Open Forum Infectious Diseases BRIEF REPORT their HCV status and may withhold information about HCV Risk-Based Hepatitis C Screening risk factors. Previous work by our group in Egypt showed that in Pregnancy Is Less Reliable Than risk-based screening missed 10% of chronically infected preg- Universal Screening: A Retrospective nant women . Our study was conducted at the University of Maryland Medical Center (UMMC) in Baltimore, a city where Chart Review 26 000 to 40 000 individuals are infected with HCV . We 1 2 3 Sarah Boudova, Katrina Mark, and Samer S. El-Kamary aimed to determine the proportion of women tested for HCV 1 2 Division of Malaria Research, Institute for Global Health, Department of Obstetrics, 3 during pregnancy, the prevalence of HCV among women being Gynecology and Reproductive Sciences, and Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland tested, and the association between testing and risk factors for HCV during pregnancy. Current guidelines recommend only hepatitis C virus (HCV) METHODS risk-based screening during pregnancy. We examined screening practices at a major medical center and found inconsistent risk- This study is a retrospective secondary data analysis using elec- based screening and the presence of HCV among women with tronic medical records (EMRs) of pregnant women presenting no known risk factors. We make a case for the implementation to UMMC for antenatal care from January 1 to December 31, of universal HCV screening during pregnancy. 2016. A list of women presenting for antenatal care was gen- Keywords. hepatitis C virus; pregnancy; risk factors; uni- erated by a Current Procedural Terminology code query, and versal screening. their EMR records were examined. Visits reviewed included their first antenatal visit until termination of pregnancy, deliv- ery, cessation of care at UMMC, or December 31, 2016, which- Hepatitis C virus (HCV) is a major cause of morbidity and ever came first. Records from outside hospitals and outpatient mortality, causing liver cirrhosis, hepatocellular carcinoma, clinics were not reviewed. Some women had more than 1 preg- and death . The global prevalence of HCV is estimated to be nancy that began or ended in 2016. Each pregnancy was consid- 1.0% (95% confidence intervals [CI] 0.8%–1.1%) in 2015, cor - ered individually in analysis. responding to 71.1 million (62.5–79.4 million) infections . Data were collected from the problem list and medical notes In the United States, approximately 3.5 million individuals are on the number of antenatal visits at UMMC, history of IVDU, infected, and this number is likely to climb given the current transplant, or blood transfusions before 1992, long-term hemo- opioid epidemic . In the United States, 1%–2.5% of preg- dialysis, tattoos, piercings, and receipt of clotting factors or IgG nant women are infected with HCV with a 6% risk of vertical before 1987, and whether each mother was tested for HCV. transmission [3, 4]. HCV during pregnancy is associated with Our definition of HCV testing was any testing for anti-HCV fetal growth restriction, low birthweight, vertical transmission, antibodies and qualitative or quantitative HCV RNA. Among and gestational hypertension . Current national guidelines women tested for HCV, additional information was gathered recommend only risk-based screening during pregnancy and on their HCV status, whether they were diagnosed during this subsequent screening of children born to HCV-infected moth- pregnancy, and whether they previously had a diagnosed HCV ers [6, 7]. Risk factors include intravenous drug use (IVDU), infection. transplant or blood transfusions before 1992, long-term hemo- Means, standard deviations, and proportions were calculated dialysis, tattoos and piercings, and receipt of clotting factors or using Microsoft Excel 2013. Associations between HCV testing IgG before 1987 . However, many women are unaware of and risk factors were calculated using 2-tailed Fisher exact tests. e U Th niversity of Maryland, Baltimore, Institutional Review Board formally reviewed this study and determined the analysis Received 29 January 2018; editorial decision 11 February 2018; accepted 15 February 2018. of this de-identified data set to be exempt. Correspondence: S. Boudova, PhD, 685 West Baltimore Street, Room 480 Baltimore, MD 21201-1509 (firstname.lastname@example.org). RESULTS Open Forum Infectious Diseases © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Medical records from 1426 pregnancies were reviewed. On Society of America. This is an Open Access article distributed under the terms of the Creative average women had 6.6 (SD, 4.8) prenatal visits at UMMC. Of Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any the 1426 pregnancies, 100 (7.0%) were tested for HCV. None medium, provided the original work is not altered or transformed in any way, and that the work of the women had received clotting factors or IgG before 