Universal hepatitis C screening for younger adults may be the next essential step in eradicating the infection suggests pediatric ID specialist Claudia Espinosa, MD, MSc.
Q. Hepatitis C is sometimes perceived as predominantly a disease of older people. How is that changing?Dr Espinosa: "Traditionally, we have seen a high prevalence in the baby boomer population due to many transmissions that probably happened between the 1960s and 1980s, before the hepatitis C virus was identified. Now, the new epidemic of IV drug use is driving the changes in the epidemiology for hepatitis C. Many of these are young people, are likely to be white and live in rural areas.
"Because of the drug use epidemic, we also have more women of childbearing age and pregnant women who are infected with HCV that could transmit the infection to their babies. We see young teenagers who may be affected because of the same reason, and I also know from working with our adult gastroenterologists that there have been so many young patients that are already having symptoms of chronic disease, and they don’t have risk factors-they don't do drugs, but they may have been infected perinatally from their mothers, or maybe some household member had the infection, and they have been undiagnosed for many years, increasing the chances of worse liver disease by the time they seek medical attention.
"We are learning more and more about the prevalence of HCV in young people now that we are increasing the screening here in Kentucky, which makes me wonder how many more states who are not doing the screening maybe have the same problem."
Q. How significant is this issue in areas like Kentucky? What are you seeing in terms of HCV prevalence in younger people?
Dr Espinosa: We have done some research with a large health system here in Kentucky looking at the odds of having a positive HCV antibody or viral RNA test in adults. We found that the chances that we’re going to see a positive test is essentially doubled in younger adults as compared to baby boomers, and that’s just with risk-based screening of the younger adult cohort.
For the baby boomer population, we have universal screening recommended by the Centers for Disease Control and Prevention (CDC). However, really the ones that are perpetuating the infection are the younger people now, so maybe the guidelines and screening policy need to be changed to include universal screening for younger adults, especially in places like Kentucky where we have a high incidence and prevalence in that population.
Q. Your report notes that sofosbuvir/ledipasvir & sofosbuvir/ribavirin regimens are now approved for individuals as young as age 12 years. How is the treatment landscape changing for young people with HCV? Will there be more regimens approved?
Dr Espinosa: FDA approval was based on studies demonstrating that those medications work as well in children as they do in adults. There is now data showing a very good rate of sustained viral reduction in children as young as 6 years of age.
The treatment really has significantly changed how we look at the disease. Today, we have available to use in adults many of these direct antiviral drugs that are very safe, with few adverse events, and that are highly effective. However, doing clinical trials in children is more complicated than in adults due to different regulations and other issues. As a result, it is taking longer to obtain approval for those antivirals and making them available for children too.
Currently, we are waiting for the approval in children of other antivirals already being used in adults. Clinical trials with several of these antivirals are ongoing, and I know of many of them that are actively recruiting patients.
Q. HCV guidelines recommend universal screening of pregnant women, and now Kentucky has made it the law. What are the potential implications of this new law?
Dr Espinosa: "I am very happy to say that at least here in Kentucky, legislators paid attention to this public health issue and it is now a state law. It is a good thing and the first step to eliminate one day perinatal transmission. However, implementation of this law may pose some challenges for some healthcare systems and I am not sure that they are prepared. Regardless, I really hope that universal screening will help with the identification of infected women that can be treated and cured before the next pregnancy. The law also states that HCV status has to be included permanently in the newborn’s record facilitating identification of those infants that were perinatally exposed to HCV and require further follow up.
"Lack of maternal HCV status information in the baby’s medical record is a problem because perinatally exposed babies sometimes go into foster care, they are adopted, they change names, they change pediatricians, they change environments ... many times those kids may be just lost in the system, but if we make this part of their medical record, we hope that at least someone will notice it and do follow-up."
Q. What kind of an impact could universal screening have?
Dr Espinosa: I really feel that this is the way to go to eliminate HCV infection. There is stigma related to hepatitis C testing and I think stigma makes providers reluctant to do the testing. In addition, some women don't want to have that information in their medical records, and that may be a reason why we are not identifying all affected patients with risk-based screening. Universal screening would reduce those barriers: we are going to do it because it’s necessary, and we don’t have to ask you what you did in the past, who you were hanging out with-many other questions we wouldn’t need to ask to assess risk factors.
Q. What role can primary care providers play in addressing this demographic shift in hepatitis C?
Dr Espinosa: Primary care providers have a big role in the process of HCV eradication in younger populations. There are more young people infected in rural areas than in metro areas. In rural areas, specialists are scarce. Why not train primary care providers in how to treat this infection? Through the KY health department, there is a pilot program in the state called the Kentucky Hepatitis Academic Mentoring Program (KHAMP). KHAMP will train primary care providers in rural areas on how to screen, what tests to do to evaluate liver disease, how to obtain authorization for treatment, and all those other issues related to HCV management, so they become comfortable treating these patients. If we are going to just sit here in the metro area and wait for patients to come, we are not going to be able to treat everybody. We need the providers in the rural areas to combat this epidemic, and I think that by providing more education and support, we are hopefully going to see a decrease in the prevalence of hepatitis C in the state of Kentucky.
To read Dr Espinosa's full study: Espinosa C, Jhaveri R, Barritt AS. Unique challenges of hepatitis C in infants, children, and adolescents. Clin Ther. 2018;40:1299-1307.