All pregnant women in the United States should be screened for hepatitis C, say specialists

20 Sep 2018 Keith Alcorn
Originally published on www.infohep.org

Hepatitis C specialists from several of the largest medical schools in the United States say that changes in the epidemiology of hepatitis C over the past decade make it essential to switch to a policy of universal screening in pregnant women. Their recommendation is published as a 'Viewpoint' article in the journal Clinical Infectious Diseases.

They point to the recent increase in hepatitis C diagnoses among young white, non-urban drug users in states such as Indiana and Kentucky.

A 2017 study by the US Centers for Disease Control and Prevention estimated that between 1.25% and 1.63% of pregnant women were hepatitis C virus (HCV) antibody positive in the United States. The study concluded that around 29,000 women with HCV gave birth each year and 1700 infants had HCV infection.

Current guidance from the Society of Maternal-Fetal Medicine and the American College of Obstetrics and Gynecology is that pregnant women should be screened for hepatitis C if they report risk factors for hepatitis C such as a history of injecting drug use.

But the authors of the Viewpoint say that too many cases of hepatitis C are being missed because healthcare providers fail to ask about potential risk factors and pregnant women may not wish to disclose information about drug use.

On the other hand, pregnant women are more likely than others to accept testing and remain engaged in care owing to concerns about the health of their unborn child, say the authors. Furthermore, a maternal HCV diagnosis is likely to lead to testing of HCV-exposed infants and of partners. Harm reduction counselling could also be provided for current drug users.

Diagnosis during pregnancy would also allow changes in obstetrical practice to avoid invasive procedures that might increase the risk of HCV transmission.

As blood is already sampled for blood typing, rubella, hepatitis B and HIV testing in pregnancy, adding a test for hepatitis C would not impose any additional burden on pregnant women or healthcare providers. Screening is likely to be cost-effective since the prevalence of HCV is higher than for other screening tests in pregnancy already proven to be cost-effective, notably HIV infection.

The strongest argument for screening, say the authors, is that women cannot benefit from curative treatment until they have been diagnosed. At the moment, no direct-acting antivirals are licensed for use during pregnancy (although an ongoing clinical trial is testing the regimen of sofosbuvir/ledipasvir (Harvoni) in pregnant women). If women were diagnosed during pregnancy, an 8-week regimen has the potential to cure HCV and prevent HCV transmission to the unborn child, before delivery.

What’s more, say the authors, until universal screening uncovers the true extent of HCV infection in pregnant women and providers demand treatment for women during pregnancy, “pharmaceutical companies will not consider this population for therapy.”

“In the current era of injection drug use and increasing HCV cases, the best public health strategy to reduce the prevalence and incidence of HCV is identification and treatment of as many young adults as possible to reduce the reservoir of individuals able to infect others.”