Although hepatitis C virus (HCV) infection during childhood is rare, it has significant consequences for patients, families, and society.1 Liver disease will develop in as many as one-third of people who acquire HCV as children,1 and studies show that even asymptomatic HCV infection has a negative effect on the well-being of children and their caregivers.1-4 In the United States, the financial burden of pediatric HCV infection is estimated at $17 million to $40 million annually.5 Experts with the divisions or Reproductive Health and Viral Hepatitis at the Centers for Disease Control and Prevention (CDC) published an article examining how best to prevent and treat HCV virus infection in children.5 

They noted that mother-to-child vertical transmission is the leading cause of HCV infection in children, accounting for approximately 60% of cases, and also predicted that expanded use of direct-acting antiviral agents (DAAs) and prenatal screening for HCV would reduce vertical transmissions sharply.5 In an interview, lead author Athena Kourtis, MD, PhD, MPH, Associate Director for Data Activities at the CDC and adjunct professor of Pediatrics at Emory University School of Medicine in Atlanta, Georgia, discussed challenges and successes in reducing rates of pediatric HCV infection and the potential role for DAAs. “DAAs have revolutionized treatment, as they can cure HCV in the great majority of people treated….There are reasons to believe that such treatment during pregnancy will be helpful in reducing the risk of transmission, but this has yet to be shown in the appropriate clinical studies,” she cautioned.

Vertical Transmission of HCV

“Approximately 6% of children born to mothers with HCV will acquire [the virus],” said Dr Kourtis, who noted that HCV can be transmitted during pregnancy or at delivery. Of note, the risk for HCV transmission is 11% for children born to women who also have HIV.6 Dr Kourtis also said that limited data suggest in-utero transmission typically happens late in pregnancy, around the third trimester. Risk factors for intrapartum HCV transmission include ruptured membranes for more than 6 hours, fetal monitoring, and episiotomies.5 Cesarean section has not been shown to reduce the risk for vertical transmission and is not recommended.5 “Transmission after delivery is very unlikely unless the mother has cracked or bleeding nipples and is breastfeeding,” Dr Kourtis said.

The prevalence of pediatric HCV infection is unclear. One study estimated that 1700 infants in the United States are infected each year, but that is likely a low approximation.7 Dr Kourtis explained that CDC guidelines recommend screening only those pregnant women with risk factors that increase the likelihood for the presence of anti-HCV antibodies. However, “women may not report or the clinician may not suspect [some] factors that increase risk, such as injection drug use…as you can imagine, this may result in not testing some women who are infected,” she said.

Over the past decade, HCV rates have surged in the United States, “driven by increases in nonurban young adults associated with injection drug use,” Dr Kourtis said. Where HCV infection was previously a concern primarily for male veterans and baby boomers, she said “the new wave is happening largely in young adults and teenagers — of both sexes.”

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