Integrating Prevention, Control
and Therapy for Viral
Hepatitis:
The Canadian Model
David M. Patrick, MD, FRCPC, MHSc
Associate Professor
University of British Columbia
Centre for Disease Control
Vancouver, Canada
Rationale for Integration
R = ßcD
ß is the risk of transmission per contact
c is the number of contacts per unit time
D is the duration of infectiousness
•Acting on any one variable may not be enough.
•Ignoring the infected is not defensible.
Control Strategies

Contact Rate - c
– Health Promotion
 safer sex
 substance use
– Blood safety
– Regulation of food and
water sources
– Occupational Health
practices
– Travel Clinics
– Macro-economics

Transmission Risk-ß
– Immunization
– Isolation methods


Barrier Methods – gloves /
condoms
Precautions around
Parenteral Exposures
– Hygiene
Control Strategies - D

Treat and cure the infection
– Screening
– Diagnosis
– Contact Tracing

Non-curative treatment which eliminates
infectiousness
Model for an Integrated Hepatitis Approach
Consistent screening/ testing supplemented
by epidemiological studies
Link test results to clinical follow-up and
management records
Integrated prevention and care management
Measure outcomes
Improvements in Process
Prevention & and Care Research
Updated & evaluated guidelines
for prevention and management
Information on drivers of incidence.
Modification of prevention programming
National Level Organizations

Health Canada
 Canadian Viral
Hepatitis Network
 Canadian Liver
Foundation
National Level Links: Canada
Health Protection Branch
Blood Regulation
Organ Regulation
Health Promotion and
Programs Branch
Hep Compensation Dept
Canadian Blood System
BLOOD SAFETY
Blood-Borne Pathogens
includes CABBI
Winnipeg Labs
Hepatitis
CJD and Genetics
Cancer Bureau
Cancer and Blood
HIV Bureau
Retrovirus Surveillance
National Laboratory
Winnipeg:
•Reference centre for Public Health
•Development of new diagnostic tests for hepatitis
•In collaboration with Medical Devices therapeutics
for lot releases for new hepatitis kits
•Quality Assurance and Quality Control for
evaluation of panels in hospital laboratories and
blood system
•Centre of Excellence for new viral hepatitis & BBP
Community Acquired Blood-Borne
Infections Section
Mandate: Surveillance, risk assessment, prevention and
control of viral hepatitis and emerging blood-borne
pathogens
Activities:
-
-
Surveillance
Targeted research
Knowledge synthesis, analysis and policy development
Recommendations on prevention and control
Surveillance for Viral Hepatitis and
Emerging Blood-Borne Pathogens in Canada
Enhanced surveillance
– is a sentinel health region surveillance system for acute
hepatitis B and acute hepatitis C
– consists of 6 municipalities, approximately 16% of
Canada’s population
– provides data on incidence of acute hepatitis B and
hepatitis C and transmission patterns
Acute Hepatitis B
Incidence 2000
7
Per 100,000 pys
6
5
4
3
2
1
0
<15 yrs
15-29 yrs 30-39 yrs 40-59 yrs
Male
Female
*Data from 4 sites, 11% of Canadian population
Total
60+ yrs
Total
Acute Hepatitis C Incidence –
2000*
8
Per 100,000 pys
7
6
5
4
3
2
1
0
<15 yrs
15-29 yrs
30-39 yrs
Male
40-59 yrs
Female
Total
*Data from 4 sites, 11% of Canadian population
60+ yrs
Total
Enhanced Surveillance Risk
Factor Information

Substance use most important risk factor for
hepatitis C, significant for hepatitis B
 Risky sexual behaviour important risk
factor for hepatitis B, especially among gay
and bisexual men
 Significant proportion of cases have no
known risk factor
Percent of case
Ethnicity of Hepatitis B and C
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Aboriginal
Afroamerican
Asian
Hep B
*Vancouver cases April 1, 2000-March 31, 2001
Caucasian
Hep C
Other
Unknown
Surveillance for Viral Hepatitis and
Emerging Blood-Borne Pathogens in Canada
Hospital Surveillance Centres and the Canadian
Viral Hepatitis Network


Sentinel Regions Surveillance:
– less effective in assessing the burden of disease
– difficult to follow up the natural history
Applications of Hospital Based Surveillance:
– Blood-borne pathogens and chronic diseases
– evaluation of medical practices as well as interventions
– education, counseling and other public health functions
Integrated Approach
Clinical
Data
Laboratory
Data
• prevalence
Required
Knowledge
• natural history
(Scrambled Data)
Vital
Statistics
Population Health/
Policy Requirements
Billing
Data
• intervention
effectiveness
• economic burden
Canadian Viral Hepatitis
Network
• representation from provinces/territories, non-government organizations, Statistics Canada,
CIHI, academics/clinicians and the Centre for Infectious Disease Prevention & Control
Population & Public Health
Working Groups
Infectious Diseases
Expert Advisory Groups
• input on issues and priorities to
Steering Committee/Working
Groups
Technical Working
Group
Secretariat
Support
• data & data management expertise
• statistical expertise
• provided by Health Canada
Canadian Liver Foundation

