Patient Presentation
A pediatrician got a phone call from a childcare center director regarding a preschool child with Hepatitis C infection. They had recently moved to the area and the child had not previously been in childcare. The parents had disclosed this information to the director and told her that they had been told that the child could safely attend childcare and only universal precautions needed to be followed for the child’s health and the health of the other children and childcare professionals. After receiving verbal permission from the parents, the director had placed a telephone call to the state childcare regulating agency to confirm any particular regulations the center needed to follow. While awaiting a response, she also contacted the pediatrician for guidance. The pediatrician reviewed the current American Academy of Pediatrics RedBook® recommendations which confirmed that the child could safely attend the childcare center, and that universal precautions should be used. Additionally the pediatrician noted, “That you already have policies and procedures in place for using gloves and other protective equipment for minor cuts or blood spills. You and the other people just need to follow them for this child just like you would for any other child.” Later, the pediatrician heard from the director that the state regulating agency also reiterated the same advice.
Discussion
It is estimated that 180 million people worldwide are infected with Hepatitis C (HCV) which includes ~11 million children. In the United States it is estimated that there were 30,500 acute HCV cases in 2014, and 2.7-3.9 million people with chronic HCV. Many infections are not identified. It is estimated that “…only 5-15% of HCV-infected children in the United States are identified.”
Problems associated with HCV include acute hepatitis (including fever, malaise, dark-urine, abdominal pain, jaundice, appetite loss, nausea, emesis, clay-colored stools), acute fulminant hepatitis (not common in children), hepatic fibrosis, hepatic cirrhosis, and hepatocellular carcinoma.
Vertical transmission (particularly with HIV-coinfected mothers), injection drug use and iatrogenic exposures (blood, blood product or solid organ recipients, blood exposures through needlesticks, tattooing, etc.) are the most common ways children and youth are infected. International adoptees, particularly from the high prevalence areas of Africa, China, Russia, Eastern Europe, and Southeast Asia, are also at risk. Sexual transmission between heterosexual partners has not been demonstrated in prospective studies. Transmission among family contacts is uncommon.
Acute symptoms can appear from 2-12 weeks (up to 24) weeks after infection. Clearing of the HCV infection does occur especially in infants and toddlers (clearing after age 3 with vertical transmission is uncommon), but 60-80% of pediatric infections persist. Being asymptomatic is the most common symptom with chronic HCV infection. Adult patients may only be recognized when they donate blood which is screened for HCV, or have elevated transaminases on routine testing. More serious problems with chronic HCV infection can occur decades after infection.
Liver disease and other problems progress more slowly in children than adults so only 1-2% of children will have cirrhosis. Factors for progression include being immunocompromised, obese, co-infected with HIV or Hepatitis B and probably other viral factors. For adults the numbers are not as good. According to the Centers for Disease Control in the United States:
“Of every 100 persons infected with HCV, approximately
1-5 will die from the consequences of chronic infection (liver cancer or cirrhosis)”
Diagnosis is made by being seropositive for anti-HCV IgG which is confirmed by polymerase chain reaction for HCV RNA. Genotyping is also helpful to guide treatment. Genotype 1 is most common. Other biomarkers are being evaluated to also help guide treatment such as possibly Vitamin D or single nucleotide polymorphisms. Treatment by an experienced team of specialists is recommended. Currently approved treatment includes interferon and ribaviran but these drugs have side effects. There are currently new treatment for adults (HCV protease, polymerase and NS5A inhibitors) that are more effective with fewer side effects and pediatric trials are ongoing in 2016 that researchers are hopeful will show that these drugs can be used in the pediatric population. Because of the slow progression in the pediatric age group, some patients are being carefully watched and not treated while awaiting the results of these new studies.
Unfortunately good prevention techniques for vertical transmission are not available. There is no current vaccine or immunoglobulin such is used for Hepatitis B vertical transmission. Elective caesarean section does not appear to decrease the risk of transmission, but other interventions such as no scalp monitoring or amniocentesis may.
Learning Point
Health considerations for children with HCV include:
- Post exposure prophylaxis with immunoglobulin is not recommended.
- Exclusion from childcare attendance is not recommended.
- General household contact is recommended as HCV is not transmitted by general contact such as sharing utensils, food/water, touching, etc. Infected children should not share nail clippers, razors, and toothbrushes. Transmission in saliva is low.
- Universal precautions are recommended for minor cuts. Fresh or dried blood should be cleaned with 1 part bleach/10 parts water solution with protective gloves.
- Breastfeeding by a HCV-positive mother is okay, but the mother should consider abstaining if nipples have sores or cracks.
- Routine maternal testing while pregnant is not indicated.
- Routine immunizations are indicated.
- Sports and school participated are indicated.
- Healthy behaviors should be encouraged including avoidance of alcohol, drugs, self-tattooing and piercing and multiple sexual partners.
Questions for Further Discussion
1. Why do health care providers not worry about Hepatitis D and E as much as A, B, and C?
2. What precautions should be taken for people with active Hepatitis A or Hepatitis B?
3. How is Hepatitis B prevented?
Related Cases
- Disease: Hepatitis C
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Infectious Diseases | Preventive Medicine and Health Maintenance | School
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Hepatitis C.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Centers for Disease Control. Hepatitis C. Available from the Internet at: http://www.cdc.gov/hepatitis/HCV/index.htm (rev. May 31, 2015, cited 11/1/2016).
Red Book® Online. Hepatitis C. American Academy of Pediatric Committee on Infectious Diseases. Kimberlin, DW, Brady MT, Jackson MA, Long SS. eds. 2015. Available from the Internet at http://redbook.solutions.aap.org/chapter.aspx?sectionid=88187160&bookid=1484 (cited 11/1/16).
Pawlowska M, Domagalski K, Pniewska A, Smok B, Halota W, Tretyn A. What’s new in hepatitis C virus infections in children? World J Gastroenterol. 2015 Oct 14;21(38):10783-9.
Lee CK, Jonas MM. Hepatitis C: Issues in Children. Gastroenterol Clin North Am. 2015 Dec;44(4):901-9.
Ohmer S, Honegger J. New prospects for the treatment and prevention of hepatitis C in children. Curr Opin Pediatr. 2016 Feb;28(1):93-100.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 