CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children - United States, 2023

Abstract

The elimination of hepatitis C is a national priority (https://www.hhs.gov/sites/default/files/Viral-Hepatitis-National-Strategic-Plan-2021-2025.pdf). During 2010-2021, hepatitis C virus (HCV) acute and chronic infections (hereinafter referred to as HCV infections) increased in the United States, consequences of which include cirrhosis, liver cancer, and death. Rates of acute infections more than tripled among reproductive-aged persons during this time (from 0.8 to 2.5 per 100,000 population among persons aged 20-29 years and from 0.6 to 3.5 among persons aged 30-39 years). Because acute HCV infection can lead to chronic infection, this has resulted in increasing rates of HCV infections during pregnancy. Approximately 6%-7% of perinatally exposed (i.e., exposed during pregnancy or delivery) infants and children will acquire HCV infection. Curative direct-acting antiviral therapy is approved by the Food and Drug Administration for persons aged ≥3 years. However, many perinatally infected children are not tested or linked to care. In 2020, because of continued increases in HCV infections in the United States, CDC released universal screening recommendations for adults, which included recommendations for screening for pregnant persons during each pregnancy (Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC recommendations for hepatitis C screening among adults-United States, 2020. MMWR Recomm Rep 2020;69[No. RR-2]:1-17). This report introduces four new CDC recommendations: 1) HCV testing of all perinatally exposed infants with a nucleic acid test (NAT) for detection of HCV RNA at age 2-6 months; 2) consultation with a health care provider with expertise in pediatric hepatitis C management for all infants and children with detectable HCV RNA; 3) perinatally exposed infants and children with an undetectable HCV RNA result at or after age 2 months do not require further follow-up unless clinically warranted; and 4) a NAT for HCV RNA is recommended for perinatally exposed infants and children aged 7-17 months who previously have not been tested, and a hepatitis C virus antibody (anti-HCV) test followed by a reflex NAT for HCV RNA (when anti-HCV is reactive) is recommended for perinatally exposed children aged ≥18 months who previously have not been tested. Proper identification of perinatally infected children, referral to care, and curative treatment are critical to achieving the goal of hepatitis C elimination.

FIGURE 1

Rates* of laboratory confirmed acute hepatitis C virus infection,^† by age group — United States, 2006–2021^§,¶ Source: National Notifiable Diseases Surveillance System, CDC. * Rates per 100,000 population. ^† Reported confirmed cases. For the case definition, see https://ndc.services.cdc.gov/conditions/hepatitis-c-acute/. ^§ The number of viral hepatitis cases reported to CDC in 2020 and 2021 might be lower than in years before the COVID-19 pandemic began. The decrease might be related to fewer people seeking health care and being tested for viral hepatitis during the COVID-19 pandemic. ^¶ Changes in case definitions should be considered when examining temporal trends. For more information regarding the case definitions used in 2021, see https://www.cdc.gov/nndss/index.html.

FIGURE 2

Number of laboratory confirmed* chronic hepatitis C virus infection cases,^† by sex and age — United States, 2021^§,¶ Source: National Notifiable Diseases Surveillance System, CDC. * During 2021, cases of chronic hepatitis C were either not reportable by law, statute, or regulation; not reported; or unavailable to CDC from Arizona, District of Columbia, Hawaii, Indiana, Kentucky, North Carolina, Rhode Island, and Texas. ^† Only laboratory confirmed, newly diagnosed, chronic hepatitis C cases are included. For the case definition, see https://ndc.services.cdc.gov/conditions/hepatitis-c-chronic/. ^§ The number of viral hepatitis cases reported to CDC in 2020 and 2021 might be lower than in years before the COVID-19 pandemic began. The decrease might be related to fewer people seeking health care and being tested for viral hepatitis during the COVID-19 pandemic. ^¶ Changes in case definitions should be considered when examining temporal trends. For more information regarding the case definitions used in 2021, see https://www.cdc.gov/nndss/index.html.

FIGURE 3

Algorithm for hepatitis C virus testing of perinatally exposed children — United States, 2023*^,†,§,¶ Abbreviations: FDA = Food and Drug Administration; HCV = hepatitis C virus; NAT = nucleic acid test. * Perinatally exposed children are children born to pregnant persons with HCV infection. ^† Perinatally exposed children aged 7–17 months who have not previously been tested also should receive a NAT for HCV RNA. ^§ Off-label use of an FDA-approved diagnostic test requires validation by the testing laboratory. ^¶ No further follow-up needed after a negative HCV RNA performed at age 2–6 months unless clinically warranted (i.e., clinical symptoms or signs or laboratory findings consistent with hepatitis C).

FIGURE 4

Algorithm for hepatitis C virus testing of perinatally exposed children* aged ≥18 months who have not previously been tested^† — United States, 2023 Abbreviations: anti-HCV = hepatitis C virus antibody; HCV = hepatitis C virus; NAT = nucleic acid test. * Perinatally exposed children are children born to pregnant persons with HCV infection. ^† Not tested for perinatal HCV transmission with a NAT for HCV RNA at age 2–17 months.