Post on 31-Mar-2015
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
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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