Established 1969
 supports research
 public information and
education
– living with liver
disease programs
– help-line
– pamphlets
– awareness programs
#S
#S
#S
Annualized Rate of HCV
by Service Area/Centre
(per 100,000 population)
&
V
&
V
&
V
British Columbia
< 100
100 - 200
> 200
Rural and Semi-Urban
Community Reporting HCV
#S
Below BC Mean
#S
Above BC Mean
#S
#S #S
#S
#S
N
#S
#S
#S
#S S
#
#S
BC Health Authorities
Interior
NORTHERN
E
W
Fraser
S
Vancouver Coastal
#S
#S#S
Nisga'a
#S
#S
Sources:
Vancouver Island
Hepatitis C data are from Epidemiology Services, BC Hepatitis Services
and Laboratory Services divisions of the BC Centre for Disease Control.
#S
#S
Northern
Population figures are from the Statistical Profile of Canadian Communities,
Census 1996, Statistics Canada.
#S
#S
Nisga'a
#S
#
S
#S
Note: The Nisga'a Health Council will
remain an independent health authority.
Geographic data are from BC STATS, BC Ministry of Finance and Corporate
Relations.
#S
#S
#S
#S
#S #S
#S
#S
&
V
Prince George
#S
#S
#S
Explantion of Spider Diagram Analysis:
#S
#S
On this map, all rural, semi-urban and
urban communities with populations less
than 25,000 are assigned to the closest
"service centre". A service centre is
defined as an urban community with a
population of 25,000 and greater, and has
clinical services to provide HCV treatment.
#S
#S
#S
#S
The annualized HCV rate reported on this
map represents the cumulative rate of HCV
of all communities within the service area.
The mean annual HCV rate from 1992-2000
is 106.4 cases per 100,000 population for BC.
#S
#S
#S
#S
#S
#S
#S
INTERIOR
#S
#S
West Vancouver
FRASER
North Vancouver
COASTAL
#S
#S
Port Coquitlam
#S
&V
V
&V
& V
&&V
& V
&&V
V
&
&V
V
&
V
& V
& V
&
V
#S
Maple Ridge
Mission
#
# #S
#S S
#
#S S
#S
#S #S #S S
#
#S
#S
#S #S
S
Delta #
#S
#
#
#S
#S
#S #S
Vancouver
#
#
#S
#S
#S #S
#
&
V
Richmond
#S
Chilliwack
#
#S #S
Duncan
#S
#S
##S
S
#
Nanaimo
VANCOUVER
ISLAND
#S
#S
#S
Burnaby
&
V
#S
#
S
Surrey
#S
Abbotsford
##S#S
S
#S
20
##S
S
#S
0
20
Kilometers
&
V
Southwest BC Inset Map
#S #S
Victoria
#S
#S
#S
#S
COASTAL
#S
&
V
&
V
#S
#S#S
#S
Campbell River
VANCOUVER
#S
#S #S
#S
ISLAND
#S
#S
#S
#S
#S
#
S
#S
&
V
&
V
&
V
#S
#S
#S
#
S
FRASER
#S
#S #S #S
#S#S
#S #S#S
# S
#S #S#S#S#S#S #S S
##S#S
#S #S#S
#S
#S
#S
&&
V
&V
V
&V
&& V
&V
&
V
& V
V
&V
&V
&V
&&
V
V
&
V
&
V
#S #S
#S
#S #S
#S
#S #S
#S
#S #S
#S
#S
#S
#S #S
#S
#S
#S #S
#S
##S #S
S
#S
#S
#S
#S
#S#S
#
S
#S
#
S
#S
#S
#S
Vernon
#S
#S
#S
#S
#S
Kamloops
#S
#S
#S
#S
#
S
#S
VANCOUVER
#S
New Westminster
#S
#S
#S
Langley
#S
#S
#S
#S
#S
#S
Coquitlam
#S
#S
#S
##S
S
#S
#S
VANCOUVER
#S
#S
Kelowna
#S
#S
#S
#S
#S
##S #S
S
#S
#S
# #S
S
#S
#S
#S
#S
#S
#S
Penticton
#S
#S
#S
#S
#S
#S
##S
S
#S
#S
#S#S #S#S
#S
#
S
#S
200
0
Kilometers
See Southwest BC Inset Map
200
Goals of BC Hepatitis Services
•Optimal Surveillance
•Evidence-based Prevention
• Care Management
•New, effective, & expensive drugs that
improve outcomes  are they cost-effective?
Population
Individual
Was a Centre for
Excellence the Answer?
British Columbia Centre for
Disease Control
Communicable Disease Control
Epidemiology
Microbiology
Clinical Services
Surveillance

