Treatment of hepatitis B and C in children

Chronic viral hepatitis B and C infections are highly prevalent and create a substantial burden to healthcare systems globally. These two chronic infections are the cause of significant global morbidity and mortality with approximately 1 million annual deaths attributable to them and their sequelae. Children are vulnerable to both infections. The availability of new drugs and new therapeutic strategies are increasing the complexity and individualizing the management of children with viral hepatitis. Therefore, it is extremely important to educate and advise pediatricians concerning the new lines of treatment. More than 350 million persons worldwide are infected with HBV. Although its incidence has dramatically declined since the implementation of universal immunization programs in many countries, scores of children are still being infected each year. Despite its benign course, chronic hepatitis B (CHB) during childhood and adolescence, 3-5% and 0.01-0.03% of chronic carriers develop cirrhosis or hepatocellular carcinoma (HCC), respectively, before adulthood. Treatment of CHB in childhood has been hampered by the long delay in licensing new drugs for pediatric use. Safe and effective antiviral therapies are available in adults, but few are labeled for use in children, and an accurate selection of whom to treat and the identification of the right timing for treatment are needed to optimize response and reduce the risk of antiviral resistance. Although several guidelines on the management of adult patients with CHB have been published by major international societies, the clinical approach to infected children is still evolving, and is mostly based on the expert opinions. Standard interferon (IFN)-α is still the treatment of choice for most children with HBV infection. Licensing of highly-effective nucleoside/nucleotide analogues (NA) for older children and adolescents has opened new possibilities of treatment. However, the risk of emergence of drug resistant strains is a public health problem and a major long-term issue for young patients. Before starting a child on NAs, the risks of treatment should be carefully weighed against the possible benefits. As the management of special patient populations is problematic and not evidence-based, their referral to highly specialized centers is strongly recommended. The World Health Organization estimates that over 250 million people worldwide are chronically infected with HCV. In countries where adults have a high prevalence of HCV infection, an increased prevalence in children can also be expected. In Egypt, for example, approximately 1-2% of children are infected. The child infected with HCV must be over 2 years old in order to be treated by a licensed drug. The standard of care therapy is pegylated IFN-α plus ribavirin with success rates as similar in adults. The first-wave, first-generation oral direct acting anti-virals (DAAs) telaprevir and boceprevir were licensed by the FDA for use in HCV genotype 1 infection in adults in 2011. Telaprevir and boceprevir must be coadministered with pegylated IFN-α and ribavirin. Sofosbuvir, the second-wave DAA has been approved in adults in January 2014 and other DAAs are on the way of approval soon in adults. Some DAAs are being tested for children and the results are eagerly awaited.