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Robinson, Joan L. M.D.

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The Pediatric Infectious Disease Journal: November 2000 - Volume 19 - Issue 11 - p 1114
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To The Editors:

I question the conclusions reached by Sinha and Das. 1 The assumption that treatment of all children with chronic hepatitis C infection with antivirals is cost-effective may be in error based on the following: (1) It is not known how the long term prognosis of chronic hepatitis C in children compares with the prognosis in adults. Spontaneous viral clearance appears to be a more common event in children than in adults, 2 so it seems possible that long term prognosis of chronic hepatitis may also be better in children. All calculations in the paper depend on the probabilities chosen for progression to cirrhosis. These values are extrapolated from adult values, and even the adult values are not yet established. (2) A sustained response rate of 58% is quoted for 6-month interferon treatment trials. However, it is not clear from the text that this is 58% of the 67% who had end of treatment response, which is only 39% of the treated patients. Nonetheless in the analysis antiviral treatment was the favored strategy as long as sustained response rate was >3%. However, again one questions the probabilities chosen for progression to cirrhosis because it does not seem logical that it would be worthwhile treating if the response rate were this low. (3) It is becoming clearer that adults who have no fibrosis after 10 years of chronic hepatitis have an excellent long term prognosis. 3 It seems premature to recommend treatment for all children until the risk of progression in different risk groups is better understood. (4) The conclusion that treatment is cost-effective ignores the possibility that antiviral treatment that proves to be ineffective could induce resistance and jeopardize success when more effective antiviral drugs become available. Also, it has been suggested that treatment with interferon in patients with mild hepatitis can alter the host immune response and result in persistent elevation of liver enzymes above pretreatment levels. 3

Given the slow progression of chronic hepatitis C in the vast majority of children and the high probability that more effective treatment strategies will become available in the next decade, I believe that antiviral treatment should be considered only in children who have moderate or severe hepatitis.

Joan L. Robinson M.D.

1. Sinha M, Das A. Cost effectiveness analysis of different strategies of management of chronic hepatitis C infection in children. Pediatr Infect Dis J 2000; 19: 23–30.
2. Aach RC, Yomtovian RA, Hack M. Neonatal and pediatric posttransfusion hepatitis C: a look back and a look forward. Pediatrics 2000; 105: 836–42.
3. Levine RA. Treating histologically mild chronic hepatitis C: monotherapy, combination therapy, or tincture of time? Ann Intern Med 1998; 129: 323–6.

Hepatitis C

© 2000 Lippincott Williams & Wilkins, Inc.