| |
HCV Doubles Among Pregnant People - Association of Individual and Community Factors With Hepatitis C Infections Among Pregnant People and Newborns
|
| |
| |
JAMA Health Forum Oct 2021
Download the PDF here
Between 2009 and 2019, there were a total of 39 380 122 pregnant people who had live births residing in counties reporting HCV, among whom 138 343 (0.4%) were diagnosed with HCV. The overall rate (per 1000 live births) of HCV in pregnant people increased from 1.8 to 5.1 between 2009 and 2019.
Between 2009 and 2019, HCV infections more than doubled among pregnant people in the US; however, this increase varied substantially by individual characteristics and county factors. We found that American Indian/Alaska-Native and White people without a 4-year college degree were at highest risk of having HCV. Furthermore, county-level factors were also associated with different levels of risk, with the proportion of population employed associated with lower levels of risk of HCV over time. Although individual and county-level factors associated with HCV among pregnant people have been poorly understood, they appear to mirror many of the dynamics associated with the opioid crisis.2,15,17
Key Points
Question What individual and county factors are associated with hepatitis C virus (HCV) infection among pregnant people and which county factors modify risk among those at highest risk?
Findings In this retrospective repeated cross-sectional study of US counties and 39 380 122 pregnant people with live births, White and American Indian/Alaska Native people without a 4-year college degree had the highest individual risk of HCV. High levels of county employment mitigated the rise of HCV infections among people with the highest risk of acquiring the virus.
Meaning US HCV infections among pregnant people grew fastest among White and American Indian/Alaska Native people without a 4-year degree; however, county-level factors, including higher levels of employment, modified this risk.
Abstract
Importance The opioid crisis has increasingly affected pregnant people and infants. Hepatitis C virus (HCV) infections, a known complication of opioid use, grew in parallel with opioid-related complications; however, the literature informing individual and community risks associated with maternal HCV infection is sparse.
Objectives To determine (1) individual and county-level factors associated with HCV among pregnant people and their newborn infants, and (2) how county-level factors influence individual risk among the highest risk individuals.
Design, Setting, and Participants This time-series analysis of retrospective, repeated cross-sectional data included pregnant people in all US counties from 2009 to 2019. We constructed mixed-effects logistic regression models to explore the association between HCV infection and individual and county-level covariates. Analyses were conducted between June 2019 and September 2021.
Exposures Individual-level: race and ethnicity, education, marital status, insurance type; county-level: rurality, employment, density of obstetricians.
Main Outcomes and Measures Hepatitis C virus as indicated on the newborn’s birth certificate.
Results Between 2009 and 2019, there were 39 380 122 pregnant people who met inclusion criteria, among whom 138 343 (0.4%) were diagnosed with HCV. People with HCV were more likely to be White (79.9% vs 53.5%), American Indian or Alaska Native (AI/AN) (2.9% vs 0.9%), be without a 4-year degree (93.2% vs 68.6%), and be unmarried (73.7% vs 38.8%). The rate (per 1000 live births) of HCV among pregnant people increased from 1.8 to 5.1. In adjusted analyses, the following factors were associated with higher rates of HCV: individuals identified as White (adjusted odds ratio [aOR], 7.37; 95% CI, 7.20-7.55) and AI/AN (aOR, 7.94; 95% CI, 7.58-8.31) compared with Black individuals, those without a 4-year degree (aOR, 3.19; 95% CI, 3.11-3.28), those with Medicaid vs private insurance (aOR, 3.27; 95% CI, 3.21-3.33), and those who were unmarried (aOR, 2.80; 95% CI, 2.76-2.84); whereas, rural residence, higher rates of employment, and greater density of obstetricians was associated with lower risk of HCV. Among individuals at the highest risk of HCV, higher levels of county employment, accounting for other factors, were associated with less of a rise in HCV infections over time.
Conclusions and Relevance In this cross-sectional study, maternal and newborn HCV infections increased substantially between 2009 and 2019, disproportionately among White and AI/AN people without a 4-year degree. County-level factors, including higher levels of employment, were associated with lower individual risks of acquiring the virus.
