Enhanced Hepatitis Strain & Surveillance System (EHSSS) in Review

2000-2011

BCCDC Hepatitis Site

Site Investigator: Liza McGuinness

2

Overview

BCCDC EHSSS Two major goals: Obtain more accurate assessment of current

infection levels Track HBV & HCV transmission risk factors

BCCDC site, province of British Columbia: Responsible for most of BC (2000-2011 excluded

City of Vancouver, 2012 → exclude Vancouver Coastal Health Authority)

Coordinated by Hepatitis, Clinical Prevention Services at BCCDC

Follow up all identified acute HBV and HCV

3

Overview Between 2000-2011

1180 individuals identified as of February 16, 2012 319 Acute HBV, 853 Acute HCV, 7 Acute HBV/HCV co-infection

HCV/HBV numbers decreasing

106

78

5449

1722 18

6 8

79

90

55

8274

51

91

44

34

413333

28

50

29

0

20

40

60

80

100

120

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

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 (Interior, Fraser)

Future: federal & provincial corrections re: information access

7

For all mono-infected cases 2000-2011n= 319 acute HBV, n= 853 acute HCV

8

0%

20%

40%

60%

80%

100%

50 + yrs. 9 13 3 10 8 8 7 5 9 9 1 3 85

40 to 49 yrs. 8 12 5 4 9 15 6 4 6 4 2 3 81

30 to 39 yrs. 4 12 8 11 10 14 12 6 5 4 3 1 87

20 to 29 yrs. 8 12 12 7 6 4 7 1 2 1 0 1 61

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

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total

Acute HBV Cases by Age

9

Acute HBV Cases by Gender

818 9 9 7 11 12

2

83 1

391

21 32 19 24 26 30 22

15

1415 5

5228

0%

20%

40%

60%

80%

100%

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

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 0 0 28

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

Interior 3 5 2 3 3 9 4 2 3 2 1 1 38

Vancouver Island 9 14 7 14 12 8 5 5 4 3 1 2 84

Fraser 11 22 14 11 13 20 19 10 15 10 4 5 154

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total

*

* Van Coastal cases exclude City of Vancouver (population 651,048 in 2011)

11

0%

20%

40%

60%

80%

100%

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

40 to 49 yrs. 5 8 9 9 14 7 18 16 17 13 13 11 140

30 to 39 yrs. 12 33 19 33 17 17 21 29 34 15 13 14 257

20 to 29 yrs. 18 40 17 24 39 23 34 27 37 38 22 20 339

0 to 19 yrs. 7 8 4 7 8 6 10 2 6 7 2 0 67

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total

Acute HCV Cases by Age

12

Acute HCV Cases by Gender

24 26 38 39 29 46 39 57 45 2922 439

20 46 25 36 43 26 44 40 49 33 2527 414

45

0%

20%

40%

60%

80%

100%

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Total

Male

Female

82% (55/67) 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 6 3 53

Northern 2 13 5 7 13 4 13 11 12 11 6 4 101

Interior 10 16 10 8 8 11 18 14 11 11 5 7 129

Vancouver Island 11 25 13 27 20 15 18 12 21 9 5 9 185

Fraser 14 32 21 24 33 22 37 41 56 41 31 25 377

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total

*

* Vancouver Coastal Cases do not include City of Vancouver† 8 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 2007-11) 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 2000-2011n=191/319 acute HBV n=220/853 acute HCV

16

1014

18 2126 30 23

1015

10

6 8

17 34

9

4

2 5 95 3

1

2 1

85 5

21 3

1 11

1

1

4

21

0%

20%

40%

60%

80%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Interviewed Unable to locate Language BarrierRefused Died

Acute HBV Interviews by Year

17

1423

9

26 32

1112 6

2429

1618

25 6238

39 36

36 70 68

39

2623

22

8

31

3 5 4 9 13 8 7 518 7 8 6

20

10411 4

1 1 11 2

0%

20%

40%

60%

80%

100%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Interviewed Unable to locate Corrections*

Language Barrier Refused Died

Acute HCV Interviews by Year

* Corrections tracked starting in 2008

18

For interviewed 2000-2011acute HBV (n=191) acute HCV (n=220)

19

Acute HBV Risk factors 2000-11

In the previous 12 mo’s before diagnosis:

28% no risk factors identified (54/191) 44% only 1 risk factor identified (84/191)

o 41% - only sexual risk factors (79/191)o 2% - only IDU (3/191)o 1% - only NIDU (2/191)

20

Acute HBV Risk factors 2000-11

In previous 12 mos before diagnosis:

28% had risk factor combinations (53/191) 11% - NIDU & sexual risk factors (21/191) 5% - IDU, NIDU & sexual risk factors (9/191) 3% - IDU, NIDU, sex & incarceration risk factors

(6/191) 3% - IDU & sexual risk factors (5/191) 2% - IDU, NIDU & incarceration (4/191)

(Other risk factors or combinations = 4% (8/191))

21

Acute HBV Risk factors 2000-11

In the previous 12 mos before diagnosis:

17% - injection drug use (32/191) – in

3 cases was single risk factor

7% - incarcerated – all in combination with drug use 13/191

22

Acute HBV Risk Factors 2000-11

161

75

49 4526

0

20

40

60

80

100

120

140

160

180

2000-2011Diff Sex NIDU IDU Incarceration Same sex

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

Lifetime risk factors:

(84%)

(39%)

(26%) (24%)

(14%)

23

Acute HBV IDU Proportions

1

6

3

10

7 8 6 2 31

0

2 49

9

8

15

11

19 22 17 8 129

6

6 142

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

Total

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

24

HBV Risk Factors 2000-11

17 cases did not report lifetime drug use, prison and/or sex risk factors 3 - Medical exposure during travel to India 2 - Travel to foreign country 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 2000-11

In the previous 12 mo’s before diagnosis:

No risk factors identified (10%, 22/220) Only 1 risk factor identified (19%, 41/220)

6% - injection drug use only (13/220) 9% - only sexual risk factors (19/220) 4% - non-injection drug use only (8/220) <1% - incarceration only (1/220)

26

Acute HCV Risk factors 2000-11

In the previous 12 mo’s before diagnosis:

70% - injection drug use (153/220) (13/153 cases = single risk factor)

15% - had been incarcerated (34/220) (1/34 case = single risk factor)

27

Acute HCV Risk Factors

203180 179

83

440

50

100

150

200

250

2000-2011

Diff sex NIDU IDU Incarceration Same sex

Lifetime risk factors:

(92%)(82%) (81%)

(38%)

(20%)

28

HCV Risk Factors 2000-11

5 cases reported no lifetime drug use, prison or sex risk factors 1 - Reported living with a son who was an

IDU (2010) 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

87

34

2724

41

56

78

22

0

10

20

30

40

50

60

70

80

90

100

1 Risk Factor 2 Risk Factors 3 Risk Factors 4 Risk Factors

HBV HCV

HBV & HCV Multiple Risk Factors

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

46%

19%18%

25%

35%

10%14% 13%

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

HBV

Sex n=84/191

44%

NIDU & Sex n=20/191

10%

IDU, NIDU & Sex

n=16/191

8%

IDU, NIDU, Incarceration & Sex n=24/191

13%

HCVSex n=13/220

6%

IDU & Sex n=19/220

9%

IDU, NIDU & Sex n=79/220

36%

IDU, NIDU, Incarceration & Sex n=71/220

32%

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 now decreasing for

last 3 years 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, Adrienne Pelton for data entry and interviewing, & our partners in public health who conduct interviews on behalf of the EHSSS