1987, is properly cited. For commercial re-use, please contact email@example.com or had a transplant or blood transfusion prior to 1992. Forty DOI: 10.1093/ofid/ofy043 BRIEF REPORT • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/3/ofy043/4868646 by Ed 'DeepDyve' Gillespie user on 16 March 2018 pregnancies occurred in women with a history of IVDU, 35 of risk-based screening in baby boomers has led the Centers occurred in women with HIV, 6 occurred in women with tat- for Disease Control and Prevention to recommend universal toos or piercings, and 1 occurred in a woman with long-term screening in those born between 1945 and 1965 . hemodialysis (Table 1). We argue that universal HCV screening should be intro- Among 78 pregnancies in women with any risk factor, the duced during pregnancy. Knowledge of HCV status changes majority (50/78, 64.1%) were not tested. Of these 50 women, 17 how obstetricians manage patients in order to reduce the risk had a history of IVDU, 22 were HIV+, 5 had tattoos, 1 was on of vertical transmission (eg, avoiding invasive testing and use long-term hemodialysis, 1 had previously had a positive HCV of fetal scalp electrodes). Universal screening is logistically feas- test, and 4 had multiple risk factors. The association between ible and can identify new cases of HCV at a time when women having a risk factor and being tested (Table 1) was statistically regularly encounter the health care system and can be referred significant for pregnancies in women with IVDU or with HIV for treatment. This approach has been successful for prevention or any risk factor. There was no statistically significant associ- of mother-to-child transmission of HIV. HIV screening in preg- ation between having a tattoo/piercing or being on long-term nancy is universal even though HIV-positive mothers account hemodialysis and being tested. for only 8500 (0.02%) of births per year in the United States Of the 100 pregnancies in which women were tested for HCV, . In our sample, 0.7% of the women were HCV-positive, 10 (10%) were positive (0.7% of the 1426 pregnancies). Eight which is likely an underestimation as only 7% were tested. were women with histories of IVDU (1 was also HIV+). One Additionally, HIV treatment is lifelong whereas HCV treatment pregnancy was in a woman who had a tattoo/piercing, and 1 is a 1-time 12-week curative course that will prevent the woman pregnancy (10%) was from a woman with no known risk fac- from transmitting infection to her future children or other tors for HCV. Five (50%) of these cases were newly diagnosed adults. Universal HCV screening with repeat screening in the during this pregnancy. Among these women, 4 were HIV+ and third trimester for high-risk women, as done for HIV, should 1 had no known risk factors. Three women previously known to be implemented. be HCV positive were not tested this pregnancy (women with a er Th e has been resistance to HCV screening during preg- history of HCV were retested for viral load). nancy because of the significant side effects of past treatment with pegylated interferon alpha and ribavirin, and the terato- DISCUSSION genic effects of ribavirin. However, new highly effective direct We found that 7% of pregnant women receiving prenatal care at acting antiviral agents are curative, have far fewer side effects, UMMC were tested for HCV and 5% had risk factors for HCV. and may be approved for use in pregnancy once clinical trials However, among women with known HCV risk factors, nearly (www.clinicaltrials.gov #NCT02683005) are completed. Until two-thirds were not screened for HCV. We found that 10% of then, they can be used to treat postpartum women aer t ft hey HCV+ pregnancies occurred in women with no reported risk have completed breast-feeding. factor. However, the presence of tattoos or piercings was rarely We were surprised by the number of women screened for recorded in the EMR unless the tattoos were extensive, or if HCV with no recorded risk factors. It is possible that busy piercings could interfere with breastfeeding or vaginal deliv- clinicians did not document risk factors they identified, were ery. History of IVDU is likely higher than identified. Women not clear about current screening guidelines, or had a high may not divulge prior IVDU due to fear of legal retribution or suspicion for HCV despite patient denial of risk factors. It is discrimination from health care providers. For these reasons, also likely that some women were tested as part of a hepatitis we believe that the actual number of women with risk factors panel that is oen o ft rdered following unexplained elevated liver was likely higher than reported here. This finding of targeted function tests. Also, despite national guidelines, many clini- screening being ineffective is not surprising. Limited efficacy cians included HCV when patients requested STD screening. Table 1. Frequency of HCV Risk Factors Based on Whether or Not Women Were Tested for HCV Risk Factor Tested for HCV (n = 100), No. (%) Not Tested for HCV (n = 1326), No. (%) P Value Intravenous drug use 19 (19) 21 (1.6) <.0001 HIV positive 10 (10) 25 (1.9) <.0001 Tattoos or piercings 1 (1) 5 (0.4) .354 Clotting factors or IgG before 1987 0 (0) 0 (0) 1.000 Organ transplant or blood transfusion before 1992 0 (0) 0 (0) 1.000 Long-term hemodialysis 0 (0) 1 (<0.1) 1.000 Any risk factor 28 (28) 50 (3.8) <.0001 Abbreviation: HCV, hepatitis C virus. Total not equal to sum of individual risk factors due to multiple risk factors in some women. 