Public Health Information System
 Transfusion Transmitted Infection Reporting
 Laboratory Linkage
– testing, PCR and genotyping at the BCCDC
– bar-coded labels for specimens

link provider, patient and outcome
– pilot treatment cohort tracking system

Specific Studies
– seroprevalence; enhanced surveillance
– IDU and MSM cohorts
Hepatitis A Prevention

Hygiene
 Food Inspection
 Travel Advisories
 Immunization
–
–
–
–
High Risk (MSM, IDU)
Chronic Liver Disease
Targeted Blitzes
Contacts and Outbreak Control
Hepatitis A in Canada and
B.C.
Rate per 100,000 population
30
25
20
BC
Canada
15
10
5
0
92
93
94
95
96
97
98
99
0
1
Reported Hepatitis A Vancouver 19972001 – Risk Factors
MSM
30
Vaccination
Campaigns
25
SROs
15
10
5
IDUs
Unknown
Dr. Patricia Daly
Contact
Travel
DTES/IDU
MSM
Oct-01
Jul-01
Apr-01
Jan-01
Oct-00
Jul-00
Apr-00
Jan-00
Oct-99
Jul-99
Apr-99
Jan-99
Oct-98
Jul-98
Apr-98
Jan-98
Oct-97
Jul-97
Apr-97
0
Jan-97
Cases
20
Immunization for Hepatitis B
High Risk since 1980’s
 Age 11 since 1992

– But routine pre-natal screening and readily
available HBIG and birth dose

Infants since 2000
Hepatitis B in Canada and
B.C.
Rate of Acute Disease per 100,000 population
12
10
8
BC
Canada
6
4
2
0
92
93
94
95
96
97
98
99
0
1
Hepatitis B Age-group 11-20
Cases of Acute Disease per 100,000 population
25
20
15
BC
10
5
0
92
93
94
95
96
97
98
99
0
Antenatal Seroprevalence of Anti-Hep B core, 1999
Percent Reactive
20%
18%
16%
14%
12%
11.1%
11.9%
10.4% 10.4%
10%
7.4%
8%
6.5%
5.2%
6%
4%
2%
0.0%
0.7%
1.5%
0.0%
0%
Age
Group
15-16
17-18
19-20
21-22
23-24
25-29
30-34
35-39
40-44
Total
43
41
39
37
35
Total
Age
33
31
29
27
25
23
21
19
17
90
80
70
60
50
40
30
20
10
0
15
IU
Geometric Mean Titre
for anti-HBs by Age
Hepatitis C Prevention

Blood screening
 Harm Reduction
– street nurses
– NEP (no parephenalia stuff)
– No safe injection sites but starting
Hepatitis C in Canada and
B.C.
Rate per 100,000 population
250
200
150
BC
Canada
100
50
0
92
93
94
95
96
97
98
99
0
1
Vancouver Injection
Drug User Cohort
100
HIV
80
HCV
60
40
20
0
Dec 96 May 97
Jun 97 Nov 97
Dec 97 May 98
Jun 98 Nov 98
Dec 98 May 99
Jun 99 Nov 99
HIV
19.4
6.0
2.5
2.5
3.4
2.0
HCV
64.8
27.2
23.4
28.9
20.7
16.7
Chronic Viral Hepatitis Therapy

Funding not a huge problem
 Catering to patient population is
 Type distribution
– Hep C 65% 1; 35% non 1 mostly 2&3

Consumer advocacy is building
 Specific Efforts for Street Involved
including pilot integrated treatment clinics
in each region
Hepatitis B Therapy

Lamivudine still not curative
 coverage for one year (case by case review
thereafter)
 e ag pos and pre-core mutants
Issues of Importance when Developing
Education Programs Identified by
Provincial Hepatitis Advisory Committee





need for consumer & professional education
nursing education to support advanced practice
include co-infection with HIV & chemical
dependency
professional & consumer involvement in
development of curriculum & materials
broad representation on advisory committee
Challenges

Funding of IT
 Multiple blood-borne infections in
marginalized populations
– eg. substance use

Historic problems and marginalization for
First Nations (Aboriginal Groups)
 Immigration
 Trend to reduced spending on social issues
Global Context

Vaccines are still job one
 WHO coverage assessments
– not operational yet

Rapid tests and treatment
– We’re not so sure
– Cost efficacy
– Rx good value but not like vaccine
Where next?

Better linkage of public health and
treatment
 Health Care Worker Education
 Nurse practitioners
 Integrated drug and hepatitis Rx
 Broader population programs for Hepatitis
A immunization?
Acknowledgements

Mel Krajden, Gail Butt, Warren Hill
 Tony Giulivi, Leslie Forester
 Patricia Daly