Childhood hepatitis C burden falls worldwide but progress stalls in high-burden regions

A new analysis of the Global Burden of Disease (GBD) Study 2023 estimates that roughly 10.16 million children and adolescents under 20 years of age were living with chronic hepatitis C virus infection worldwide in 2023, up slightly from 9.98 million in 1990. The proportion of young people infected declined more clearly, from 0.443 percent of the under-20 population in 1990 to 0.380 percent in 2023, a relative drop of 14.1 percent. Mortality and disability fell faster: deaths among children and adolescents dropped by about a third over the same period, and disability-adjusted life years, or DALYs, declined by a similar margin. Yet the study also flags a worrying signal. After the late 2010s, the modelled prevalence estimates stopped falling and edged upward, a pattern the authors interpret cautiously but one that coincides with pandemic-era disruptions to hepatitis C testing and treatment services.

The analysis, a secondary study of publicly available GBD 2023 results, is among the first to provide a comprehensive, long-term global assessment of paediatric chronic hepatitis C across prevalence, mortality, DALYs, age groups, sex, geography, and socioeconomic development. It covers 204 countries and territories from 1990 to 2023, organised across seven GBD super-regions. Chronic hepatitis C in children is largely silent: most infected young people show no symptoms, but in an unknown proportion the infection progresses silently over years toward liver fibrosis and, in some, cirrhosis, with hepatocellular carcinoma possible in those with advanced fibrotic disease. Roughly half of infants who acquire the virus from their mothers clear it spontaneously by age three, but children who have not cleared the infection by then usually remain chronically infected into adulthood, sustaining transmission and accumulating risk of severe liver disease later in life.

The GBD 2023 modelling framework behind these estimates is complex. Chronic hepatitis C prevalence is derived from anti-HCV antibody seroprevalence data, which indicate exposure but cannot by themselves distinguish current infection from resolved past infection. The model converts antibody positivity into estimates of current RNA-positive infection using a meta-analytically derived ratio and adjusts for treatment-related cure, drawing on treatment data from 34 countries assembled with the Coalition for Global Hepatitis Elimination. Estimation runs through DisMod-MR 2.1, a Bayesian meta-regression framework that synthesises heterogeneous epidemiological inputs across age, sex, location, and year while enforcing consistency among incidence, prevalence, remission, and excess mortality. Mortality is modelled separately with the Cause of Death Ensemble model, which tests multiple model specifications and combines the better-performing ones. Where sex- or age-stratified inputs were unavailable, modelled patterns were used to split estimates, which means those contrasts are partly model-dependent.

Geographically, the burden in 2023 was strikingly uneven. The highest country-level prevalence estimates were in Turkmenistan at 0.646 percent, Myanmar at 0.645 percent, Cambodia at 0.633 percent, Egypt at 0.595 percent, and Ghana at 0.591 percent, with additional high estimates across parts of Central Asia and sub-Saharan Africa. At the other extreme, several high-income European settings recorded the lowest estimates, including Iceland at 0.088 percent, Norway at 0.097 percent, the Netherlands at 0.104 percent, and Sweden at 0.107 percent. Across super-regions, sub-Saharan Africa had the highest prevalence at 0.488 percent, the highest mortality rate at 0.1469 deaths per 100,000 under-20s, and the highest DALY rate at 12.21 per 100,000. The high-income super-region recorded a prevalence of 0.181 percent, a mortality rate of 0.0049 deaths per 100,000, and 0.45 DALYs per 100,000. Prevalence declined in six of the seven super-regions between 1990 and 2023, the exception being the combined Central Europe, Eastern Europe, and Central Asia region, while mortality and DALYs fell in all seven.

Country-level trajectories varied widely. Mongolia recorded the largest relative reduction in prevalence, at 54.4 percent, followed by Georgia at 41.6 percent and Spain at 37.6 percent. In contrast, Zimbabwe, American Samoa, and Bhutan saw the largest relative increases in prevalence rate, at 24.3, 24.2, and 23.2 percent respectively. Mortality and DALY rates fell in most countries, with the largest relative reductions observed in Eastern Asia, where South Korea showed the steepest declines in both measures. In absolute global terms, estimated annual deaths among children and adolescents fell from 2,008 in 1990 to 1,590 in 2023, and DALYs fell from roughly 168,860 to 135,033. Years of life lost accounted for the majority of DALYs, reflecting the fact that hepatitis C kills few children but those deaths represent substantial lost healthy life.

Age emerged as a defining feature of the paediatric epidemic. Prevalence rose stepwise with age throughout the study period: in 2023 it was estimated at 0.088 percent among children younger than five years, 0.274 percent at ages five to nine, 0.472 percent at ages 10 to 14, and 0.691 percent among adolescents aged 15 to 19. This gradient is consistent with the natural history of the infection. Infants who fail to clear vertically acquired virus carry it into early childhood, and horizontal exposures, including needle use and sexual transmission, become increasingly relevant during adolescence, particularly among young people at elevated risk. The authors note that the direction of this age pattern is more robust than its precise magnitude, because directly observed age-specific paediatric data remain sparse and the steepness of the GBD gradient differs from earlier modelling work that suggested a more modest climb across age groups.