2 • OFID • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/5/3/ofy043/4868646 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Potential conifl cts of interest. All authors: no reported conflicts of Future studies of physician attitudes toward HCV screening interest. All authors have submitted the ICMJE Form for Disclosure of may elucidate this. Potential Conflicts of Interest. Conflicts that the editors consider relevant to Our study has several limitations. As this is a retrospective the content of the manuscript have been disclosed. analysis of EMRs, there may be missing data due to insuffi- References cient documentation of HCV test results or risk factors; or 1. El-Kamary SS, Jhaveri R, Shardell MD. All-cause, liver-related, and non-liver-re- HCV screening conducted at another center. Our data are lated mortality among HCV-infected individuals in the general US population. from 1 center and may not represent findings at other hospi- Clin Infect Dis 2011; 53:150–7. 2. Polaris Observatory HCV Collaborators. Global prevalence and genotype dis- tals or the nation at large, although similar results were found tribution of hepatitis C virus infection in 2015: a modelling study. Lancet in a prospective study in Cleveland . Finally, we were una- Gastroenterol Hepatol 2017; 2:161–76. 3. Edlin BR, Eckhardt BJ, Shu MA, et al. Toward a more accurate estimate of the ble to follow children born to these women and cannot com- prevalence of hepatitis C in the United States. Hepatology 2015; 62:1353–63. ment on vertical transmission. While future studies would 4. Arshad M, El-Kamary SS, Jhaveri R. Hepatitis C virus infection during pregnancy benefit from a multicenter prospective design with standard- and the newborn period–are they opportunities for treatment? J Viral Hepat 2011; 18:229–36. ized protocols for determining HCV risk factors at first ante- 5. Connell LE, Salihu HM, Salemi JL, et al. Maternal hepatitis B and hepatitis C car- natal visit and long-term follow-up of mother-infant pairs, rier status and perinatal outcomes. Liver Int 2011; 31:1163–70. 6. American College of Obstetricians and Gynecologists. ACOG practice bulletin we do not believe that this should delay potentially life-saving No. 86: viral hepatitis in pregnancy. Obstet Gynecol 2007; 110:941–56. policy changes. 7. Smith BD, Morgan RL, Beckett GA, et al. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965. HCV is a promising target for eradication; it is curable, only MMWR Recomm Rep 2012; 61:1–32. transmitted by humans, and has a low infection rate . The larg- 8. El-Kamary SS, Hashem M, Saleh DA, et al. Reliability of risk-based screening for hepatitis C virus infection among pregnant women in Egypt. J Infect 2015; est obstacle is identifying cases—individuals are oen un ft aware 70:512–9. of their status and have infrequent contact with the health care 9. Maryland Department of Health and Mental Hygiene. 2014 annual report imple- system. Universal screening is already being rolled out in baby mentation of hepatitis B and hepatitis C prevention and control in Maryland Health–general article §18–1002. 2014. Available at: https://phpa.health.mary- boomers. Expanding universal screening to pregnancy could be land.gov/Documents/Hepatitis-Report-2014.pdf. Accessed 23 September 2017. an important tool in HCV control and ultimately eradication. 10. Pregnant women, infants, and children | gender | HIV by group | HIV/AIDS | CDC. 2017. Available at: https://www.cdc.gov/hiv/group/gender/pregnant- women/index.html. Accessed 23 September 2017. Acknowledgments 11. Waruingi W, Mhanna MJ, Kumar D, Abughali N. Hepatitis C virus universal Financial support. This work was supported by the National Institute screening versus risk based selective screening during pregnancy. J Neonatal of Allergy and Infectious Diseases (F30AI114195-01 to S.B.). This work Perinatal Med 2015; 8:371–8. also benefited from a USAID US-Egypt Science and Technology Joint Fund 12. Thomas DL. Global control of hepatitis C: where challenge meets opportunity. (61225 to S.S.E.K. Nat Med 2013; 19:850–8. BRIEF REPORT • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/3/ofy043/4868646 by Ed 'DeepDyve' Gillespie user on 16 March 2018
Open Forum Infectious Diseases – Oxford University Press
Published: Mar 1, 2018
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