Maternal Social Determinants of Health Impact Pediatric HCV Screening

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

Leveraging administrative healthcare data for 1780 children born to mothers with HCV RNA in Canada, study results highlighted the impact of several social determinants of health on HCV screening by 2 years of age as well as factors associated with an increased probability of screening.¹

According to the World Health Organization (WHO), there are an estimated 58 million people with chronic HCV infection globally, with 3.2 million cases affecting adolescents and children. Although it is a less common form of transmission, HCV can be passed from an infected mother to her child. In order to meet the WHO’s global hepatitis strategy aiming 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,” Jennifer Flemming, MD, FRCPC, associate professor of Medicine and Public Health Sciences at Queen's University, and colleagues wrote.¹ “Little data exist surrounding if and how [social determinants of health] may influence paediatric HCV screening.”

To further explore this association, investigators retrospectively examined administrative healthcare data for individuals covered under the Ontario Health Insurance Plan in Ontario, Canada. Information was sourced and accessed through ICES, a designated prescribed entity authorized to collect and use health data without obtaining individual consent.¹

The study included children born to individuals ≥ 15 years of age with evidence of positive HCV RNA during pregnancy from January 1, 2000, to December 31, 2016. Births were captured from the MOMBABY dataset and children were followed until the end of 2018.¹

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

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

Other demographics and confounders of interest included maternal age at the time of 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 persons with HCV RNA were identified, 29% (n = 516) of whom were screened for HCV by age 2. The median age of the pregnant cohort at the time of birth was 30 years (Interquartile range [IQR], 26–34) and 2% had HIV co-infection. Within 1 year prior to conception or during pregnancy, 30% had a visit with a GI, 13% had a visit with an infectious disease specialist, and 94% had a visit with an obstetrician/gynecologist.¹

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

Further analysis revealed younger maternal age (RR, 0.98 per 1-year increase; 95% CI, 0.97-0.99), HIV co-infection (RR, 1.69; 95% CI, 1.16-2.48), and GI specialist involvement (RR, 1.18; 95% CI, 1.00-1.39) were associated with increased probabilities of screening. Additionally, investigators noted having both GI and infectious disease specialist visits was associated with a 28% increase in odds of screening.¹

“Our data suggest that efforts to improve HCV screening in rural and remote locations, heightened education of HCV+ mothers and primary care providers on the importance of post-natal screening and understanding barriers to screening among those living in highly dependent neighbourhoods could translate into improvements in paediatric HCV screening,” investigators concluded.¹

References:

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