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Ann-Sofi Duberg
- Department of Infectious Diseases, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Karin Lindahl
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Huddinge, Sweden
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44
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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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45
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Domínguez-Rodríguez S, Prieto L, Fernández McPhee C, Illán-Ramos M, Beceiro J, Escosa L, Muñoz E, Olabarrieta I, Regidor FJ, Roa MÁ, Viñuela Beneítez MDC, Guillén S, Navarro-Gómez ML, Ramos Amador JT. Perinatal HCV Transmission Rate in HIV/HCV Coinfected women with access to ART in Madrid, Spain. PLoS One 2020; 15:e0230109. [PMID: 32271775 PMCID: PMC7144987 DOI: 10.1371/journal.pone.0230109] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 02/22/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Maternal HIV coinfection is a key factor for mother-to-child transmission (MTCT) of HCV. However, data about HCV MTCT in HIV/HCV-coinfected pregnant women on combined antiretroviral treatment (ART) are scarce. This study assessed the HCV MTCT rate in the Madrid Cohort of HIV-infected women. METHODS Retrospective study within the Madrid Cohort of HIV-infected pregnant women (2000-2012). Epidemiological, clinical and treatment related variables were analysed for the mother and infant pairs. HCV MTCT rate was determined. RESULTS Three hundred thirty-nine HIV/HCV-coinfected women and their exposed infants were recorded. A total of 227 (67%) paired mother-children had available data of HCV follow-up and were included for the analysis. Sixteen children (rate 7.0%, 95%CI 3.7-10.4%) were HCV infected by 18 months of age, none of them coinfected with HIV. HIV/HCV-coinfected pregnant women were mostly of Spanish origin with a background of previous injection drug use. HCV-genotype 1 was predominant. The characteristics of mothers that transmitted HCV were similar to those that did not transmit HCV with respect to sociodemographic and clinical features. A high rate (50%) of preterm deliveries was observed. Infants infected with HCV were similar at birth in weight, length and head circumference than those uninfected. CONCLUSION MTCT rates of HCV among HIV/HCV-coinfected women on ART within the Madrid cohort were lower than previously described. However, rates are still significant and strategies to eliminate any HCV transmission from mother to child are needed.
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Affiliation(s)
- Sara Domínguez-Rodríguez
- Hospital Universitario 12 Octubre, Madrid, Spain
- Fundación SEIMC-GESIDA, Madrid, Spain
- * E-mail: (MLNG); (SDR)
| | - Luis Prieto
- Hospital Universitario 12 Octubre, Madrid, Spain
| | - Carolina Fernández McPhee
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, (IISGM), CoRISpe, Spain Universidad Complutense, Madrid, Spain
| | | | - José Beceiro
- Hospital Príncipe de Asturias, Alcalá de Henares, Spain
| | - Luis Escosa
- Servicio de pediatría hospitalaria, enfermedades infecciosas y tropicales, Instituto de Investigación IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain
| | - Eloy Muñoz
- Hospital Universitario 12 Octubre, Madrid, Spain
| | | | - Francisco Javier Regidor
- Servicio de pediatría hospitalaria, enfermedades infecciosas y tropicales, Instituto de Investigación IdiPAZ, Hospital Universitario La Paz, Madrid, Spain
| | | | - María del Carmen Viñuela Beneítez
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, (IISGM), CoRISpe, Spain Universidad Complutense, Madrid, Spain
| | | | - Maria Luisa Navarro-Gómez
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, (IISGM), CoRISpe, Spain Universidad Complutense, Madrid, Spain
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain
- * E-mail: (MLNG); (SDR)
| | - José Tomás Ramos Amador
- Hospital Clínico San Carlos, Madrid, Spain
- Red de Investigación Translacional en Infectología Pediátrica (RITIP), Madrid, Spain
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46
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Jhaveri R. We Need a New National Strategy for Hepatitis C Virus Screening. Pediatrics 2020; 145:peds.2019-3060. [PMID: 32060139 DOI: 10.1542/peds.2019-3060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2019] [Indexed: 01/25/2023] Open
Affiliation(s)
- Ravi Jhaveri
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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47
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Lopata SM, McNeer E, Dudley JA, Wester C, Cooper WO, Carlucci JG, Espinosa CM, Dupont W, Patrick SW. Hepatitis C Testing Among Perinatally Exposed Infants. Pediatrics 2020; 145:peds.2019-2482. [PMID: 32060140 PMCID: PMC7049945 DOI: 10.1542/peds.2019-2482] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hepatitis C virus (HCV) prevalence doubled among pregnant women from 2009 to 2014, reaching 3.4 per 1000 births nationwide. Infants exposed to HCV may acquire HCV by vertical transmission. National guidelines recommend that infants exposed to HCV be tested; however, it is unclear if these recommendations are being followed. Our objectives were to determine if infants exposed to HCV were tested and to determine hospital- and patient-level factors associated with differences in testing. METHODS In this retrospective cohort study of infants exposed to HCV who were enrolled in the Tennessee Medicaid program, we used vital statistics-linked administrative data for infants born between January 1, 2005, and December 31, 2014. Infants were followed until 2 years old. Multilevel logistic regression was used to assess the association of HCV testing and hospital- and patient-level characteristics. RESULTS Only 23% of 4072 infants exposed to HCV were tested. Infants whose mothers were white versus African American (96.6% vs 3.1%; P <.001), used tobacco (78% vs 70%; P <.001), and had HIV (1.3% vs 0.4%; P = .002) were more likely to be tested. Infants exposed to HCV who had a higher median of well-child visits (7 vs 6; P <.001) were more likely to be tested. After accounting for maternal and infant characteristics and health care use patterns, African American infants were less likely to undergo general testing (adjusted odds ratio 0.32; 95% confidence interval, 0.13-0.78). CONCLUSIONS Testing occurred in <1 in 4 infants exposed to HCV and less frequently among African American infants. Public health systems need to be bolstered to ensure that infants exposed to HCV are tested for seroconversion.
