CDC updates recommendations for perinatal hepatitis C testing

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In a Morbidity and Mortality Weekly Report (MMWR) published 3 November, the US Centers for Disease Control and Prevention (CDC) issued updated guidelines for perinatal hepatitis C virus (HCV) testing. This is the third set of guidelines concerning screening for perinatally exposed infants and children since perinatal hepatitis C was made a reportable disease in 2018. The updates focus on test types and timing, specifically for perinatally exposed infants and children. These guidelines aim to connect HCV-positive infants and children to care, reduce underreporting by increasing detection and aid HCV elimination in the US.

Hepatitis C is a virus that affects the liver and can be acute or chronic. Most cases of hepatitis C are asymptomatic, which increases the risk of underdiagnosis and underreporting. When present, symptoms include jaundice, nausea, vomiting, abdominal pain, fever, fatigue, dark urine and light stool. Chronic HCV infection can lead to liver complications such as fibrosis, cirrhosis and hepatocellular carcinoma. Hepatitis C is transmitted via contact with infected blood, such as during injection drug use, unprotected sex, blood transfusions and perinatal exposure (in utero, during birth or after birth).

The MMWR notes that cases of acute hepatitis C have been on the rise since 2010 and that in 2021 there were 5,023 reported cases. The CDC estimates there are 69,800 acute cases due to underreporting. Hepatitis C can infect people of all ages, but the largest burden of acute HCV infections has been in people of childbearing age (20–39 years). The CDC reports that the rate of HCV has tripled in this group from 2010–21, which accounts for 52% of acute cases.

Accordingly, rates of HCV infection have also been increasing in pregnant people. Laboratory data from 2011–14 indicated that 0.73% of pregnant people were currently infected with HCV. The MMWR also notes that the rate of HCV infection in pregnant people rose 20% from 2016–20. This may be due to both increased rates of HCV in people aged 20–39 years and increased screening of at-risk people since 2018. HCV in pregnant people has translated to perinatal infections: 6–7% of babies born to pregnant persons with a current HCV infection contract HCV themselves. There were 199 reported cases of perinatal HCV infection in 2021; the CDC asserts that this is likely an underestimation.

In response to this burden of perinatal HCV and to eliminate hepatitis C, the CDC has updated its guidelines on HCV screening. When perinatal hepatitis C first became notifiable in 2018, the guidelines recommended testing for people at risk for HCV infection. In 2020, the CDC updated HCV screening recommendations to include testing for all persons aged 18 years and older “at least once” and one HCV test during each pregnancy. The newest guidelines focus on the babies themselves. All babies born to persons with a current (antibody and RNA-positive) or probable (antibody-positive and RNA-indeterminate) HCV infection are considered perinatally exposed.

The CDC recommends HCV RNA testing for babies ages 2–6 months and for babies aged 7–17 months if not already tested. Previously untested babies ages 18 months and older should receive HCV antibody testing, followed by RNA testing with a positive antibody result. This update will likely increase the number of reported perinatal HCV cases, reduce the proportion of undiagnosed cases and increase rates of care for HCV-infected infants and children.

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Insufficient screening and underreporting do not only affect infants and pregnant people. A recent study examining NHANES data from 2013–18 found that 39.9% of people with HCV infection were not aware of their status. This did not significantly change between sexes, age groups, or over time, indicating a need for increased education and awareness about the virus. GlobalData epidemiologists assert that this new screening guideline will reduce the proportion of undiagnosed hepatitis C cases as well as lower the prevalence of hepatitis C in the population over time.