Enhanced Hepatitis Strain & Surveillance System (EHSSS) in Review

2000-2009

BCCDC Hepatitis Services Site

Site Investigator: Liza McGuinness

2

Overview

BCCDC EHSSS - Public Health Agency of Canada sponsored project Two major goals:

Obtain more accurate assessment of current infection levels

Track HBV & HCV transmission risk factors BCCDC site in BC:

Responsible for province of BC (excludes City of Vancouver)

Coordinated out of BC Hepatitis Services Follows all acute HBV and HCV

3

Overview Between 2000-2009

1060 individuals identified as of Feb 12, 2010 305 Acute HBV, 748 Acute HCV, 7 Acute HBV/HCV co-infection

HCV numbers increasing/HBV numbers decreasing

107

75

1722 18

80

89

55

8274

51

91

44

33

423332

29

50

29

0

20

40

60

80

100

120

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

HCV HBV

4

Case Definitions

Acute HBV HBsAg and HBcIgM reactive with

compatible clinical history and symptoms

Acute HCV Seroconversion from anti-HCV nonreactive

to anti-HCV reactive within 12 months

5

Challenges

Centralized acute HCV surveillance Limited ability to contact acute HCV across the

province from the BCCDC

Corrections Restricted or no access to individuals who test

positive in federal or provincial corrections

6

Initiatives

Regular reconciliation process ongoing with lab, iPHIS & Vancouver EHSSS

Regional Health Authorities assuming EHSSS follow up for acute HCV

Future: federal & provincial corrections re: information access

7

For all mono-infected cases 2000-2009n= 305 acute HBV, n= 748 acute HCV

8

0%

20%

40%

60%

80%

100%

50 + yrs. 9 13 4 9 8 8 7 5 9 9 81

40 to 49 yrs. 8 12 8 4 9 15 6 4 6 4 76

30 to 39 yrs. 4 12 5 11 10 15 11 6 5 4 83

20 to 29 yrs. 8 12 12 7 6 4 7 1 2 1 60

0 to 19 yrs. 0 1 0 1 0 0 2 1 0 0 5

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total

Acute HBV Cases by Age

9

Acute HBV Cases by Gender

8 18 9 9 7 12 112

83

87

21 32 20 23 26 30 2215

1415

218

0%

20%

40%

60%

80%

100%

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Total

Female MaleInfection predominates in males

10

Acute HBV Cases by Health Authority

0%

20%

40%

60%

80%

100%

Vancouver Coastal 4 5 2 5 5 1 4 0 0 2 28

Northern 2 4 3 0 0 3 2 0 0 1 15

Interior 3 5 2 3 3 9 4 2 3 2 36

Vancouver Island 9 14 8 13 12 9 4 5 4 3 81

Fraser 11 22 14 11 13 20 19 10 15 10 145

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total

*

* Vancouver Coastal Cases exclude the City of Vancouver

11

0%

20%

40%

60%

80%

100%

50 + yrs. 2 2 2 1 4 2 7 5 12 5 42

40 to 49 yrs. 5 8 9 9 14 7 18 16 17 12 115

30 to 39 yrs. 12 33 19 33 17 17 21 29 35 15 231

20 to 29 yrs. 18 40 17 24 39 23 33 28 37 36 295

0 to 19 yrs. 7 8 4 7 8 6 10 2 6 7 65

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total

Acute HCV Cases by Age

12

Acute HCV Cases by Gender

24 26 38 39 29 46 39 58 43 387

20 46 25 36 43 26 43 41 49 32 361

45

0%

20%

40%

60%

80%

100%

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Total

Male

Female

83% (54/65) of those 19 or under diagnosed with acute HCV are female

13

Acute HCV Cases by Health Authority

0%

20%

40%

60%

80%

100%

Vancouver Coastal 6 5 2 8 8 2 2 1 5 5 44

Northern 2 13 5 7 13 4 13 11 12 10 90

Interior 10 16 10 8 8 11 17 15 11 11 117

Vancouver Island 11 25 13 27 20 14 18 12 22 9 171

Fraser 14 32 21 24 33 23 37 41 56 39 320

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total

*

* Vancouver Coastal Cases do not include City of Vancouver† 6 cases not listed on chart originated in the Yukon

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Acute HBV/HCV Co-infection

7 cases since 2000 (no new cases 2007-9) 5 males 30-49 yrs; 2 females 20-29 yrs 5 cases in VIHA, 1 in Interior, 1 in Fraser

4 consecutive cases in Victoria from 2003-06 5 interviews

2 had incarceration, sexual, IDU* & NIDU** risk factors

2 had sexual, IDU and NIDU risk factors 1 had been incarcerated & had sexual and

NIDU risk factors

* Injection Drug Use = IDU** Non Injection Drug Use (Smoking crack pipes or snorting) = NIDU

15

For all mono-infected cases for 2000-2009n=177/305 acute HBV, n=185/748 acute HCV

16

1014

19 20

26 3122

1015

10

17 34

9

4

2 5 95 3

2

2 1

85 5

21 3

3

1 1 1

2

111

0%

20%

40%

60%

80%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Interviewed Unable to locate Refused Died Language Barrier

