National Liver Awareness Month isn't until October, but this past week saw a burst of activity around hepatitis concerns.
Eliminate Hepatitis C?
I'm having trouble understanding the details of President Biden's plan to eliminate hepatitis C in the US over the next 5 years; it's a nice idea, but it sounds impossible to me, especially in the setting of our country's current backlash against public health. The short explanation covered the basics of the proposal and seems sound, just very tough to implement. Remember, hepatitis C disproportionately affects communities with the greatest challenges to health care access.
The President's plan is completely focused on adults, but let's not forget about the children. Two studies by an international hepatitis C group appeared this week in Clinical Infectious Diseases and refined common wisdom about intrauterine/perinatal hepatitis C transmission.
It's important to note that both of these studies started at a time before availability of highly effective anti-HIV and anti-HCV therapy. The first article re-analyzed data from a prospective cohort of 1749 mother/infant pairs. The numbers are likely to be more accurate than previous studies because of the prospective nature and large size of the databases as well as utilizing more frequent testing. Vertical transmission, either in utero or at delivery, might be slightly higher than previously thought, about 7% in HIV-negative women and 12% in HIV-infected women. However, spontaneous clearance of infection by age 5 years in the infants was a bit higher than previously thought, which is good news and also will help inform any treatment protocols for children experiencing vertically-transmitted hepatitis C.
The authors also estimated, based on a separate analysis with a number of assumptions, that about 25% of infections occurred early in utero, 66% late in utero, and 9% at delivery. So, this lends support to current recommendations against using cesarean section to prevent newborn HCV infection.
The second article, by the same group, looked at a smaller number (179) of infected infants and further refined estimates. Most clearance of infection occurred within the first year of life. Any treatment regimen for infants likely should start after 3 years of age to avoid overtreatment of children who would clear on their own.
The accompanying editorial by Ravi Jhaveri is a longer summary than I presented here and is a good starting place for those who want to learn more, but unfortunately you need a journal subscription to view it.
Before leaving the topic of hepatitis C, let me also refer interested readers to the World Health Organization hepatitis C page. WHO goals for hepatitis C are a little different from US plans, though still steep: they propose elimination of hepatitis C as a public health threat by 2030. This endpoint is defined as a 90% decrease in new chronic infections and a 65% decrease in mortality using 2015 data as a baseline comparator.
New Hepatitis B Screening Guidelines
Also last week, CDC refined screening guidelines for hepatitis B in adults. It applies to individuals 18 years of age and older and better defines risk groups, but basically recommends screening everyone at least once. A nice accompaniment is a graph to aid interpretation of hepatitis B test results - something imprinted in my brain forever because I've had to explain it numerous times to students, trainees, and healthcare providers. It's complicated, but the graphs help.
Polio and Summer Vacations
Did you ever think we would need to worry about contracting polio on summer vacation? Welcome to the present. The increase in worldwide polio mostly is driven by infection with vaccine-derived strains from individuals who received live poliovirus vaccines that have not been used in the US since 2000; live polio vaccines are still used in some resource-poor countries. The US injectable inactivated polio vaccine is very effective, but those who are partially- or un-immunized are at risk to be infected with either live or vaccine-derived polio strains. CDC puts polio at a Level 2 concern for travelers, meaning to practice enhanced precautions. Their webpage lists areas with active polio. Now and through the summer is a good time to ask patients and families if they plan international travel and ensure immunizations are up to date. I know everyone is anxious to enjoy postponed summer travel, but we should all be careful.
In browsing other resources about polio, I came across an interesting campaign from Pakistan using "truck art" to help families overcome vaccine misconceptions and decide to immunize their children against polio. I'll leave you with this delightful image.
