November 1, 2021
Dear Colleague:
The purpose of this letter is to inform OB/GYN providers of the Centers for Disease Control and Prevention and U.S. Preventive Services Task Force hepatitis C virus (HCV) screening recommendations for adults and pregnant persons. Universal HCV screening among pregnant persons during each pregnancy is now recommended, regardless of risk. This recommendation was recently endorsed by the American Academy of Obstetrics and Gynecology.
HCV is the most reported bloodborne infection in the U.S. (1) An estimated 2.4 million persons nationally and 116,000 New Yorkers are living with HCV (2, 3). Approximately four in 10 people living with HCV do not know they have it (4). Injection drug use is the primary risk factor for HCV infection (1). Pregnant persons have a 5.8% chance of transmitting the virus to their baby. That chance doubles in babies born to individuals who are coinfected with HIV and HCV or who have high HCV viral loads (5,6). Nationally, HCV has been on the rise among persons of reproductive age. HCV prevalence doubled in women aged 15 to 44 years from 2006 to 2014 (7).
Testing for HCV infection requires two laboratory tests. The first test screens for HCV antibodies. If this initial HCV antibody test is reactive, it must be immediately followed with an HCV RNA confirmatory test on the same specimen or a second specimen collected at the same time. If HCV RNA is detected, active HCV infection is confirmed. To ensure the complete and timely diagnosis, HCV reflex testing is recommended to ensure that the HCV RNA test is performed following all reactive HCV antibody screening tests. Reflex testing allows active HCV infection to be confirmed or excluded with a single test order, obviates the need for the patient to return for follow-up testing, expedites identification of persons with current HCV infection, and allows for prompt linkage to HCV care and treatment.
New HCV treatments, direct acting antivirals (DAAs), are not yet approved for use in pregnancy. Safety data during pregnancy is favorable. However, the data are preliminary and larger studies are needed. Until DAAs are approved for use during pregnancy, testing during pregnancy for HCV infection is the most beneficial intervention for pregnant persons and their infant. Many pregnant individuals only have access to health care during pregnancy and the immediate postpartum period. The postpartum period may also be an appropriate time to discuss and initiate HCV treatment. Treatment can be as short as 8 weeks and with few side effects. NYS Medicaid recently removed prior authorization requirements for HCV medications, making it easier for providers to prescribe and patients to access HCV treatment.
Testing during pregnancy also allows for identification of infants who should receive testing at a pediatric visit. Therefore, it is important that the HCV status of each pregnant person is communicated in a timely manner to the pediatrician. Testing of infants consists of HCV RNA testing at or after age 2 months or anti-HCV testing at or after age 18 months (8). Although DAA treatment is not approved for children aged <3 years, infected children aged <3 years should be monitored.
Finally, when reporting any HCV case in a pregnant person to the local health department, providers should indicate the pregnancy status of the individual.
Resources
HCV educational materials are currently available free of charge through the NYS Department of Health AIDS Institute.
• Educational materials targeting pregnant people:
‒ HCV and Pregnancy Brochure, https://www.health.ny.gov/publications/16039.pdf
‒ Ask To Be Tested for Hepatitis C During Each Pregnancy Poster, https://www.health.ny.gov/publications/16112.pdf
‒ Get Tested, Treated and Cured Before Becoming Pregnant Poster, https://www.health.ny.gov/publications/16114.pdf
• Additional HCV educational materials and order forms are available at: https://www.health.ny.gov/diseases/communicable/hepatitis/hepatitis_c/educational_materials.htm
Clinical guidelines for the management and treatment of persons living with hepatitis C are available at:
Additional information on HCV prevention, screening, care, and treatment can be found at: https://www.health.ny.gov/diseases/communicable/hepatitis/hepatitis_c/
Sincerely,
Johanne E. Morne, MS
Deputy Director for Community Health, Office of Public Health
Director, AIDS Institute and Center for Community Health
View the Dear Colleague Letter here.
References
1. CDC. Viral hepatitis surveillance—United States, 2017. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/hepatitis/statistics/2017surveillance/index.htm
2. Hofmeister MG, Rosenthal EM, Barker LK, et al. Estimating prevalence of hepatitis C virus infection in the United States, 2013–2016. Hepatology 2019;69:1020–31.
3. Center for Disease Analysis Foundation, in collaboration with the New York State Department of Health (2019). Report produced for internal use only not for public dissemination
4. CDC. Hepatitis C: By the numbers. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/Hepatitis-c-by-the-numbers.pdf.
5. Benova L, Mohammond YA, Calvert C, Abu-Raddad LJ. Vertical transmission of hepatitis C virus: systematic review and meta-analysis. Clin Infect Dis 2014; 59:765-73.
6. Dunkelberg JC, Berkley EM, Thiel KW, Leslie KK. Hepatitis B and C in pregnancy: a review and recommendations for care. J Perinatol. 2014 Dec; 34(12):882-91.
7. Koneru A, Nelson N, Hariri S, et al. Increased hepatitis C virus (HCV) detection in women of childbearing age and potential risk for vertical transmission- United states and Kentucky, 2011-2014. MMWR Morb Mortal Wkly Rep 2016; 65:705-710.
8. American Association for the Study of Liver Diseases (AASLD); Infectious Diseases Society of America (IDSA). HCV guidance: recommendations for testing, managing, and treating hepatitis C. Alexandria and Arlington, VA: AASLD and IDSA; 2019. https://www.hcvguidelines.org/contents
Last Updated on July 24, 2023 by HepFree NYC
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