Hepatitis C

While there is currently no way of preventing mother-to-baby transmission of hepatitis C, identifying women who have hepatitis C during pregnancy means that interventions that increase the risk of transmission to the baby can be avoided and effective treatments commenced after the birth or cessation of breastfeeding.

35.1 Background

Hepatitis C is a blood-borne virus that is one of the major causes of liver cirrhosis, hepatocellular carcinoma and liver failure. Perinatal transmission is the main source of hepatitis C in Australian children. Babies with hepatitis C are mostly born to mothers who used intravenous drugs, had invasive procedures overseas or have tattoos (Ridley et al 2010).

35.1.1 Hepatitis C in Australia

• Rates of notification of hepatitis C: Overall there was a 15% decline in the hepatitis C notification rate in Australia between 2007 and 2016 (from 58.8 to 49.9 per 100,000) (The Kirby Institute 2017a). However, since 2012, the rate has increased by 12% (from 44.5 to 49.9 per 100,000), with most of this increase occurring in 2015 and 2016.^[24] In contrast, the age-standardised notification rate of newly diagnosed hepatitis C infection in the Aboriginal and Torres Strait Islander population increased by 25% between 2012 and 2016 (from 138.1 to 172.7 per 100,000) (The Kirby Institute 2017b).
• Age: Among women, rates of notification remained stable between 2012 and 2016 in the 40 years and over age group (from 36.9 to 35.6 per 100,000) and declined in the 25–39 age group (from 88.5 to 56.5 per 100,000) and the 15–24 age group in 2016 (45.5 to 25.2 per 100,000) (The Kirby Institute 2017a).
• Geographical distribution: The notification rate of newly diagnosed hepatitis C in 2016 was highest in the Northern Territory (76.0 per 100,000), followed by Queensland (58.7 per 100,000), New South Wales (55.0 per 100,000), and Tasmania (54.4 per 100,000). Hepatitis C notification rates either remained stable or increased slightly between 2012 and 2016. In New South Wales, rates increased by 17% between 2015 and 2016 (from 47.1 to 55.0 per 100,000). Rates of notification in 2016 were higher in inner and outer regional areas (65.3 per 100 000) than in remote and very remote areas (46.8 per 100 000) and major cities (41.2 per 100 000) (The Kirby Institute 2017a).

Observational studies conducted in Australia also identified people who inject drugs Liu et al 2009, Iversen et al 2010, Islam et al 2013, Graham et al 2016 and people in prison van der Poorten et al 2008, Miller et al 2009, Teutsch et al 2010, Reekie et al 2014, Graham et al 2016 as at higher risk of testing positive for hepatitis C antibodies or infection.

35.1.2 Risks associated with hepatitis C in pregnancy

The clearest and most serious risk associated with maternal hepatitis C in pregnancy is transmission of the infection to the baby. There are several factors that influence the risk of mother-to-infant transmission:

• risk of transmission is estimated to be 5.8% (95%CI 4.2 to 7.8%) among antibody–positive and RNA-positive women (Benova et al 2014)
• the highest reported transmission rates occur in infants born to mothers who are both hepatitis C and HIV positive, with rates as high as 36% Panda et al 2010, Benova et al 2014
• risk of transmission is increased with a higher maternal viral load of hepatitis C Panda et al 2010, Valladares et al 2010, Garcia-Tejedor et al 2015
• risk is increased with intrapartum invasive procedures (fetal scalp blood sampling or internal electronic fetal heart rate monitoring via scalp electrode) (OR 10.1; 95% CI 2.6 to 39.02) and episiotomy (OR 4.2; 95%CI 1.2 to 14.16) Panda et al 2010, Gagnon et al 2014, Rac & Sheffield 2014, Garcia-Tejedor et al 2015
• transmission does not appear to be influenced by mode of birth Panda et al 2010, Ghamar Chehreh et al 2011, Cottrell et al 2013, Rac & Sheffield 2014 or gestational age at birth (Panda et al 2010)
• prolonged rupture of membranes may increase the risk of transmission Panda et al 2010, Cottrell et al 2013, however this could be related to maternal viral load and length of membrane rupture (Rac & Sheffield 2014)
• amniocentesis in women infected with hepatitis C does not appear to significantly increase the risk of vertical transmission but very few studies have properly addressed this possibility Panda et al 2010, Gagnon et al 2014, Rac & Sheffield 2014
• there is no evidence that breastfeeding is associated with an increased risk of hepatitis C transmission to the newborn Panda et al 2010, Valladares et al 2010, Cottrell et al 2013, HIV Medicine">ASHM 2015, unless the nipples are cracked and/or bleeding Rac & Sheffield 2014, HIV Medicine">ASHM 2015.

