Differences in viral hepatitis management in children and adults

A symposium addressed chronic viral hepatitis management in children, and whether all children with chronic viral hepatitis should be treated.

Should all adults and children with chronic viral hepatitis be treated?

The first question to which Dr. Giuseppe Indolfi of Meyer University Children's Hospital in Florence, currently chairman of the Hepatology Committee of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), and Professor Alessio Alghemo of Humanitas University in Milan, an expert in gastroenterology, addressed is whether all adults and children with chronic viral hepatitis should be treated.

Talking about hepatitis C, for example, adults have long benefited from approved treatments, while children have only recently had access to specific therapies. For children, the efficacy of new drugs has been surprising, with high response rates. However, in these patients, the main challenge has been poor treatment compliance, especially in younger children. Although liver fibrosis is less severe in children than in adults, treatment primarily aims to eliminate early infection to improve quality of life and prevent transmission. For children, the decision to treat can be complicated by the lack of long-term data and the difficulty of assessing disease progression without a valid comparison.

Treating all children with chronic viral hepatitis can lead to significant long-term benefits, reducing the risk of future liver complications and improving quality of life.

Hepatitis C therapy also in children and adolescents

New direct-acting antiviral (DAA) drugs have demonstrated high efficacy even in pediatric patients; however, poor treatment compliance, especially in younger children, remains an area of concern.

It has been pointed out that early treatment can lead to significant benefits in reducing the risk of future liver complications and improving quality of life. In addition, long-term safety data indicate that treatment does not adversely affect children's growth or endocrine development.

For adults, it was pointed out that the decision to treat depends on the specific case and the presence of other medical conditions. However, in general, treatment is recommended if it is expected to benefit the patient. Even in older adults or those with other comorbidities, treatment of hepatitis C can lead to significant improvements in quality of life and prognosis.

The role of physicians in ensuring access to treatment was then discussed, especially in low- and middle-income countries where treatment availability remains a problem.

Focus on hepatitis B and hepatitis D

Most pediatric cases of hepatitis B occur in the perinatal period, despite efforts to prevent mother-to-child transmission. In fact, there is a low but significant rate of prophylactic failure, leading to a high probability of developing chronic infection during the first year of life. Most still experience spontaneous antigen seroconversion within the first few years of life, but some may develop an active response over time, leading to increased transaminases and risk of liver fibrosis.

The discussion then shifted to treatment protocols for adults, highlighting how the World Health Organization (WHO) has recently expanded treatment indications for adolescents.

Finally, the issue of treatment of hepatitis delta was raised, pointing out that although it is considered a highly progressive disease, there is still a small percentage of patients who show no signs of progression. It was discussed whether to treat all patients or limit treatment to those who show signs of disease progression, also considering the costs and challenges associated with drug administration.

In general, it emerged that despite differences in treatment indications and protocols, the main goal remains to improve clinical outcomes for all patients with chronic viral hepatitis, balancing the risks and benefits of treatment according to individual needs and available resources.

Early treatment to prevent sexual transmission, especially in young people with high viral loads, was also discussed. Cases were discussed in which sexually active individuals, despite not having a treatment indication, may be concerned about transmitting the virus to their partners.  In such situations, treatment can be considered as a preventive measure to reduce the risk of transmission, even if it does not completely eliminate it.

Who should continue follow-up after a sustained virologic response?

From a pediatric perspective, the follow-up management of patients was discussed. It was found that while some patients can be left out of follow-up because they meet certain low-risk criteria, it is important to maintain regular monitoring for those with more advanced disease or comorbidities.

Also speaking of follow-up, some issues were raised regarding the transition of pediatric patients to adult care. This transition can be difficult for both patients and physicians.

Finally, the role of family physicians in the follow-up of patients after treatment was discussed. It was pointed out that in some settings, such as in Italy, family physicians may not be able to monitor patients on a regular basis, which could lead to a loss of continuity of care.

  1. Alghemo A, Indolfi G. Meet the experts - Differences in the management of viral hepatitis in children and adults. EASL 2024. Thursday, 6 Jun, 14:00 - 15:00 CEST