(MMWR) Increased Hepatitis C Detection in Women of Childbearing Age and Potential Risk for Vertical Transmission

CDC
According to Morbidity and Mortality Weekly Report (MMWR) Kentucky had the highest incidence of acute hepatitis C infections from 2011 through 2014 with the rate of infants born to women diagnosed with hepatitis C increasing 124 percent.

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MedPage Today
Vertical HCV Transmission on the Rise
by Molly Walker
Staff Writer, MedPage Today
Mother-to-child transmission of hepatitis C virus (HCV) infection is increasing nationally, though the problem is particularly prevalent in Kentucky, CDC researchers reported.

Morbidity and Mortality Weekly Report (MMWR)
Increased Hepatitis C Virus (HCV) Detection in Women of Childbearing Age and Potential Risk for Vertical Transmission — United States and Kentucky, 2011–2014

Weekly / July 22, 2016 / 65(28);705–710

Discussion Only

Read Full Report on the CDC website

The national increases in HCV detection among women of childbearing age, HCV testing among infants, and the proportion of infants born to HCV-infected mothers suggest increased risk for mother-to-child transmission of HCV. This risk might be higher in certain areas of the United States, as illustrated by the findings in this report for Kentucky, which might be related to increasing illicit injection drug use (5). KDPH surveillance data for pregnant women are also consistent with demographic patterns of HCV incidence overall in Kentucky and nationally (6).

Many opportunities to improve identification and monitoring of HCV infection among women of childbearing age and infants exist. CDC recommends HCV testing for persons with a history of injection drug use and others at risk, including persons infected with HIV and persons with recognized exposures (e.g., health care workers after needle sticks or mucosal exposure to HCV-positive blood) (1,7). It is important that providers assess women of childbearing age, particularly pregnant women, for HCV risk and test accordingly. CDC also recommends HCV testing of children born to HCV-infected women (1,7). Several organizations have published guidelines on HCV testing of children,** but harmonization is needed to ensure that all women who are pregnant or planning pregnancy and all infants born to HCV-infected women are appropriately tested and linked to care if they are infected.

The potential for mother-to-child transmission of HCV has prompted some jurisdictions to consider changes in HCV case identification strategies and reporting policies. For example, the Philadelphia Department of Public Health recently demonstrated improved identification of infants born to HCV-infected mothers by cross-matching maternal information (including mother’s name and date of birth) on birth certificates to women in HCV surveillance registries (9). In 2015, Kentucky mandated reporting of all HCV-infected pregnant women and children through age 60 months, as well as all infants born to all HCV-infected women.^†† Development of national reporting criteria to include a case definition for perinatal HCV infection could standardize reporting across states.

Reporting pregnancy status as part of HCV laboratory-based surveillance would also facilitate case identification. Improved surveillance can inform HCV screening and testing recommendations for pregnant women. Furthermore, there is an opportunity to detect HCV infection through routine HCV testing of infants identified as having perinatal exposure to illicit drugs, or neonatal abstinence syndrome, and their mothers; this could enhance HCV case identification as suggested by the large proportion of HCV antibody-positive pregnant women in Kentucky who report injecting illicit drugs.

The findings in this report are subject to at least four limitations.
First, incomplete information on pregnancy status on case report forms used for surveillance in Kentucky and maternal HCV infection status on birth certificates might underestimate rates of infants born to HCV-infected mothers. Second, identifying cases of HCV-infected persons, including pregnant women, relies on completeness of reporting; therefore, the data from KDPH are likely underestimates. Third, laboratory data were limited to a single commercial laboratory and thus might not represent the United States and Kentucky populations.

Finally, HCV-infected mothers cannot be linked to their children using laboratory data, and information on children’s age in the laboratory data are limited, making it difficult to determine whether children are appropriately tested and have current infection; thus, HCV detection rates among children aged ≤2 years were not included in this report.

These findings underscore the importance of providing primary prevention services (7) and following current recommendations to identify persons at risk for HCV infection and test accordingly; doing so among pregnant women would improve early identification of HCV-infected infants and linkage of the mother and infant to care and treatment. Furthermore, identifying HCV-infected women of childbearing age before pregnancy, with linkage to care, treatment, and cure, would avoid HCV infection during pregnancy and prevent mother-to-child transmission. Expanding current and developing new public health policies to increase HCV detection among women of childbearing age (especially pregnant women) and infants should be considered; however, additional data are needed to better assess HCV prevalence among pregnant women and their infants and investigate options for perinatal prevention, care, and treatment.

Summary

What is already known about this topic?

Illicit injection drug use is a risk factor for hepatitis C virus (HCV) infection; recent increases in injection drug use and increases in incidence of HCV infection among young persons have been observed in the United States.

What is added by this report?
During 2011–2014, increased rates of HCV detection (antibody or RNA positivity) among women of childbearing age and HCV testing (antibody or RNA) among children aged ≤2 years were observed both nationally and for Kentucky (22% and 14%, nationally; >200% and 151%, Kentucky). During the same period, birth certificate data showed the proportion of infants born to HCV-infected mothers increased 68% nationally and 124% in Kentucky.

What are the implications for public health practice?
Increased HCV testing of pregnant women, harmonized testing guidelines for children born to HCV-infected women, and adoption of a standardized perinatal HCV case definition might improve early identification of infants born to HCV-infected women and subsequent linkage of the mother and infant to care and treatment to prevent HCV-related sequelae.

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