35.2 Testing for hepatitis C infection in pregnancy

Internationally, routine testing of pregnant women for hepatitis C has not been recommended CPS 2008, ACOG reaffirmed 2016, NICE updated 2016. In Australia, RANZCOG suggests that all pregnant women be tested for hepatitis C RANZCOG 2016.

35.2.1 Targeted versus universal testing

Studies were largely consistent in finding that hepatitis C seropositivity was associated with the following risk factors:

• injecting drug use McDermott et al 2010, Diab-Elschahawi et al 2013, Lambert et al 2013, Wilson & Beckmann 2015
• receipt of blood transfusion or organ transplant Diab-Elschahawi et al 2013, Wilson & Beckmann 2015
• history of tattooing or body piercing Diab-Elschahawi et al 2013, Lambert et al 2013
• use of intranasal cocaine Diab-Elschahawi et al 2013, Lambert et al 2013
• incarceration (Diab-Elschahawi et al 2013)
• origin from a country of high prevalence Diab-Elschahawi et al 2013, Lambert et al 2013; these include Africa and central and east Asia WHO 2016.

Additional findings were:

• only high severity risk factors (exposure to intravenous drug use or to the blood of a hepatitis C-positive individual) were significantly associated with testing positive for hepatitis C antibodies (P=0.002) (McDermott et al 2010)
• age, history of prior pregnancy and healthcare employment were additional considerations (El-Kamary et al 2015).

However, studies have estimated that, compared to universal testing, targeted testing would fail to identify 2.5 to 27% of seropositive women Diab-Elschahawi et al 2013, Lambert et al 2013, El-Kamary et al 2015, Wilson & Beckmann 2015.

35.2.2 Clinical utility of testing

The clinical utility of testing for hepatitis C in pregnancy is limited by the lack of effective treatment options to avoid mother-to-child transmission during pregnancy or childbirth Dunkelberg et al 2014, Rac & Sheffield 2014, Poliquin et al 2015, Aebi-Popp et al 2016.

However, new treatment options (direct-acting antiviral agents) for people living with hepatitis C have become available and were recently listed on the Australian Pharmaceutical Benefits Scheme (PBS). While these treatments have not been proven to be safe in pregnancy or during breastfeeding Rac & Sheffield 2014, Aebi- Popp et al 2016, women who are diagnosed with hepatitis C during pregnancy could commence such curative treatment after completion of breastfeeding (or immediately after the birth if the infant is not breastfed), thus reducing their risk of significant liver disease and the risk of perinatal infection for subsequent pregnancies.

In addition, knowledge of a woman’s hepatitis C status means interventions that may increase the risk of mother-to-baby transmission (fetal scalp blood sampling, internal electronic fetal heart rate monitoring via scalp electrode, episiotomy) can be avoided.

35.2.3 Costs of testing

No cost-effectiveness studies relevant to the Australian context were identified. A study in the Netherlands found a modest cost-effective outcome for testing first-generation non-Western women (Coretti et al 2015) and a study conducted in the United States (Hahne et al 2013) found that universal testing was not cost-effective with or without elective caesarean section. However, a study in the United Kingdom found that antenatal testing and postnatal treatment was feasible and effective at an acceptable cost (Selvapatt et al 2015).

35.2.4 Planned invasive procedures

Testing of women who are to have a planned invasive procedure has been recommended, due to the risk of hepatitis C transmission to the baby.

35.2.5 Testing process

If an initial test for hepatitis C antibodies is positive, a confirmatory hepatitis C ribonucleic acid (RNA) test will allow assessment of the potential implications and associated risks for the woman and her baby HIV Medicine">ASHM 2015.

35.2.6 Other considerations

For a woman with a diagnosis of hepatitis C during pregnancy, referral to an infectious diseases specialist or hepatologist, as well as to hepatitis support groups for information and advice, should be made during the pregnancy HIV Medicine">ASHM 2015. This will facilitate provision of accurate information, counselling and linkages for follow-up and treatment if desired after the birth.

35.3 Practice summary: hepatitis C testing

When

In the antenatal period.

Who

• Midwife
• GP
• obstetrician
• Aboriginal and Torres Strait Islander health worker
• multicultural health worker.

What

• Discuss hepatitis C testing
  Explain that if hepatitis C is identified during pregnancy, interventions that increase the risk of transmission can be avoided and that effective treatment can be started after pregnancy/breastfeeding.
• 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.

35.4 Resources

• NSW Ministerial of Health (2014) Clinical Guidelines for the Management of Substance Use During Pregnancy, Birth and the Postnatal Period. North Sydney: NSW Ministry of Health.

35.4.1 Websites

• Hepatitis NSW
• Hepatitis SA
• Hepatitis Victoria
• Hepatitis Queensland
• Hepatitis WA
• Northern Territory AIDS and Hepatitis C Council
• Hepatitis ACT 
• Tasmanian Council on AIDS, Hepatitis C and Related Diseases