Hepatitis C in Children

Hepatitis C infection (HCV) is a chronic viral infection of the liver that affects upwards of 1-2 percent of adults. Fortunately, in children and adolescents, hepatitis C is less common, but it remains a significant health issue. In this article I will address the most common questions about hepatitis C in children and adolescents.

What is the frequency of HCV in children and adolescents?

HCV occurs in about 0.15% of 6-11 year olds and 0.4% of 12-19 year olds. It is estimated that there are 23,000 to 46,000 children in the US with HCV. The recent opioid epidemic is leading to an increasing frequency in adolescents and young adults.

How do children acquire HCV?

Most children are infected with HCV at birth. This is called vertical transmission of infection (from mother to child). If a mother has HCV, her child has a 1 in 20 chance of becoming infected at birth. A high HCV viral load in the mother has a higher the risk of infection to her newborn infant. Interventions at birth, such as C-section delivery, have not been shown to alter the risk of infection at birth.

Adolescents acquire HCV in ways similar to adults by engaging in behaviors that increase their risk of blood exposure, such as IV drug use, sharing needles and high-risk sexual behaviors.

How do you diagnose HCV in children?

In children over 2 years of age, HCV is diagnosed by testing like that used in adults. If a child or adolescent is suspected of having HCV, initial testing is to screen with the anti HCV antibody test that measures protein in the blood that is made by the body to fight germs such as viruses or bacteria. If the antibody test is positive, infection should be confirmed with a direct viral test like HCV PCR.

In infants born to mothers with HCV, the mother’s HCV antibody crosses the placenta like all antibodies and can stay in the blood of an infant for up to 18 months. Therefore, you cannot use the anti-HCV antibody test to screen for HCV in infants less than 18 months of age. The American Academy of Pediatrics (AAP) recommends testing with the antibody test at 18 months or later since treatment of HCV is not recommended for infants less than 3 years of age. Many families are anxious about the risk of infection to their child. In that circumstance, we recommend testing with the HCV viral test like the HCV-PCR. This should not be done until at least 3 months of age due to a high rate of temporarily positive tests in infants under 3 months of age.

What happens to children who are infected with HCV?

The outcome of HCV infection depends somewhat on how the child acquired HCV. For children who acquire the infection by vertical transmission, up to 40% will clear the virus on their own (spontaneous clearance), without treatment by 2 years of age. There are reports of children clearing the virus on their own as late as 7 years of age. This is different than adults, who can also have spontaneous clearance, but virtually never after 6 months after their infection. Those children who do not clear the virus by 2 years of age are considered chronically infected with HCV. In children who acquired the virus by vertical transmission, most have mild liver disease with upwards of 80% with minimal to no scarring of the liver (fibrosis) by 18 years of age. A subset of children, 20-25% can have more aggressive disease and can develop advanced scarring of the liver (cirrhosis) as early as 8 years of age. While HCV is the leading indication for liver transplantation in adults, it is a very rare indication for liver transplantation in children.

In adolescents who acquire HCV by high-risk behaviors, the outcome of HCV is felt to be similar to adults. Upwards of 80% will develop chronic HCV and many of those will go on to develop chronic liver disease with cirrhosis in 20-30 years.

What follow up is needed for a child with HCV?

Since HCV is a rare disorder in children, the AAP and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition recommend that a physician who has experience with Pediatric HCV infection should evaluate children with HCV. This is usually a Pediatric Hepatologist. Most children with HCV have no obvious symptoms or outward effects from HCV. Children with HCV should have ongoing monitoring of growth and nutrition. They should have assessment of their viral load and determination of the genotype of their HCV virus. They should have periodic screening of liver function by blood tests and, at least for those with significant liver disease, periodic screening for liver cancer. Most children have intermittently elevated AST and ALT (liver enzymes). While some children with high AST and ALT will have aggressive liver disease, some children can have aggressive liver disease without major abnormalities in their AST and ALT. Liver biopsy is still the best tool for assessment of scarring in the liver in children, but is usually not needed. There are new methods of determining the degree of scarring in the liver, like transient elastography, in children that are more available.

Children with HCV should receive the hepatitis A and B vaccines. They should receive an annual influenza vaccine.

Families and children should be educated on the risk of HCV transmission and the techniques for avoiding blood exposure such as avoiding sharing toothbrushes, razors and nail clippers and the use of gloves to clean up blood.

Are there any restrictions recommended for children with HCV?

Children who have HCV do not need to be restricted from activities such as sports. Open cuts and abrasions should be covered during sporting activities or when others might come in contact with the wounds. The AAP has recommended that individuals such as coaches and nurses practice universal precautions for all blood-contaminated injuries.

Acetaminophen or ibuprofen in standard doses are generally safe for children with HCV unless they have very advanced liver disease.

What treatments are available for children and adolescents with HCV?

For children ≥12 years of age direct acting antiviral therapy is now approved. This currently includes sofosbuvir with or without ribavirin or the combination of ledipasvir/sofosbuvir. Response rates are similar to those of adults. About 90-95% of children with genotype 1 HCV infection will achieve a sustained viral response (SVR: no virus detected in the blood by HCV-PCR 24 weeks after completing treatment) following 12 weeks of treatment with sofosbuvir/ledipasvir. The side effects of the treatment are minimal and children generally tolerate side effects better than adults and exhibit very minimal changes in their quality of life. The recent advances in the treatment of HCV in adults with the approval of several more interferon free direct acting antiviral regimens has spawned clinical trials of these additional direct acting antiviral treatments in children and adolescents we anticipate results in the next year. The Pediatric Liver Center at Children’s Hospital Colorado has been studying HCV infection and treatments since the early 1990s and remains a leader in the care and research in HCV infection in children.

Which children with HCV should be treated?

There is no simple answer to this question. Treatment in children should be individualized. There are some guidelines that are beginning to emerge. The treatment recommendations are changing rapidly as new treatments become available. See www.hcvguidelines.org/unique-populations/children

Children less than 3 years of age should not be treated except in special circumstances. Children with evidence of aggressive liver disease should be considered for treatment to prevent progression of disease. Children who are ≥12 years old or weigh ≥35 kg with chronic HCV infection should be considered for treatment with direct acting antiviral treatment options that vary depending on genotype.

In all cases, treatment decisions should be individualized to the child and the family.

Where can I get more information about HCV infection in children?

Parents of Kids with Infectious Diseases: pkids.org
Kids Health from Nemours: kidshealth.org
American Liver Foundation: www.liverfoundation.org
Living with Hepatitis C, A survivors Guide by Gregory Everson has a chapter on Pediatric HCV.

Guidelines

See www.hcvguidelines.org for the most up to date recommendations.