US Maternal Hepatitis C Infections Increased 16-Fold Since 1998

The prevalence of hepatitis C virus (HCV)-positive pregnancies among US women increased more than 16-fold from 1998 – 2018, according to new cross-sectional data.

New research from a team of US investigators showed more than 5 in 1000 pregnancies resulted in a positive case of HCV in 2018—a substantial jump from the 0.34 cases per 1000 pregnancies observed 20 years prior. Accompanying this severe increase in maternal HCV infections are likelier adverse perinatal outcomes, which investigators believe warrant a greater adoption of universal screening for hepatitis C in each pregnancy.

Led by Berkeley N. Limketkai, MD, PhD, of the Vatche & Tamar Manoukian Division of Digestive Disease in the department of medicine at David Geffen School of Medicine at UCLA, investigators sough to estimate the temporal trend of HCV-positive pregnancies during the opioid epidemic, as well as to identify maternal and perinatal outcomes associated with hepatitis C during the time period.

As the most common chronic bloodborne infection among Americans—generally driven by injection drug use—acute HCV prevalence increased 3-fold from just 2010 – 2015 alone, “coinciding with increased heroin and synthetic opioid overdose deaths during the opioid epidemic,” investigators noted.

“More than one-third of newly reported HCV cases were among women, and the highest incidence consistently occurred among persons aged 20 to 39 years,” Limketkai and colleagues wrote. “From 2014 to 2017, HCV cases among pregnant women in the US exceeded that of hepatitis B and syphilis combined, despite HCV being the only infection among the 3 not to receive universal screening during prenatal care.”

Data had been previously scarce on HCV infections during pregnancy, investigators noted, though efforts to bridge the literature gap has led to opportunities to better assess its prevalence and impact on expecting or new mothers in past decades.

They conducted their cross-sectional analysis using women giving in-hospital childbirth or experiencing spontaneous abortion included in the National Inpatient Sample of the Healthcare Cost and Utilization Project from 1998 – 2018. Investigators sought a primary outcome of temporal trend of annual HCV prevalence among pregnant women throughout the opioid epidemic; secondary outcomes included associations of maternal HCV infections, and maternal and perinatal adverse events.

In the 2-decade span of assessment, investigators observed >70 million hospital admissions that which resulted in childbirth or spontaneous abortion. In total, 137,259 (0.20%; 95% CI, 0.19 – 0.21) involved mothers with HCV. Infected patients were primarily White (77.4%; 95% CI, 76.1 – 78.6); their median age was slightly older than HCV-negative women (27.2 vs 28.0), and they were more likely to have a lower socioeconomic status (40.0% vs 26.9%).

Investigators additionally observed that HCV-positive women were significantly more likely to report a history of tobacco (41.7% vs 4.0%), alcohol (1.8% vs 0.1%), opioid (28.9% vs 0.3%), and cocaine (6.9% vs 0.3%), respectively, than HCV-negative women.

Over the span of the analysis, maternal HCV infection prevalence increased from 0.34 (95% CI, 0.26 – 0.41) cases per 1000 pregnancies in 1998 to 5.3 (95% CI, 4.9 – 5.7) per 1000 in 2018. The proportion of HCV-positive pregnancies increased in all age groups, but was greatest among women aged 18 – 20 years (22-fold) and 21 – 30 years (31-fold). Investigators noted the latter age group experienced “an accelerated increase” in HCV posirtive pregnancies following the second wave of the opioid epidemic in 2010.

Women with HCV infections were at greater odds of cesarean deliveries (adjusted odds ratio [AOR], 1.19; 95% CI, 1.15 – 1.22), preterm labor (AOR, 1.10; 95% CI, 1.05 – 1.14), poor fetal growth (AOR, 1.29; 95% CI, 1.21 – 1.37) and fetal distress (AOR, 1.11; 95% CI, 1.08 – 1.15).

However, infected women were additionally at 12% lower odds of spontaneous abortion (AOR, 0.88; 95% CI, 0.82 – 0.95).

Limketkai and colleagues wrote that the earliest recommendation for universal HCV screening during pregnancy was not available until 2018; as such, they believe their findings may have even underestimated the prevalence of hepatitis C-positive pregnancies in the US during the 21st century.

“Given an approximate 38% spontaneous viral clearance among women acutely exposed to HCV and 3.7 million births in the US in 2021, we conservatively estimate approximately 12 000 pregnancies yearly with HCV viremia,” investigators wrote. “Thus, at a 6% risk of vertical transmission, approximately 725 infants are born with HCV infection in the US each year.”

The team concluded that their data support calls for universal HCV screening in each pregnancy, as proposed by leading health organizations including the Centers for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists (ACOG).

“Perinatal care and delivery may be the initial health care exposure for many women,” investigators wrote. “These touchpoints represent an opportunity for health care professionals to identify HCV infection and link women and their children to appropriate specialist care.”

References

1. ^{Chen P, Johnson L, Limketkai BN, et al. Trends in the Prevalence of Hepatitis C Infection During Pregnancy and Maternal-Infant Outcomes in the US, 1998 to 2018. JAMA Netw Open. 2023;6(7):e2324770. doi:10.1001/jamanetworkopen.2023.24770}
2. ^{Centers for Disease Control and Prevention. Viral hepatitis. and TB Prevention. 2017 Surveillance. Accessed June 7, 2022. https://www.cdc.gov/hepatitis/statistics/2015surveillance/index.htm}