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
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,
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.”