Hepatitis C in Children

—Alan Franciscus, Editor-in-Chief

It is estimated that Hepatitis C (HCV) occurs in about 0.15% of 6-11 year-olds and 0.4% of 12-19 year-olds.  It is estimated that there are 23,000 to 46,000 children in the US with HCV.1  The actual number of children with HCV is unknown because children are not routinely tested for it.

Prior to 1992, the most common transmission route for HCV in children was through blood transfusion, blood products, and organ transplantation.  Now that blood products and organs are screened for hepatitis C the most frequent transmission of hepatitis C in infants is mother-to-child transmission.  The second most common transmission route in children and teenagers is in those who share equipment to inject drugs (needles, cookers, cotton, water, etc.)

Transmission of HCV from an HCV-infected mother-to-infant occurs about 6% of the time.  It can occur up to 10% of the time if a mother is coinfected with HIV and hepatitis C.  Also, a high viral load increases the risk of mother-to-infant transmission.   Unfortunately, there are no effective strategies or drugs to prevent the transmission of HCV from mother to child.  

When a baby is born to an HCV-infected mother, the child will acquire the mother’s HCV antibodies. For this reason, the child will not be tested for HCV antibodies for 18 months.  This is the period that it takes for the baby’s body to clear out the mother’s antibodies.
An HCV RNA or viral load test can be given as early as one month.  It might be too early since the HCV RNA, or viral load fluctuates during the acute infection phase.  Also, babies have a high rate of natural clearance.  Most medical providers prefer to wait out the 18-month period to test for HCV antibodies and the confirmatory HCV RNA (viral load test).

Table 1.  Children for whom screening is recommended.

• Children and adolescents with unexplained elevated aminotransferasesChildren at risk for vertically acquired HCV
• Children from regions with high prevalence of HCV (adoptees, refugees, immigrants)
• Children and adolescents with HIV
• Children or adolescents who are victims of sexual assault
• Adolescents with multiple sexual partners
• Adolescents who are or were intravenous drug users, even if only once in the past
• Children or adolescents who have ever been on dialysis
• Sexual partner of HCV-infected person
• Children or adolescent who have received needle stick (needles, piercing or tattooing)*

Source:  Mack CL1, Gonzalez-Peralta RP, Gupta N, et al. NASPGHAN practice guidelines:
Diagnosis and management of hepatitis C infection in infants, children, and adolescents Pediatric Gastroenterol, Nutr 2012;54:838-855

Baker R. Viral Hepatitis. In: Pohl JF, editor. Pediatric Gastroenterology. Baton Rougue, FL: CRC Press: 2014.  pp 313-327

*I read this recommendation with interest because we know that receiving a tattoo or piercing in a commercial parlor is safe.  .

Chronic Infection
Approximately 75% of infants who are acutely infected with hepatitis C will continue to chronic infection.  In children, the rate of disease progression is slow.  There is, however, a small percentage (estimated at less than 2%) of children in whom there is a rapid rate of disease progression that could lead to fibrosis and cirrhosis.

Watch, Wait and Protect
A baby born to an HCV-infected mother should receive the hepatitis A and hepatitis B vaccines to protect the child from becoming infected with another liver disease.  As well the baby and child should receive other immunizations to protect the health of the child.

Hepatitis C is not spread by casual contact and infected children should not be restricted from attending daycare or school.  Children should be taught that they should not share toothbrushes, nail clippers, razors or any other items that have the potential to transmit hepatitis C.

Any drug, herb or supplement that the child is given should be screened to make sure that it is liver safe.  When the child is older, a discussion should take place about sex, drugs, and alcohol.

Most importantly, a child should be medically monitored on a regular basis.

When to Tell a Child
Telling a child that they have hepatitis C can be one of the most difficult decisions a parent can ever make.  The timing is the most important decision.  The best advice is never to lie to a child.  We have an excellent fact sheet that can provide plenty of advice to parents.  http://hcvadvocate.org/hepatitis/factsheets_pdf/TellChild_HCV.pdf

Treatment
As stated above most children have a slowly progressive disease.  For the small percentage that have severe fibrosis or cirrhosis, immediate treatment may be needed.   The decision to treat or not is never easy and in children it is even more difficult.  Some questions that are important to consider include:

• Can treatment be postponed until the interferon-free therapies are available?
• Is there an interferon-free clinical trial that your child can enroll in?
• Are you and your child ready to take on interferon treatment and the side effects?
• The new medications are very expensive—there is always the possibility that your insurance company may not cover the new medications.

Current treatment of pegylated interferon plus ribavirin is approved for children who are three years and older with compensated cirrhosis.

Again, most children have slowly progressive disease, and it takes decades before serious liver disease develops.  By this time, children will age to adults and be eligible for interferon- and ribavirin-free therapies that approach 100% effectiveness.

The Future
Hepatitis C infections are on the rise.  The so-called Second Epidemic of hepatitis C is affecting females equally as males.  As a result, there will be many women of child-bearing age that will become pregnant and have children who may also have hepatitis C.

For the first time, there is an opportunity to prevent mother-to-child transmission. Direct-acting antiviral medications without ribavirin that are pregnancy category B.

