Hepatitis C, Perinatal Infection

Does not include acute or chronic hepatitis C.

Reporting Information

Class B

Report a case, suspected case, and/or positive laboratory result to the local public health department in which the patient resides by the close of the next business day. If patient residence is unknown, report to the local public health department in which the reporting healthcare provider or laboratory is located.

Reporting Form(s) and/or Mechanism

The Ohio Disease Reporting System (ODRS) should be used to report cases and lab findings to the Ohio Department of Health (ODH). For healthcare providers without access to ODRS, the Ohio Confidential Reportable Disease Form (HEA 3334) may be used.

The Positive Laboratory Findings for Reportable Disease Form (HEA 3333) may be used for laboratories without access to ODRS or electronic laboratory reporting (ELR) to report positive results.

The Viral Hepatitis Case Report (CDC OMB 0920-0728) is available for use by the local public health department when following up with cases. Do not send this form to ODH unless otherwise requested; information collected from the form should be entered into ODRS where fields are available.

Agent

Hepatitis C virus (HCV) is classified in the Flaviviridae family and, until recently, was the only member of the Hepacivirus genus. Hepatitis C virus is a single-stranded, positive-sense RNA virus, 55-65 nm in diameter. At least 7 different genotypes and more than 80 subtypes of hepatitis C virus exist. In the United States, the most common genotype is genotype 1 (about 70%).

Case Definition

Background

Screening recommendations and interpretation of perinatal hepatitis C virus (HCV) laboratory test results for infants born to HCV-infected mothers differ from those for adolescents and adults. There has been a reported increase of HCV infection among women of childbearing age in numerous jurisdictions in the United States, and overall rates of HCV infection during pregnancy have increased 20% from 2016-2020 as a result. While there are no measures currently recommended for prevention of HCV transmission by pregnant women to their infants, HCV in pediatric populations can lead to significant illness and it is important for those children to be appropriately assessed and in clinical care for HCV infection. Available curative HCV therapies are not currently recommended for pediatric patients under the age of 12, but that may change as data become available on the use of recently approved medications in younger pediatric populations.

There is no one standard HCV screening recommendation for infants born to HCV infected mothers. Available guidelines consistently recommend against antibody testing for children under 18 months of age due to transient maternal HCV antibody that may not reflect actual infection status of the child. However, there are multiple recommended timelines for HCV ribonucleic acid (RNA) screening of infants born to HCV-infected mothers. These include not testing until at least two months of age and, in some cases, recommending repeat serial testing of infants if an infant tests positive on one test, if done before 12 months of age. There is concern that testing outside of recommended parameters may identify transient HCV RNA in infants that may spontaneously clear the infection following perinatal exposure. Inappropriate testing and loss of follow-up of infants born to HCV-infected mothers has been reported.

Due to the increasing occurrence of HCV infections in people of reproductive age, as of 2020 the CDC recommends HCV screening for all pregnant people once during each pregnancy, regardless of risk factor history.

Clinical Criteria

Perinatal hepatitis C in in pediatric patients may range from asymptomatic to fulminant hepatitis.

Laboratory Criteria for Diagnosis

• HCV RNA positive test results for infants between 2 to 36 months of age; OR
• HCV genotype test results for infants between 2 to 36 months age; OR
• HCV antigen test results for infants between 2 to 36 months of age.

Epidemiologic Linkage

Maternal infection with HCV of any duration, if known. Not known to have been exposed to HCV via a mechanism other than perinatal (e.g., not acquired via healthcare).

Case Classification

Confirmed

Infant who has a positive test for HCV RNA nucleic acid test (NAT), HCV antigen, or detectable HCV genotype at ≥2 months and ≤36 months of age AND is not known to have been exposed to HCV via a mechanism other than perinatal.

Criteria to Distinguish a New Case from an Existing Case

Test results prior to 2 months of age should not be used for classification. Test results after 36 months of age should be reported under the 2016 acute and chronic HCV infection case definition (15-ID-03) and not as perinatal HCV infection. Cases in the specified age range that are known to have been exposed to HCV via healthcare and not perinatally should be reported under the 2015 position statement. Event date should be based on earliest relevant laboratory test date within the 2- to 36-month window.

Comments

If a child reported as a perinatal case of HCV continues to have positive HCV RNA NAT, HCV antigen, or detectable HCV genotype when they are older than 36 months, they are considered a chronic case of HCV. A chronic HCV reportable condition should be created in ODRS for continued positive test results after 36 months of age.

Signs and Symptoms

Most infants infected with HCV at birth have no symptoms and do well during childhood.

Diagnosis

As infants will have maternal antibodies to HCV, they should not be tested using the antibody test until 18 months of age or later. If an earlier diagnosis is desired or an infant is perinatally exposed, the infant should be tested with the HCV RNA test beginning at 2 months of age.

Test Name Abbreviations

Epidemiology

Source

Hepatitis C virus (HCV) is found in human blood and blood products. It can be transmitted at the time of birth from mother to infant. There is currently no treatment to prevent vertical transmission from occurring.

Occurrence

Hepatitis C infection is prevalent throughout the world and is the most common chronic bloodborne infection in the United States. Approximately 6 of every 100 infants born to HCV-infected mothers become infected with the virus.

The rate of women of childbearing age (WCBA) testing positive for hepatitis C increased by 22% across the United States between 2011 and 2014 (from 139 to 169 per 100,000 WCBA), according to a new report from the Centers for Disease Control and Prevention (CDC). Over the same time period, the national rate of infants born to women living with hepatitis C increased by 68% (from 0.19% to 0.32%). In Ohio, if the perinatal HCV case definition were to be applied to cases reported in 2017, there would have been 33 perinatal HCV cases at a rate of 0.28 per 100,000.

In 2021, the states with the highest number of reported perinatal HCV cases were Ohio, Pennsylvania, Indiana, and Tennessee.

The risk is increased by the presence of maternal HCV viremia at delivery and is 2 to 3 times greater if the woman is coinfected with HIV. Most infants infected with HCV at birth have no symptoms and do well during childhood. More research is needed to find out the long-term effects of perinatal HCV infection.

Public Health Management

Case

Treatment

New direct acting antiviral treatments for hepatitis C are not approved for use in those under 12 years of age, including newborns and infants.

For acute hepatitis C virus (HCV) infection, supportive care is the mainstay of treatment. Early initiation of antiviral therapy is not defined. In chronic HCV infection, the goal is to identify complications and suitable candidates for antiviral therapy. The purpose of antiviral therapy is to ameliorate symptoms and reduce the risk of progressive liver disease.

Consultation with a gastroenterologist may be indicated. Long-term monitoring is essential because the risk of liver cancer is still high, even in sustained virologic responders. In children, a well-defined interval for monitoring is not known, but every 6 to 12 months is probably reasonable to assess alanine aminotransferase (ALT) levels and clinical status. Serum ALT levels have no consistent relationship to liver histologic findings. Longitudinal assessment of hepatitis C virus RNA provides a strong correlation with liver histologic results but is a weaker predictor of rate of progression.

Prevention and Control

Vaccination

There is no vaccine for hepatitis C.

Special Information

Questions about reporting, surveillance, and epidemiology for perinatal hepatitis C or requests for data should be directed to the ODH Hepatitis Surveillance Program at (614) 387-2722.

Questions about the testing, prevention, and control of perinatal hepatitis C should be directed to the ODH Hepatitis Prevention Program at (614) 387-2722.

Many excellent fact sheets and other resources are available at the Centers for Disease Control and Prevention (CDC) Hepatitis website.