As policymakers consider efforts to improve outcomes for pregnant people and infants affected by the opioid crisis, mitigating the rise of HCV in this population should be a public health priority. As clinicians implement new guidelines, which aim to universally test pregnant people for HCV, it may be important to bolster medical and public health systems to ensure adequate follow-up and connection to treatment. maternal-child health public health systems are often delivered through a patchwork of public programs, perhaps missing touchpoints to identify and educate families at risk for HCV in public programs (eg, Special Supplemental Nutrition Program for People, Infants, and Children, Maternal, Infant, and Early Childhood Home Visiting Program). Policymakers could consider programs that improve care coordination or care between people and their infants, treatment for opioid use disorder, and management of HCV. Finally, improving access to medications for opioid use disorder among people of reproductive age and pregnant people should remain a key public health goal because this has been demonstrated to reduce injection drug use,32 the chief risk factor for acquiring HCV. Despite evidence that medications for opioid use disorder improve outcomes,33 pregnant people are less likely to be accepted to treatment for opioid use disorder than nonpregnant people.34
In 2019, about half (49.6%) of counties in the US had at least 1 case of HCV, and most births (96.0%) occurred in those counties. The median (IQR) HCV rate in those counties was 6.36 (2.90-14.45) per 1000 births. Counties with the highest rates tended to be in the Northeast and in Appalachia. For example, among counties with at least 100 births, 8 of the top 10 counties of maternal HCV prevalence in the US were in Appalachia, including 4 in Kentucky, 1 in North Carolina, 1 in Tennessee, 1 in Virginia, 1 in West Virginia, 1 in Montana, and 1 in North Dakota. A total of 1197 of 2571 counties (46.6%) reached the prevalence threshold of 0.1% or greater and these counties accounted for 2 850 479 total births (76%; Figure 3) of the 3 747 882 US births during 2019. Geographic variation from 2009 and 2018 can be found in eFigures 2 to 11 in the Supplement.
Conclusions
In this cross-sectional study, HCV infections were a rising threat to maternal-child health in the US. We found that the rise of HCV occurred disproportionately among AI/AN and White pregnant people without a 4-year college degree, however, the level of risk in this population was lower in counties with higher levels of employment. Nationwide, despite rising HCV prevalence the virus has not historically been universally screened in pregnancy and public health systems to ensure maternal-infant dyads are evaluated and treated for HCV are lacking. As systems are developed to prevent, evaluate, and treat dyads at risk for HCV they should consider both the individual and community risks that may influence risk of acquiring the virus.
Discussion
Between 2009 and 2019, HCV infections more than doubled among pregnant people in the US; however, this increase varied substantially by individual characteristics and county factors. We found that AI/AN and White people without a 4-year college degree were at highest risk of having HCV. Furthermore, county-level factors were also associated with different levels of risk, with the proportion of population employed associated with lower levels of risk of HCV over time. Although individual and county-level factors associated with HCV among pregnant people have been poorly understood, they appear to mirror many of the dynamics associated with the opioid crisis.2,15,17
In the present study, AI/AN and White race, particularly when combined with lower education, were associated with higher HCV diagnoses, regardless of community measures. This resembles research on deaths of despair described by economists Case and Deaton as deaths due to suicide, alcohol, and overdose.15 Similar to the findings of their work, we found that AI/AN and White pregnant people without a 4-year degree were the most likely group to be diagnosed with HCV. However, even the group of people at highest risk based on these individual factors experienced different probabilities of HCV in counties with and without high employment, with much greater risk in those counties with low (10th percentile) employment levels. Research suggests that rural White2 and AI/AN people20 have high rates of opioid-related diagnoses during pregnancy and NOWS, and these same groups had the highest incidence of HCV in this study. However, in adjusted models, rurality was associated with decreased risk, suggesting that other factors (eg, education, employment) may account for the differential HCV risk observed in HCV prevalence between rural and urban settings. Notably, although research has consistently focused on opioid-related complications among White people,2 nonwhite people, and infants receive less evidence-based care for both HCV and opioid use disorder and face disproportionate challenges in the child welfare system. For example, Black pregnant people with OUD are less likely to be prescribed medications for opioid use disorder,21 Black infants exposed to HCV are less likely to be tested for HCV,7 and Black parents whose infants are placed in foster care for substance exposure are less likely to be reunified with their parents.22,23 As systems are developed to address the rising numbers of maternal-infant dyads affected by HCV, it is critical that any intervention is applied equitably and addresses unequal treatment in these associated systems of care.
