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Hepatitis C in 2020: a North American Society for Pediatric SOCIETY PAPER Hepatitis C in 2020: A North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper ÃDaniel H. Leung, yJames E. Squires, zRavi Jhaveri, §Nanda Kerkar, jjChuan-Hao Lin, ôParvathi Mohan, #Karen F. Murray, ÃÃRegino P. Gonzalez-Peralta, yyEve A. Roberts, and zzShikha S. Sundaram ABSTRACT 09/01/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3IJrtBKuSsQVsKRVaZGM1l4DvatJ7+0OA9ytY7fNKvII= by https://journals.lww.com/jpgn from Downloaded Downloaded medications, known as direct-acting antivirals (DAAs) which target these In 1989, a collaboration between the Centers for Disease Control (CDC) and proteins, were introduced to treat HCV infection. These highly effective from a California biotechnology company identified the hepatitis C virus (HCV, antiviral agents are now approved for use in children as young as 3 years of https://journals.lww.com/jpgn formerly known as non-A, non-B hepatitis virus) as the causative agent in the age and have demonstrated sustained virologic responses exceeding 90% in epidemic of silent posttransfusion hepatitis resulting in cirrhosis. We now most genotypes. Although tremendous scientific progress has been made, the know that, the HCV genome is a 9.6 kb positive, single-stranded RNA. A incidence of acute HCV infections has increased by 4-fold since 2005, single open reading frame encodes a 3011 amino acid residue polyprotein compounded in the last decade by a surge in opioid and intravenous drug use. that undergoes proteolysis to yield 10 individual gene products, consisting of Unfortunately, awareness of this deadly hepatotropic virus among members by 3 structural proteins (core and envelope glycoproteins E1 and E2) and 7 BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3IJrtBKuSsQVsKRVaZGM1l4DvatJ7+0OA9ytY7fNKvII= of the lay public remains limited. Patient education, advocacy, and counsel- nonstructural (NS) proteins (p7, NS2, NS3, NS4A, NS4B, NS5A, and ing must, therefore, complement the availability of curative treatments NS5B), which participate in posttranslational proteolytic processing and against HCV infection if this virus is to be eradicated. replication of HCV genetic material. Less than 25 years later, a new class of Key Words: hepatitis C, direct-acting antivirals, treatment, diagnosis, prevention Received December 24, 2019; accepted April 7, 2020. From the ÃDivision of Pediatric Gastroenterology, Hepatology, Nutrition, An infographic for this article is available at: http://links.lww.com/ Department of Pediatrics, Baylor College of Medicine,Texas Children’s MPG/B869. Hospital, Houston, TX, the yUPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, the zAnn & Robert H. Lurie Children’s Hospital of (JPGN 2020;71: 407–417) Chicago, the §Golisano Children’s Hospital, University of Rochester Medical Center, Rochester, NY, the jjChildren’s Hospital of Los Angeles, Los Angeles, CA, the ôChildren’s National Hospital, Washing- ton, DC, the #Cleveland Clinic Children’s Hospital, Cleveland, OH, the EPIDEMIOLOGY ÃÃAdventHealth for Children, AdventHealth Transplant Institute, he global disease burden of HCV infection in the pediatric yy Orlando, FL, the University of Toronto, Hospital for Sick Children, population is estimated to be approximately 5 million children Toronto, Ontario, Canada, and the zzChildren’s Hospital of Colorado, T Digestive Health Institute, University of Colorado School of Medicine, and adolescents (1). Prevalence rates are rising, ranging from 0.05% Aurora, CO. to 0.36% in the United States and Europe to 1.8% to 5.8% in certain Address correspondence and reprint requests to Shikha S. Sundaram, MD, developing countries, including Mexico (2,3). These reports likely MSCI, Children’s Hospital Colorado, University of Colorado School of underestimate the true prevalence, given that current ascertainment Medicine, 13123 E 16th Ave, Aurora, CO 80045 practices enable identification of only 4.9% of expected pediatric (e-mail: [email protected]). cases of HCV infection (4). Six distinct HCV genotypes have been This article has been developed as a Journal CME and MOC Part II Activity identified with significant global variation. In adults, genotypes 1 by NASPGHAN. Visit https://learnonline.naspghan.org/ to view instruc- and 2 constitute most infections in Western countries. Genotype 3 is tions, documentation, and the complete necessary steps to receive CME widely distributed in South and East Asia but is also prominent in and MOC credits for reading this article. on European countries and the United States; genotype 4 in North 09/01/2020 Disclosures: D.H.L., grant/research support: Gilead, Abbvie, CF Founda- tion; Advisory Panel: Gilead, Merck. R.J., grant support: Gilead, Abbvie, Africa and the Middle-East; genotype 5 in South Africa, and Merck; Advisory Board: MedImmune, Saol Therapeutics, Hologic, genotype 6 in Asia (5,6). Whenever reported, affected children Seqirus. R.G.