Pregnancy Category B: In humans, there are no well-controlled studies. However, in animal studies, pregnant animals received the medicine, and the babies did not show any problems related to the medicine.

However, there have not been any clinical studies using the interferon- and ribavirin-free medications in pregnant women.  As a result, studies are needed to evaluate the safety and effectiveness of these new drugs for the mother and the infant.

1American Liver Foundation
Source:  Hepatitis C in Children in Times of Changes, Robert D. Baker and Susan S. Baker Walters Kluwer Health, Inc.

Two Current Fronts of the American Health Care Wars: Hepatitis C and Cancer

The Pharmaceutical Industry, Health Insurance and Recurrent Questions of Extortion, Murder and Evil

Asking patients to delay treatment for hepatitis C is like asking patients to delay treatment for diabetes or cancer.

"Waiting for cirrhosis to happen to treat HCV is like waiting for cancer to metastasize or for diabetes to cause complications before treating it. In reality, all cause mortality and per patient per year health care costs are tripled for patients with hepatitis C, whether they have cirrhosis or not."

-- Dr. Douglas Dieterich, leading hepatitis C and liver diseases researcher and specialist at the Mount Sinai Hospital, New York City

My friend John is a retired college professor who lives on a budget. He has hepatitis C, which he acquired from a blood transfusion before the development of blood testing and screening for hep C. He does have health insurance, but like most of those seeking treatment for this condition, he has been told that he must become demonstrably sicker to qualify for treatment coverage. Meanwhile, he must not drink any alcohol and remain vigilant for symptoms, especially fatigue. Since the progression of hepatitis C to cirrhosis of the liver and cancer of the liver can take decades, and John has already had this disease for decades, he is understandably concerned. In fact, he may die sooner from other causes, his untreated hepatitis C playing an indeterminate role. There is, however, an alternative for John. If he had the $100,000+ in cash to pay for the treatment now, he could be fully and safely cured in 8-12 weeks. John does not identify himself as a socialist, and he is willing to pay what he can for treatment, but the cost in this case is overwhelming.

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EASL 2015: Hepatitis C screening essential to help catch patients with advanced liver fibrosis

Research validates the current recommendation that screening for hepatitis C, particularly among high-risk groups, is vital.

April 25, 2015, Vienna, Austria: Study results presented today at The International Liver Congress™ 2015 show that the occurrence of advanced liver fibrosis is similar for patients infected with the hepatitis C virus (HCV), whether or not they have been diagnosed.

Most individuals with HCV remain asymptomatic, which makes the diagnosis difficult. The study authors used the hypothesis that individuals whose HCV is not diagnosed are less likely to have advanced fibrosis than those who have been diagnosed. They then compared liver fibrosis between respondents of the National Health and Nutrition Examination Survey (NHANES) in the USA, in patients with diagnosed and undiagnosed HCV infection.

Of the respondents with known HCV infection, the proportion with a high, intermediate and low probability of advanced fibrosis was 14.5%, 40.3%, 45.2%, respectively; in those with undiagnosed HCV the results were 19.1%, 30.9%, 50.0%, respectively.

The study highlights that even if people are unaware they are infected with HCV, the virus affects their liver in the same way, resulting in advanced fibrosis. These results validate the current recommendation that screening for HCV, particularly among high-risk groups, is vital.

Read complete press release here....

Caffeinated drinks associated with decreased risk of liver scarring

Modest daily consumption of caffeinated drinks is associated with less advanced liver scarring in people with hepatitis C, according to a recent study by Baylor College of Medicine researchers that appears online in the journal Clinical Gastroenterology and Hepatology.

Dr. Hashem El-Serag, chief of gastroenterology and hepatology at Baylor and at the Michael E. DeBakey Veterans Affairs Medical Center and lead author of the study, said the results showed that the risk of liver scarring in hepatitis C patients was decreased when individuals regularly consumed caffeinated coffee, and to a lesser extent tea and soda.

“We found that participants who drank caffeinated coffee daily had the best results,” he said. “This is most likely do to the fact that one coffee drink has more caffeine than tea or sodas.”

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See Also: The Five: Coffee

Deferring hepatitis C treatment can lead to liver cancer and death, despite cure

HIV/HCV coinfected people who delay hepatitis C treatment remain at risk for liver failure, hepatocellular carcinoma and liver-related death even after being cured – with outcomes worsening the longer it is put off  – indicating that treatment should not be deferred until advanced disease, according to a presentation at the 2015 Conference on Retroviruses and Opportunistic Infections (CROI) last week in Seattle. Treating only after progression to cirrhosis increased the risk of liver-related death by more than five-fold and the duration of infectiousness by four-fold.

Over years or decades chronic hepatitis C virus (HCV) infection can lead to advanced liver disease including cirrhosis (scarring), hepatocellular carcinoma (HCC; a type of primary liver cancer) and end-stage liver failure. People with HIV/HCV coinfection experience faster disease progression, on average, than those with HCV alone. Successful hepatitis C treatment reduces - but does not eliminate - the risk.

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