As there is currently no way of preventing mother-to-baby transmission of hepatitis C or treating the virus during pregnancy, the benefits of screening are doubtful.
8.3.1 BackgroundHepatitis C is a blood-borne virus that is one of the major causes of liver cirrhosis, hepatocellular carcinoma and liver failure (Pembrey et al 2000). Perinatal transmission is the main source of hepatitis C in Australian children, with babies with hepatitis C mostly born to mothers who used intravenous drugs, had invasive procedures overseas or have tattoos (Ridley et al 2009). Currently, there are no specific interventions known to decrease perinatal transmission (CPS 2008; McIntyre et al 2010).
Hepatitis C in Australia
- Rates of diagnosis of hepatitis C — Of 11,486 diagnoses of newly acquired hepatitis C in 2009, 5% were among Aboriginal and Torres Strait Islander people, 32% among non-Indigenous people and Indigenous status was not recorded for 63% (NCHECR 2010a). Diagnoses among Aboriginal and Torres Strait Islander people comprised almost 5% of all diagnoses where Indigenous status was reported. Among women, rates of diagnosis were highest in the 20–29 year age group, with Aboriginal and Torres Strait Islander women diagnosed at four times the rate of non-Indigenous women (NCHECR 2010a). From 2005 to 2009, the rate of newly diagnosed hepatitis C in the Aboriginal and Torres Strait Islander population increased (from 120 to 131 per 100,000), while the rate in the non-Indigenous population decreased (from 46 to 44 per 100,000 (NCHECR 2010a).
- Prevalence in pregnancy — Prevalence among pregnant women without risk factors is the same as that among the general population (DoHA 2007).
- Geographical distribution — In 2005–2009, rates of diagnosis of newly acquired hepatitis C remained relatively stable in SA, WA and Victoria, decreased in NSW, the NT and Queensland and increased in ACT and Tasmania (NCHECR 2010b). While the rate among Aboriginal and Torres Strait Islander people in the NT was lower than in the non-Indigenous population, it is increasing (NCHECR 2010a). In SA, WA and NT, rates of diagnosis among Aboriginal and Torres Strait Islander people decreased in major cities, remained stable or decreased in outer regional, remote and very remote communities but almost doubled in inner regional areas (NCHECR 2010a).
- Incarceration — Imprisonment has been shown to be an independent risk factor for hepatitis C transmission. Hepatitis C prevalence for all prisoners is estimated at 30–40% and higher for women (DoHA 2007). Aboriginal and Torres Strait Islander peoples are 12 times more likely to be incarcerated than non-Indigenous Australians (ABS 2005).
- Country of origin — Regions of high hepatitis C prevalence (>1.0%) include south-east Asia, the Middle East, southern and eastern Europe, and parts of South America and Africa (Pawlotsky et al 1995; Frank et al 2000; RACGP 2003; Caruana et al 2005).
- Routes of transmission of hepatitis C virus — These include sharing injecting equipment (such as occurs in injecting drug use), tattooing and piercing, needle-stick injury and blood transfusion (in Australia, if transfusion occurred before 1990) (RACGP 2003). Based on reported diagnoses, hepatitis C transmission in Australia predominantly occurs among people with a history of injecting drug use (NCHECR 2010a).
Risks associated with hepatitis C in pregnancyAround 4–6% of babies born to women who are positive for both hepatitis C antibody and hepatitis C RNA during pregnancy will acquire hepatitis C (Conte et al 2000; Di Domenico et al 2006; Hardikar et al 2006; McMenamin et al 2008). Although there is consistent evidence that the risk of mother-to-child transmission of hepatitis C increases with increasing maternal viral load (Okamoto et al 2000; Tajiri et al 2001; Pembrey et al 2003), no threshold level for transmission has been identified. The risk of transmission is increased if the mother also has HIV (Pembrey et al 2003; Hardikar et al 2006).
An association between maternal hepatitis C positive status and increased risk of low birth weight, neonatal intensive care unit admissions and assisted ventilation has been suggested by a cohort study (Pergam et al 2008).
Babies who acquire hepatitis C in utero or at birth do not develop clinically apparent liver problems in early childhood, but most develop chronic hepatitis C and are likely to be at risk of longer term problems related to chronic liver disease, including hepatic fibrosis, cirrhosis, and hepatocellular carcinoma (Tovo et al 2000; Resti et al 2003; Rerksuppaphol et al 2004; Liu et al 2009).
