May 5, 2010 (New Orleans, Louisiana) — The failure to identify hepatitis C virus (HCV) infection in pediatric patients and the subsequent failure to treat it is widespread in Florida and probably in the rest of the United States, which could lead to dire consequences, according to investigators who presented a study here at Digestive Disease Week 2010.
"Based on data from our study, we estimate that among children who are identified as having HCV, the percentage of those being treated for it is unacceptably low. Early identification of pediatric hepatitis C would likely lead to cure in 50% of those who have the virus, which would spare these children from liver damage, as well as possible liver failure, liver cancer, and even early death," said Aymin Delgado-Borrego, MD, from the Department of Pediatrics at the University of Miami in Florida.
Dr. Delgado-Borrego and colleagues selected the state of Florida as the location for the initial study because it is one of the few states that requires reporting of all cases of acute and chronic HCV infection to the state's department of health. Data on all reported cases of HCV infection in Florida from 2000 to 2008 were extracted from the Merlin database, which is used by the state of Florida for surveillance of viral hepatitis and other health conditions.
The investigators are also reviewing data on HCV infection in other states in the United States. Preliminary data suggest that the lack of identification and treatment of HCV infection are not confined to Florida. "In fact, our preliminary findings suggest that the situation is worse in many other states," Dr. Delgado-Borrego reported.
The number of actual cases of pediatric HCV infection reported in Florida from 2000 to 2008 was 1755, representing only 14.4% of the 12,155 expected cases for that period, according to estimates from the National Health and Nutrition Examination Survey (NHANES) and US Census Bureau data.
Only an estimated 150 (1.2%) of the 1755 identified cases of pediatric HCV infection received medical treatment.
"There is a frightening lack of awareness among both the public and clinicians about HCV in pediatric patients," Dr. Delgado-Borrego stated.
Of the total number of expected HCV cases in adults, only 46.3% were reported in the Merlin database during the same time period, she added.
Screening at-risk populations is an important step toward improved identification of pediatric HCV infection. Dr. Delgado-Borrego recommended that primary care doctors screen children born to mothers with HCV infection. This is "the number 1 risk factor" for pediatric HCV transmission, she said. In addition, children born to mothers with HIV infection and teenagers who use illegal drugs should be screened. Pediatric patients identified with HCV infection should be referred to a pediatric gastroenterologist.
"Pediatric HCV has a heterogeneous presentation. The extent of the progression of liver disease varies among individual patients, and the timing of therapy is based on the extent of progression. This is why it is key for children with HCV infection to be under the care of a specialist who is knowledgeable about this disease and its treatments in children," she emphasized.
Pegylated interferon plus ribavirin, the only treatment for adult HCV currently approved by the US Food and Drug Administration (FDA), is not approved for children. However, several studies in children have shown surprisingly good response rates to treatment, and they tolerate it better than expected. Treatment works best if it is initiated early in the course of disease, Dr. Delgado-Borrego said, but that necessitates early identification of HCV.
High Pediatric HCV Prevalence Called "Alarming"
"These data are alarming. The study showed a higher prevalence of HCV in young children than imagined," said Frank Anania, MD, associate professor at Emory University School of Medicine in Atlanta, Georgia, in an interview with Medscape Gastroenterology after Dr. Delgado-Borrego's presentation.
Dr. Anania suggested that the lack of identification and treatment of HCV infection in children could be related to socioeconomic factors, including poverty, abuse, neglect, and not being under the regular care of a doctor.
"Identifying risk factors other than maternal–fetal transmission is very important," he noted.
Children should be universally vaccinated for hepatitis A and B, he continued. HCV could be a consequence of not receiving those vaccines, which have been shown to reduce the severity of HCV and the incidence of liver failure. In turn, not being vaccinated for hepatitis A and B could reflect socioeconomics, such as poverty and not being under a doctor's care.
"In all fairness to physicians, there is no FDA-approved treatment for children with HCV, so they may have valid reasons and concerns for not treating them," he added.
Dr. Delgado-Borrego reports receiving funding for the study from the Harold Amos Medical Faculty Development Program, the Robert Wood Johnson Foundation, and the National Institutes of Health. Dr. Delgado-Borrego and Dr. Anania have disclosed no relevant financial relationships.
Digestive Disease Week (DDW) 2010: Abstract 316. Presented May 2, 2010.
Alice Goodman is a freelance medical writer in Bearsville, New York.
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