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.
IntroductionHepatitis C virus (HCV) is a single-stranded RNA virus that causes liver inflammation that can progress over time to advanced fibrosis, cirrhosis, and hepatocellular carcinoma (HCC) [1–3]. Rates of HCV acute and chronic infections (referred hereinafter as HCV infections) have been steadily increasing in the United States since 2010, with rates of acute infections more than tripling among reproductive-aged persons as of 2021, 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 [4,5]. As a result of increasing rates of acute infections in reproductive-aged persons and subsequent chronic infections, overall rates of HCV infections during pregnancy have increased by 20% during 2016–2020 and up to tenfold during 2000–2019 [6,7]. HCV is transmitted through percutaneous exposure to infected blood; increases in infection rates have corresponded to increases in injection drug use(IDU) [8–11]. In 2020, because of the changing epidemiology of HCV infections in the United States, CDC expanded previous risk-based testing recommendations to include universal screening for all adults aged ≥18 years at least once and for all pregnant persons during each pregnancy [12]. Studies have estimated that chronic HCV infection will develop in 5.8%–7.2% of all perinatally exposed (i.e., exposed during pregnancy or delivery) infants and children [13,14], and curative direct-acting antiviral (DAA) therapy can be administered beginning at age 3 years [15,16]. However, most perinatally exposed infants and children are not tested for HCV infection and are not referred for hepatitis C care [17–20]; reasons for this might include lack of awareness of perinatal exposure by pediatric providers, lack of regular pediatric care among exposed infants and children, changes in health care providers before the time of HCV testing (recommended at age 18 months), and challenging social circumstances for parents and guardians.
This report supplements the 2020 CDC recommendations for HCV screening among adults in the United States [12], which includes universal screening among pregnant persons during each pregnancy, by recommending the timing and type of test for diagnosis of current HCV infection for infants and children born to HCV-infected pregnant persons. Because HCV epidemiology and methods of testing infants and children for HCV infection have evolved, this report replaces a previous recommendation for testing perinatally exposed infants and children included in a CDC recommendation from 1998 [21]. This report is intended to serve as a resource for persons involved in the development, implementation, delivery, and evaluation of clinical and preventive services, including health care professionals; public health officials; and professional, academic, and public health and advocacy organizations. If recommendations are implemented, more perinatally infected children will be identified and linked to care. This approach would increase the chances of timely treatment and subsequent cure that can mitigate the consequences from chronic hepatitis C and limit further transmission.
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