The rise of HCV among pregnant people has substantial implications for pregnant people and infants. Hepatitis C virus is the most common bloodborne infection in the US, infecting an estimated 2.4 million people nationwide,24 with the chief risk factor for acquiring the virus being injection drug use.9,25 Although there is no FDA-approved treatment for HCV in pregnancy, identifying HCV in pregnancy is important for providing treatment26 for pregnant people after delivery and for monitoring infants for seroconversion. Because maternal antibodies to HCV can persist, historical recommendations have been to follow and test exposed infants at age 18 months; however, more recent recommendations include earlier RNA testing, twice before age 6 months.25 Although vertical transmission of HCV is rare, occurring among an estimated 6% of exposed infants (higher with greater viral load or coinfection with HIV),27 systems to follow and identify infants with seroconversion are underdeveloped and data suggest most exposed infants are not tested.7,8,28 Although several individual risk factors have been identified that increase risk of HCV among pregnant people,5 many of these factors can be difficult to identify in clinical practice. Recent cost-effectiveness analyses suggest that universal screening of HCV in pregnancy is cost effective.29In addition, the CDC published recommendations in 2020 that communities with a prevalence of 0.1% or greater of HCV universally test pregnant people for the virus.25 Following the CDC recommendations, the US Preventative Services Task Force30 and the American College of Obstetricians and Gynecologists (ACOG) recommended universal screening of HCV in pregnancy.31 In our analysis, 45% of US counties accounting for 70% of US births met the 2020 CDC threshold, providing additional support for new recommendations of nationwide universal screening.
As policymakers consider efforts to improve outcomes for pregnant people and infants affected by the opioid crisis, mitigating the rise of HCV in this population should be a public health priority. Until recently, HCV testing of pregnant people was risk based, likely missing opportunities to identify infected pregnant people and exposed infants.7 As clinicians implement new guidelines, which aim to universally test pregnant people for HCV, it may be important to bolster medical and public health systems to ensure adequate follow-up and connection to treatment. Furthermore, maternal-child health public health systems are often delivered through a patchwork of public programs, perhaps missing touchpoints to identify and educate families at risk for HCV in public programs (eg, Special Supplemental Nutrition Program for People, Infants, and Children, Maternal, Infant, and Early Childhood Home Visiting Program). Policymakers could consider programs that improve care coordination or care between people and their infants, treatment for opioid use disorder, and management of HCV. Finally, improving access to medications for opioid use disorder among people of reproductive age and pregnant people should remain a key public health goal because this has been demonstrated to reduce injection drug use,32 the chief risk factor for acquiring HCV. Despite evidence that medications for opioid use disorder improve outcomes,33 pregnant people are less likely to be accepted to treatment for opioid use disorder than nonpregnant people.34
Limitations
Our findings should be interpreted in consideration of the limitations of our analysis. First, data obtained from birth certificates may be prone to misclassification bias with errors of omission or commission. Notably, not all states reported HCV early in the study period because they had not adopted the CDC’s Standard Birth Certificate, possibly influencing our results in those years. Second, because testing of HCV is not universal, we may detect higher rates of HCV in communities that test more frequently. Further, it is possible that people with specific characteristics were more likely to be tested than others, perhaps introducing bias into the results. Third, birth certificates may incompletely document HCV among pregnant people,35 and may be different than direct testing of HCV infections. Fourth, the ecological nature of our study cannot determine causation between the exposures and outcomes of interest. Finally, data obtained from birth certificates do not provide detail to know the timing of the infection or its chronicity.
Conclusions
In this cross-sectional study, HCV infections were a rising threat to maternal-child health in the US. We found that the rise of HCV occurred disproportionately among AI/AN and White pregnant people without a 4-year college degree, however, the level of risk in this population was lower in counties with higher levels of employment. Nationwide, despite rising HCV prevalence the virus has not historically been universally screened in pregnancy and public health systems to ensure maternal-infant dyads are evaluated and treated for HCV are lacking. As systems are developed to prevent, evaluate, and treat dyads at risk for HCV they should consider both the individual and community risks that may influence risk of acquiring the virus
| |
| |
| |
|
|
|