-P., grant support: Gilead, Abbvie, Merck, Alexion, appear to demonstrate regional distribution patterns similar to those Axcella; Advisory Panel: Alexion, GMP-orphan, Gilead. K Murray: described in adults. Consulting: Gilead, and Albireo. C.H.L., Gilead, Research grant support Historically considered a transfusion-related disease in chil- and Advisory panel. N.K., Advisory Panel: HighTide. S.S., Intercept dren, modern blood-bank screening practices have nearly elimi- Scientific Advisory Board. P.M., grant support: Gilead. nated the risk of transfusion-transmitted HCV infection (7,8). Supplemental digital content is available for this article. Direct URL Currently, mother-to-child transmission (MTCT) during the peri- citations appear in the printed text, and links to the digital files are natal period is regarded as the most common mode of infection in provided in the HTML text of this article on the journal’s Web site (www.jpgn.org). children (9). Furthermore, it appears that the transmission occurs Copyright # 2020 by European Society for Pediatric Gastroenterology, variably during the course of pregnancy and delivery, with 31% of Hepatology, and Nutrition and North American Society for Pediatric transmissions occurring in utero and 50% to 79% during the Gastroenterology, Hepatology, and Nutrition peripartum period (10,11). The pattern of virologic, clinical, and DOI: 10.1097/MPG.0000000000002814 serological events in children with perinatally acquired HCV JPGN Volume 71, Number 3, September 2020 407 Copyright © ESPGHAN and NASPGHAN. All rights reserved. Leung et al JPGN Volume 71, Number 3, September 2020 HCV RNA hepatitis C is rare (28,29), with only a single case of HCV-induced acute liver failure reported out of 986 children enrolled into the Infant antibody Pediatric Acute Liver Failure Study Group database (30). Typically, children and adolescents develop chronic HCV infection, defined as the persistence of detectable serum HCV RNA ALT for 6 months (31,32). Children with chronic hepatitis C are most often asymptomatic, although mild, nonspecific symptoms, such as fatigue and abdominal pain associated with chronic infection and ALT hepatomegaly may be found on physical examination (33). Bio- chemically, the majority of HCV-infected children have intermit- Antibody (Anti-HCV) Titer Antibody (Anti-HCV) 40 IU/L tent or persistent mild aminotransferase elevations (Fig. 1), which Maternal antibody do not correlate with histological severity (32). Histologically, hepatocellular inflammation is mild, but severe inflammation is 0 1122334 5 4 described in 3%, moderate fibrosis in 4%, and bridging fibrosis or Months Years cirrhosis in 2% to 12% (34–36) of infected individuals. Extrahe- Time after Perinatal Exposure patic manifestations of chronic hepatitis C, including membrano- FIGURE 1. Pattern of virologic, clinical, and serological events in proliferative glomerulonephritis, thyroid dysfunction with or children with perinatal hepatitis C virus infection. Following perinatal without thyroid autoimmune disease, and the development of acquisition (time 0), serum alanine aminotransferase (ALT) levels nonorgan specific antibodies, are exceedingly rare (37–42). increase, indicating the onset of clinical hepatitis. A chronic undulant pattern often emerges reflecting ongoing infection. Maternal circu- NATURAL HISTORY OF HEPATITIS C VIRUS lating antibody to HCV begins to decline in the first weeks of life, with complete resolution by 18 to 24 months of age. Divergently, the INFECTION IN CHILDREN AND ADOLESCENTS appearance of anti-HCV produced by the infant occurs shortly after Progression of chronic hepatitis C in children and adoles- infection; however, it is indistinguishable from maternal antibody. cents may follow several different routes. Spontaneous resolution of Polymerase chain reaction can detect HCV within several weeks of viremia (viral clearance) (43,44) is estimated to occur in approxi- exposure and will persist barring spontaneous viral clearance. HCV ¼ mately 20% of acutely infected adults (45–47) and in 25% to 40% hepatitis C virus. of children with MTCT, usually by age 2 (48), especially in children with higher serum ALT levels (29,44,49–53). Over age 2 years, 6% to 12% of children may still spontaneously clear the virus before adulthood (29,35,48,54–56). Spontaneous viral clearance is con- infection is shown in Figure 1. Although the rate of MTCT of HCV sidered a permanent state, essentially a ‘‘cure’’ of the HCV infec- has remained stable at 5% to 6%, the incidence of HCV infection tion, with rare (<1%)
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