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8.3.2 Screening for hepatitis C infection in pregnancy
Summary of the evidenceThere is limited evidence on screening of pregnant women for hepatitis C and routine testing is advised against in the United Kingdom (NICE 2008), the United States (ACOG 2007) and Canada (CPS 2008). The Australian Department of Health and Ageing advises that routine screening of pregnant women is not a clinically justifiable or cost effective approach (DoHA 2007). Lack of effective treatment options and potential psychological harm of false positive screening results have been cited as reasons not to screen routinely (Pembrey et al 2003; 2005).
Some bodies recommend selective testing for hepatitis C in pregnant woman with identifiable risk factors (ACOG 2007; DoHA 2007; Hepatitis Australia 2007; CPS 2008). However, population-based cohort studies suggest that screening based on risk factors may not identify all women with hepatitis C (Hutchinson et al 2004; Lui et al 2009), particularly if risk factors are not present or women conceal them (Prasad et al 2007). These studies acknowledge that screening of all women is not appropriate while an effective intervention to prevent transmission remains unavailable.
Recommendation - Grade C13. Do not routinely offer pregnant women hepatitis C testing
Practice pointn. Hepatitis C testing may be offered to women with identifiable risk factors:
- intravenous drug use or needle sharing;
- tattooing or body piercing;
- receipt of blood products or invasive procedures overseas or before 1990 in Australia; or
- country of origin has a high prevalence of hepatitis C.
Planned invasive proceduresScreening of women who are to have a planned invasive procedure has been recommended, due to the risk of hepatitis C transmission to the baby.
Practice pointo. Women who are having an invasive procedure (eg chorionic villus sampling, amniocentesis) should be offered screening for hepatitis C before the procedure.
Testing processIf an initial test for hepatitis C antibodies is positive, a confirmatory hepatitis C RNA test will allow assessment of the potential implications and associated risks for the woman and her baby.
8.3.3 Practice summary — hepatitis C screeningWhen — In the antenatal period
Who — Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander health worker; multicultural health worker
- Discuss hepatitis C screening with women with identified risk factors — Explain the association between relevant risk factors and hepatitis C infection and that, as there are no treatments to prevent transmission, follow-up of mother and baby are needed if the mother is found to have hepatitis C.
- Document and follow-up — If hepatitis C testing is undertaken, note the results in the woman’s record and advise the woman of her result. Have a system in place so that women who test positive receive education about further transmission (eg to family members) and ongoing support and their babies are followed up after birth.
- Take a holistic approach — If a woman is found to have hepatitis C, specialist advice on management may be required depending on the severity of disease and the health professional’s expertise. Other considerations include counselling and follow-up.
8.3.4 ResourcesMinisterial Council on Drug Strategy (2006) National Clinical Guidelines for the Management of Drug Use During Pregnancy, Birth and the Early Development Years of the Newborn. Sydney: NSW Health. For more information please visit NSW Department of Health website.
NSW Department of Health (Ed.) 2006. Background Papers to the National Clinical Guidelines for the Management of Drug Use During Pregnancy, Birth and the Early Development Years of the Newborn. Sydney: NSW Department of Health. For more information please visit NSW Department of Health website.
RACGP (2003) Hepatitis C: an update. Aust Fam Pract 32(10) Special feature. For more information please visit www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/HepatitisC/20031029hepc.pdf (This website link was valid at the time of submission).
WebsitesHepatitis C Council of NSW website
Hepatitis C Council of SA website
Hepatitis C Victoria website
Hepatitis Queensland website
Hepatitis WA website
Northern Territory AIDS and Hepatitis C Council website
ACT Hepatitis C Council website
Tasmanian Council on AIDS, Hepatitis C and Related Diseases website
8.3.5 ReferencesABS (2005) Prisoners in Australia, Census June 2005. Canberra: Australian Bureau of Statistics.
ACOG (2007) Viral Hepatitis in Pregnancy. ACOG practice bulletin; no. 86. Washington (DC): American College of Obstetricians and Gynecologists.
Caruana SR, Kelly HA, De Silva SL et al (2005) Knowledge about hepatitis and previous exposure to hepatitis viruses in immigrants and refugees from the Mekong Region. Aust NZ J Public Health 29:64–68.
Conte D, Fraquelli M, Prati D et al (2000) Prevalence and clinical course of chronic hepatitis C virus (HCV) infection and rate of HCV vertical transmission in a cohort of 15,250 pregnant women. Hepatol 31: 751–55.
CPS (2008) Vertical transmission of the hepatitis virus: current knowledge and issues. Position Statement of the Canadian Paediatric Society. Paediatr Child Health 13(6): 529–41.
Di Domenico C, Di Giacomo C, Marinucci G et al (2006) Vertical transmission of HCV infection: prospective study in infants born to HIV-1 seronegative women. Igiene e Sanita Pubblica 62(2): 129–42.