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Affiliation(s)
| | - Elizabeth McNeer
- Biostatistics, and,Vanderbilt Center for Child Health Policy, Vanderbilt
University Medical Center, Nashville, Tennessee
| | | | - Carolyn Wester
- Tennessee Department of Health, Nashville, Tennessee;
and
| | - William O. Cooper
- Departments of Pediatrics,,Health Policy, and,Vanderbilt Center for Child Health Policy, Vanderbilt
University Medical Center, Nashville, Tennessee
| | | | - Claudia M. Espinosa
- Division of Pediatric Infectious Diseases and,Department of Pediatrics, School of Medicine,
University of Louisville, Louisville, Kentucky
| | | | - Stephen W. Patrick
- Divisions of Neonatology and,Departments of Pediatrics,,Health Policy, and,Vanderbilt Center for Child Health Policy, Vanderbilt
University Medical Center, Nashville, Tennessee
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48
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Morgan TR. Hepatitis C Guidance 2019 Update: American Association for the Study of Liver Diseases-Infectious Diseases Society of America Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection. Hepatology 2020; 71:686-721. [PMID: 31816111 PMCID: PMC9710295 DOI: 10.1002/hep.31060] [Citation(s) in RCA: 449] [Impact Index Per Article: 112.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 11/21/2019] [Indexed: 02/06/2023]
Affiliation(s)
| | - Timothy R. Morgan
- Chief of Hepatology Veterans Affairs Long Beach Healthcare System Long Beach CA
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49
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Chaillon A, Rand EB, Reau N, Martin NK. Cost-effectiveness of Universal Hepatitis C Virus Screening of Pregnant Women in the United States. Clin Infect Dis 2019; 69:1888-1895. [PMID: 30689769 PMCID: PMC7188080 DOI: 10.1093/cid/ciz063] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/18/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hepatitis C virus' (HCV) chronic prevalence among pregnant women in the United States doubled nationally from 2009-2014 (~0.7%), yet many cases remain undiagnosed. Screening pregnant women is not recommended by the Society of Maternal-Fetal Medicine or the Centers for Disease Control and Prevention, despite new American Association For the Study of Liver Diseases (AASLD)/Infectious Diseases Society of America (IDSA) guidelines recommending screening for this group. We assessed the cost-effectiveness of HCV screening for pregnant women in the United States. METHODS An HCV natural history Markov model was used to evaluate the cost-effectiveness of universal HCV screening of pregnant women, followed by treatment after pregnancy, compared to background risk-based screening from a health-care payer perspective. We assumed a HCV chronic prevalence of 0.73% among pregnant women, based on national data. We assumed no Medicaid reimbursement restrictions by fibrosis stage at baseline, but explored differing restrictions in sensitivity analyses. We assessed costs (in US dollars) and health outcomes (in quality-adjusted life-years [QALYs]) over a lifetime horizon, using new HCV drug costs of $25 000/treatment. We assessed mean incremental cost-effectiveness ratios (ICERs) under a willingness-to-pay threshold of $50 000/QALY gained. We additionally evaluated the potential population impact. RESULTS Universal antenatal screening was cost-effective in all treatment eligibility scenarios (mean ICER <$3000/QALY gained). Screening remained cost-effective at a prevalence of 0.07%, which is the lowest estimated prevalence in the United States (in Hawaii). Screening the ~5.04 million pregnant women in 2018 could result in the detection and treatment of 33 000 women, based on current fibrosis restrictions. CONCLUSIONS Universal screening for HCV among pregnant women in the United States is cost-effective and should be recommended nationally.
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Affiliation(s)
- Antoine Chaillon
- Division of Infectious Diseases and Global Public Health, University of California San Diego
| | - Elizabeth B Rand
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nancy Reau
- Department of Internal Medicine, Rush University Medical Center, Illinois, Chicago
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego
- Population Health Sciences, University of Bristol, United Kingdom
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Orekondy N, Cafardi J, Kushner T, Reau N. HCV in Women and Pregnancy. Hepatology 2019; 70:1836-1840. [PMID: 31135999 DOI: 10.1002/hep.30791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022]
Affiliation(s)
| | - John Cafardi
- Department of Infectious Disease, Christ Hospital, Cincinnati, OH
| | - Tatyana Kushner
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nancy Reau
- Section of Hepatology, Rush University Medical Center, Chicago, IL
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