Paediatric HCV-related liver cancer remained rare. For ages 10 to 14, GBD 2023 estimated 63.2 prevalent cases, 11.9 deaths, and 926.7 DALYs globally in 2023; for ages 15 to 19, the corresponding figures were 99.3 prevalent cases, 18.5 deaths, and 1,349.8 DALYs. These estimates were not available for children younger than 10 years. Even so, years of life lost dominated the liver cancer DALY totals, underscoring that the small number of paediatric liver cancer cases carries a disproportionate weight in lost healthy life. The authors caution that the rarity of paediatric HCV-related liver cancer makes these estimates particularly uncertain.

The socioeconomic gradient in the data reinforces the picture of paediatric hepatitis C as a marker of health-system capacity rather than merely a virological legacy. In 2023, the middle sociodemographic index group had the highest prevalence at 0.454 percent, while the low SDI group had the highest mortality and DALY rates, at 0.1173 deaths and 9.85 DALYs per 100,000 under-20s. The high SDI group recorded the lowest values on all three measures. The authors argue that these gradients reflect unequal access to screening, confirmatory RNA testing, safe blood and injection practices, maternal diagnosis, and paediatric direct-acting antiviral treatment. Egypt’s experience illustrates the point: large adult screening and treatment campaigns substantially reduced population-level burden, yet residual paediatric infection persisted where antenatal and younger-child pathways were not explicitly included.

The late-period uptick in modelled prevalence after 2018 and 2019 demands careful interpretation, the authors stress, because it rests on modelled estimates with incomplete treatment uptake data for many countries during 2020 to 2023. Nevertheless, the signal aligns with documented disruptions to hepatitis C services during the COVID-19 pandemic and with the delayed incorporation of children into direct-acting antiviral programmes. Supporting signals come from national surveillance: the United States recorded 235 perinatal hepatitis C cases in 2023, 38 more than in 2022, even as testing of perinatally exposed infants declined in some areas, and Chinese surveillance showed a 6.13 percent rise in reported adult hepatitis C incidence in 2021 relative to 2020. Paediatric burden is likely mediated indirectly through reduced maternal diagnosis, delayed postpartum treatment, and incomplete follow-up of exposed infants.

The study’s authors frame the findings around four strategic priorities. National elimination plans should explicitly include children, adolescents, and pregnant women rather than assuming adult treatment scale-up will reach paediatric populations indirectly; a global policy review has found many national plans lack paediatric testing or treatment recommendations. Antenatal screening should be linked to confirmatory RNA testing, maternal treatment before pregnancy or postpartum according to local guidance, and systematic testing of perinatally exposed infants, with RNA testing recommended at two to six months of age in some guidance and persistence-of-antibody testing beyond 18 months remaining a more affordable option in low- and middle-income settings. Access to direct-acting antivirals for children aged three years and older should be treated as a core elimination activity, supported by cost-effectiveness analyses of early paediatric treatment and one-time childhood screening. Finally, global health stakeholders should prioritise regions where high prevalence intersects with weak screening infrastructure and limited maternal-child follow-up, including parts of Central Asia, sub-Saharan Africa, and South-East Asia. The authors acknowledge important limitations: estimates depend on sparse and sometimes old serological inputs, particularly in low-income settings where modelling and regional borrowing of information likely underestimate true burden, and DALYs capture only a small fraction of the lifetime burden that early treatment could prevent, since asymptomatic chronic infection carries little or no disability weight. With the World Health Organization’s 2030 elimination target approaching, the analysis suggests that adult-focused campaigns alone will not close the paediatric gap.

Subject of Research: Global burden and trends of chronic hepatitis C infection in children and adolescents, 1990 to 2023

Article Title: Paediatric chronic hepatitis C and the global elimination gap: burden and trends from 1990 to 2023 in the Global Burden of Disease Study 2023

Article References: Hong, S.-J., Zhang, X., Malik, F., Goh Suk-Hui, L., El-Shabrawi, M. H. F., Ciocca, M., Indolfi, G., Hardikar, W., Kelly, D., Schwarz, K. B., & Hartmann, P. (2026). Paediatric chronic hepatitis C and the global elimination gap: burden and trends from 1990 to 2023 in the Global Burden of Disease Study 2023. eClinicalMedicine, 101, Article 104281. https://doi.org/10.1016/j.eclinm.2026.104281

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104281

Keywords: hepatitis C, paediatric HCV, Global Burden of Disease, GBD 2023, vertical transmission, direct-acting antivirals, DALYs, elimination, sub-Saharan Africa, antenatal screening, liver cancer, epidemiology