DoHA (2007) National Hepatitis C Testing Policy. Hepatitis C Subcommittee of the Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis; the Blood Borne Virus and Sexually Transmissible Infections Subcommittee of the Australian Population Health Development Committee.
Frank C, Mohamed M, Strickland G et al (2000) The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. Lancet 355: 887–91.
Hardikar W, Elliot EJ, Jones CS (2006) The silent infection: should we be testing for perinatal hepatitis C and, if so, how? Med J Aust 184(2): 54–55.
Hepatitis Australia (2007) Improving Hepatitis C Antenatal Screening Practice. Hepatitis Australia Position Statement.
Hutchinson SJ, Goldberg DJ, King M et al (2004) Hepatitis C virus among childbearing women in Scotland: prevalence, deprivation, and diagnosis. Gut 53(4): 593–98.
Liu AJ, An EI, Murray HG et al (2009) Screening for hepatitis C virus infection in methadone-maintained mothers and their infants. Med J Aust 191(10): 535–38.
McIntyre PG, Tosh K, McGuire W (2007) Caesarean section versus vaginal delivery for preventing mother to infant hepatitis C virus transmission (Review), Cochrane Database of Systematic Reviews 2007 (4) Art. No.:CD005546.
McMenamin MB, Jackson AD, Lambert J et al (2008) Obstetric management of hepatitis C-positive mothers: analysis of vertical transmission in 559 mother-infant pairs. Am J Obstet Gynecol 199(3): 315.e1-5.
NCHECR (2010a) Bloodborne Viral and Sexually Transmitted Infections in Aboriginal and Torres Strait Islander People: Surveillance and Evaluation Report 2010. Sydney: National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales.
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NCHECR (2010b) Annual Surveillance Report. National Centre for HIV Epidemiology and Clinical Research. Sydney: University of New South Wales.
NICE (2008) Antenatal Care. Routine Care for the Healthy Pregnant Woman. National Collaborating Centre for Women’s and Children’s Health. Commissioned by the National Institute for Health and Clinical Excellence. London: RCOG Press.
Okamoto M, Nagata I, Murakami J et al (2000) Prospective re-evaluation of risk factors in mother-to-child transmission of hepatitis C virus: high virus load, vaginal delivery, and negative anti-NS4 antibody. J Infect Dis 182: 1511–14.
Pawlotsky JM, Belec L, Gresenguet G et al (1995) High prevalence of hepatitis B, C and E markers in young sexually active adults from the Central African Republic. J Med Virol 46: 269–72.
Pembrey L, Newell ML, Tovo PA et al (2005) The management of HCV infected pregnant women and their children. European paediatric HCV network. J Hepatol 43(3): 515–25.
Pembrey L, Newell ML, Tovo PA (2000) Hepatitis C virus infection in pregnant women and their children. It J Gynaecol Obstet 12: 21–28.
Pembrey L, Newell ML, Peckham C (2003) Is there a case for hepatitis C infection screening in the antenatal period ? J Med Screening 10(4): 161–68.
Pergam SA, Wang CC, Gardella CM et al (2008) Pregnancy complications associated with hepatitis C: data from a 2003-2005 Washington state birth cohort. Am J Obstet Gynecol 199: 38.e1–38.e9.
Prasad LR, Massery Spicher V, Kammerlander R et al (2007) Hepatitis C in a sample of pregnant women in Switzerland: seroprevalence and socio-demographic factors. Swiss Med Wkly 137(1–2): 27–32.
RACGP (2003) Hepatitis C: an update. Aust Fam Pract 32(10) Special feature.
Rerksuppaphol S, Hardikar W, Dore GJ (2004) Long-term outcome of vertically acquired and post-transfusion hepatitis C infection in children. J Gastroenterol Hepatol 19: 1357–62.
Resti M, Jara P, Hierro L et al (2003) Clinical features and progression of perinatally acquired hepatitis C virus infection. J Med Virol 70: 373–77.
Ridley G, Zurynski Y, Elliott E (eds)(2010) Australian Paediatric Surveillance Unit Biannual Research Report 2007–2008. Australian Paediatric Surveillance Unit.
Tajiri H, Miyoshi Y, Funada S et al (2001) Prospective study of mother-to-infant transmission of hepatitis C virus. Pediatr Infect Dis J 20: 10–14.
Tovo PA, Pembrey LJ, Newell ML (2000) Persistence rate and progression of vertically acquired hepatitis C infection. European Paediatric Hepatitis C Virus Infection. J Infect Dis 181: 419–24.