Maternal social determinants of health impact Pediatric HCV screening

Living in rural residences and highly dependent neighborhoods may negatively affect compliance with guideline-recommended pediatric screening in children exposed to hepatitis C virus (HCV) in utero, according to findings from a retrospective cohort study.¹

Using administrative health data on 1,780 children born to mothers with HCV RNA in Canada, study results highlighted the influence of several social determinants of health on HCV screening by age 2 years, as well as factors associated with an increased likelihood of screening.¹

According to the World Health Organization (WHO), there are approximately 58 million people worldwide with chronic HCV infection, with 3.2 million cases affecting adolescents and children. Although a less common form of transmission, HCV can be passed from an infected mother to her child. To meet the WHO global hepatitis strategy, which aims to reduce new hepatitis infections by 90% and deaths by 65% ​​by 2030, screening and treatment in this patient population is of paramount importance.^2,3

“Undiagnosed infections among children will increase the risk of developing liver-related complications and expose the household and close contacts, risking further transmission,” wrote Jennifer Fleming, MD, FRCPC, associate professor of medicine and public health sciences at Queen’s University and colleagues.¹ “There is little data on whether and how [social determinants of health] may affect pediatric HCV screening.

To further explore this relationship, researchers retrospectively examined administrative health data for individuals covered by the Ontario Health Insurance Plan in Ontario, Canada. The information was obtained and accessed through ICES, a designated prescribed authority authorized to collect and use health data without obtaining individual consent.¹

The study included children born to individuals aged ≥ 15 years with evidence of positive HCV RNA during pregnancy from 1 January 2000 to 31 December 2016. Births were taken from the MOMBABY dataset and children were followed until the end of 2018 Mr.¹

The primary outcome of interest was guideline-recommended HCV screening in children exposed to HCV in utero by age 2 years, defined as obtaining an HCV Ab laboratory test at 18 months of age or an HCV RNA or genotype laboratory test between 2 and 24 months after the birth.¹

The main exposures of the study are neighborhood-level maternal social determinants of health measured at birth and available in ICES data. The researchers assessed 6 domains: income quintile, dependency quintile, material deprivation quintile, housing instability quintile, ethnic diversity quintile and rural location.¹

Other demographic and confounders of interest included maternal age at delivery, HIV co-infection, hepatitis B virus co-infection, cirrhosis, alcohol and substance use disorders, and the Elixhauser comorbidity index.¹

A total of 1780 children born to individuals with HCV RNA were identified, 29% (n = 516) of whom were tested for HCV by age 2 years. The mean age of the pregnant cohort at the time of delivery was 30 years (interquartile range [IQR], 26–34) and 2% had HIV coinfection. Within 1 year before conception or during pregnancy, 30% had a visit to a gastrointestinal physician, 13% had a visit to an infectious disease specialist, and 94% had a visit to an obstetrician-gynecologist.¹

Most mothers live in the lowest income quintile (42%) and the most vulnerable quintiles for material deprivation (41%), housing instability (38%) and ethnic diversity (26%), with 11% living in rural areas. After adjusting for covariates, maternal rural residence was associated with an 18% lower probability of screening by age 2 (hazard ratio [RR]0.82; 95% CI, 0.62-1.07). The researchers also indicated that residence in the highest dependency quintile was associated with a 17% lower likelihood of pediatric HCV screening (RR, 0.83; 95% CI, 0.64-1.08).¹

Additional analysis revealed younger maternal age (RR, 0.98 per 1-year increase; 95% CI, 0.97-0.99), HIV coinfection (RR, 1.69; 95% CI, 1, 16-2.48) and involvement of gastrointestinal specialists (RR, 1.18; 95% CI, 1.00-1.39) were associated with increased odds of screening. Additionally, the researchers noted that visits to both a gastrointestinal specialist and an infectious disease specialist were associated with a 28% increase in the odds of screening.¹

“Our data suggest that efforts to improve HCV screening in rural and remote areas, increased education of HCV+ mothers and primary care providers about the importance of postnatal screening, and understanding barriers to screening among those living in highly dependent neighborhoods may lead to improvements in pediatric HCV screening,” the researchers concluded.¹

References:

1. ^{Foley MK, Djerboua M, Kushner T, et al. Maternal neighborhood-level social determinants of health and their association with pediatric hepatitis C screening among children exposed to hepatitis C during pregnancy. Pediatric and perinatal epidemiology. https://doi.org/10.1111/ppe.13042}
2. ^{World Health Organization. Hepatitis C. Newsroom. 18 July 2023. Accessed 2 February 2024. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c}
3. ^{World Health Organization. Eliminate hepatitis by 2030. Hepatitis. Accessed 2 February 2024. https://www.who.int/health-topics/hepatitis/elimination-of-hepatitis-by-2030}