Acute HBV Interviews by Year

17

1423

9

26 32

1112 6

2428

25 6238

39 36

36 69 6946

25

35 4 9 13 8 7 5

15 723

17 101 1 1

1

1 1

4

0%

20%

40%

60%

80%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Interviewed Unable to locate Refused

Died Language Barrier Corrections

*

Acute HCV Interviews by Year

* Includes 5 cases still in follow up

18

For interviewed 2000-2009 acute HBV (n=177) and HCV (n=185)

19

Acute HBV Risk factors 2000-09

In the previous 12 mo’s before diagnosis:

Only 1 risk factor identified (74/177, 42%)

69/177, 39% - only sexual risk factors 3/177, 2% - only used injection drugs 2/177, 1% - only used non-injection drugs

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Acute HBV Risk factors 2000-09

In the previous 12 mos before diagnosis:

Risk factor combinations (43/177, 24%) 20/177, 11% - non-injection drug & sexual risk

factors 9/177, 5% - injection & non-injection drug use &

sexual risk factors 6/177, 3% - injection & non-injection drug use,

sex & incarceration risk factors (all)

5/177, 3% - injection drug use & sexual risk factors

3/177, 2% - injection & non-injection drug use

(Other risk factors or combinations = 7/177, 7%; No risk factors = 52/177, 29%)

21

Acute HBV Risk factors 2000-09

In the previous 12 mos before diagnosis:

30/177, 17% - injection drug use – in only 3 cases was single risk factor

13/177, 7% - incarcerated – all in combination with drug

use (10 IDU & NIDU, 3 NIDU only)

22

Acute HBV Risk Factors 2000-09

149

71

47 43

230

20

40

60

80

100

120

140

160

2000-2009Diff Sex NIDU IDU Incarceration Same sex

Different = sex with different gender; Same sex = sex with same gender

Lifetime risk factors:

23

Acute HBV IDU Proportions

1

6

3

10

7 95 2 3

1

47

9

8

16

10

19 2217 8 12

9

130

0%

20%

40%

60%

80%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total

Reporting IDU as a risk factor Not-reporting IDU as a risk factor

24

HBV Risk Factors 2000-09

16 cases did not report drug use, prison and/or sex risk factors

3 – Medical exposure during travel to India 2 - Travel to foreign country 3 - No risk factors identified from interview 2 - Vertical transmission 1 – Other horizontal transmission 5 - Medical Related

1 - Reported only medical procedure 1 - Reported only surgery and acupuncture 1 - Reported only blood transfusion 1 - Reported only medical procedure and dental surgery 1 – Reported injection from alternative practitioner

25

Acute HCV Risk factors 2000-09

In the previous 12 mo’s before diagnosis:

Only 1 risk factor identified (34/185, 18%)

13/185, 7% - injection drug use only 13/185, 7% - only sexual risk factors 7/185, 4% - non-injection drug use only 1/185, <1% - incarceration only

26

Acute HCV Risk factors 2000-09

In the previous 12 mo’s before diagnosis:

130/185, 70% - injection drug use (13/129 cases = single risk factor)

27/185, 15% - had been incarcerated (1/27 case = single risk factor)

27

Acute HCV Risk Factors

173

150154

65 40

0

20

40

60

80

100

120

140

160

180

2000-2009

Diff sex NIDU IDU Incarceration Same sex

Lifetime risk factors:

28

HCV Risk Factors 2000-09

4 cases reported no lifetime drug use, prison or sex risk factors 1 - Dialysis in India 1 - Reported only medical procedure 1 - Reported other exposure to needles &

medical procedure (declined diff sex risk factor Q)

1 - No risk factors identified from interview

29

70

8

33 32 33

69

22

58

2

14

0

10

20

30

40

50

60

70

1 RiskFactor

2 RiskFactors

3 RiskFactors

4 RiskFactors

5 RiskFactors

HBV HCV

HBV & HCV Multiple Risk Factors

Number of participants reporting lifetime multiple risk factors for IDU, NIDU, Different-Sex, Same-Sex and Incarceration:

30

HBV & HCV Multiple Risk Factors

Increased % of acute HCV cases with multiple risk factors

1 Risk Factor

2 Risk Factors

3 Risk Factors

4 Risk Factors

HBVSex n=76/177

43%

NIDU & Sex n=18/177

10%

IDU, NIDU & Sex

n=16/177

%9

IDU, NIDU, Incarceration & Sex n=21/176

12%

HCVSex n=10/185

5%

IDU & Sex n=19/185

10%

IDU, NIDU & Diff sex n=71/185

38%

IDU, NIDU, Incarceration & Sex n=56/185

30%

Lifetime risk factor combinations

31

Summary

Acute Hepatitis B

Identified acute cases decreasing

Sexual exposure most predominant risk factor

Vaccination of those at risk in prison is important

32

Summary

Hepatitis C Virus Identified acute cases increasing Acute infections identified in youth

occurring predominately in females Unclear if due to testing bias or increased risk

Higher % of acute HCV clients present with multiple risk factors compared to acute HBV

IDU primary transmission mode reported Incarceration remains an important correlate

33

Acknowledgements

Thanks to Amanda Yu for her statistical expertise and to our partners in public health who conduct interviews on behalf of the EHSSS