Hepatitis C virus (HCV): The burden of the beast

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Following its formal debut in 1989, HCV (nee “Non-A, Non-B” virus) has come to be recognized as a major cause of morbidity and mortality in adults – accounting for the bulk of liver transplants in the US. This slowly progressive chronic liver injury is a relatively benign disease in children; HCV requires years of ongoing injury before the end stages of cirrhosis or hepatocellular carcinoma develop. But will the impact of infection acquired in childhood be felt in later years?

Most studies of the natural history of HCV infection acquired in early life indicate that while abnormal aminotransferase levels may persist, HCV infection acquired early in life is associated with a slow rate of progression and a favorable outcome during long-term follow-up. For example, 58% of a large group of subjects who acquired HCV via mini-transfusions at birth remained anti-HCV positive at follow-up 35 years later (Hepatology 2004;39:90). However, biopsies performed in these subjects showed no fibrosis in most; marked fibrosis was uncommon. The natural history of perinatally acquired HCV infection is similar. However, because of the concern that long-term complications may develop, HCV infected children are serially monitored and many are being treated despite low rate of success. There are no clear guidelines for either strategy.

Jhaveri et al generated a projection model of the impact of HCV acquired in childhood. They estimated that by 2016 the costs associated with screening and monitoring would amount to $200 million. If treatment were chosen, the costs would escalate to an estimated additional $50-100 million.

Data will soon become available regarding the effectiveness and safety of peg-interferon monotherapy versus peg-interferon plus ribavirin in children (Hepatology 2004;41:421, www.pedsc.org). This may guide our evidence-based decisions regarding the standard of care in childhood HCV infection. What the study of Jhaveri et al indicate is that the burden of HCV acquired in early life is high and this should stimulate continued research efforts: 1) to develop novel strategies for the treatment of HCV in women of child–bearing age to decrease perinatal transmission, 2) to define appropriate evidence-based, cost-effective screening and monitoring strategies, and 3) to develop more effective and reliable treatment options for children infected with HCV.