Enhanced Hepatitis Strain & Surveillance
System (EHSSS) in Review
BCCDC Hepatitis Services Site
2000-2009
Site Investigator: Liza McGuinness
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
2
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
120
107
100
91
89
74
80
80
82
75
60
55
51
44
50
40
20
29
42
29
32
33
33
17
22
18
0
2000
2001
2002
2003
2004
HCV
2005
2006
HBV
2007
2008
2009
3
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
4
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
5
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
6
For all mono-infected cases 2000-2009
n= 305 acute HBV, n= 748 acute HCV
7
Acute HBV Cases by Age
100%
80%
60%
40%
20%
0%
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Total
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
8
Acute HBV Cases by Gender
100%
80%
60%
21
32
20
23
26
30
7
12
14
22
15
15
218
40%
20%
8
18
9
9
2
3
87
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
To
ta
l
0%
8
11
Infection predominates in males
Female
Male
9
Acute HBV Cases by Health Authority
100%
80%
60%
40%
20%
0%
*
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total
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
* Vancouver Coastal Cases exclude the City of Vancouver
10
Acute HCV Cases by Age
100%
80%
60%
40%
20%
0%
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Total
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
7
8
4
7
8
6
10
2
6
7
65
0 to 19 yrs.
11
Acute HCV Cases by Gender
100%
80%
20
46
25
36
43
26
43
41
49
32 361
60%
Male
Female
40%
24
20%
45
26
38
39
29
46
39
58
43 387
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
To
ta
l
0%
83% (54/65) of those 19 or under diagnosed with acute HCV are female
12
Acute HCV Cases by Health Authority
100%
80%
60%
40%
20%
0%
*
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total
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
*
Vancouver Coastal Cases do not include City of Vancouver
† 6 cases not listed on chart originated in the Yukon
13
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
14
For all mono-infected cases for 2000-2009
n=177/305 acute HBV, n=185/748 acute HCV
15
Acute HBV Interviews by Year
100%
1
1 1
2
5
1
5
2
2
5
9
8
9
80%
4
60%
17
1
3
2
5
3
3
2
26
19
10
1
34
40%
20%
1
1
31
20
22
10
15
10
14
0%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Interviewed
Unable to locate
Refused
Died
Language Barrier
16
Acute HCV Interviews by Year
1
1 5
100%
3
1
4
1
9
13
8
7
1 5
17
80%
15
60%
25
62
39
4 3
2
1
7
*
36
38
36
69
25
69
46
40%
20%
10
14
23
26
32
28
11
9
12
0%
24
6
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Interviewed
Died
Unable to locate
Language Barrier
Refused
Corrections
* Includes 5 cases still in follow up
17
For interviewed 2000-2009 acute HBV (n=177)
and HCV (n=185)
18
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
19
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%)
20
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)
21
Acute HBV Risk Factors 2000-09
Lifetime risk factors:
160
140
149
120
100
80
60
71
40
47
20
43
23
0
Diff Sex
NIDU
2000-2009
IDU
Incarceration
Same sex
Different = sex with different gender; Same sex = sex with same gender
22
Acute HBV IDU Proportions
100%
80%
10
8
60%
19
22
16
9
17
8
12
2
3
130
9
40%
10
6
20%
7
0%
1
3
9
5
47
1
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total
Reporting IDU as a risk factor
Not-reporting IDU as a risk factor
23
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
24
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
25
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)
26
Acute HCV Risk Factors
Lifetime risk factors:
180
160
173
140
150
120
154
100
80
60
65
40
40
20
0
2000-2009
Diff sex
NIDU
IDU
Incarceration
Same sex
27
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
28
HBV & HCV Multiple Risk Factors
Number of participants reporting lifetime multiple risk factors for IDU, NIDU,
Different-Sex, Same-Sex and Incarceration:
70
70
69
58
60
50
40
33 32
33
30
22
20
10
14
8
2
0
1 Risk
Factor
2 Risk
Factors
3 Risk
Factors
HBV
HCV
4 Risk
Factors
5 Risk
Factors
29
HBV & HCV Multiple Risk Factors
Lifetime risk factor combinations
1
2
Risk Factor
Risk Factors
Sex n=76/177
NIDU & Sex
n=18/177
HBV
43%
10%
3
4
Risk Factors
Risk Factors
IDU, NIDU & Sex
n=16/177
IDU, NIDU,
Incarceration &
Sex n=21/176
%9
12%
Sex n=10/185
IDU & Sex
n=19/185
IDU, NIDU & Diff
sex n=71/185
IDU, NIDU,
Incarceration &
Sex n=56/185
5%
10%
38%
30%
HCV
 Increased % of acute HCV cases with multiple
risk factors
30
Summary
Acute Hepatitis B

Identified acute cases decreasing

Sexual exposure most predominant risk factor

Vaccination of those at risk in prison is
important
31
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
32
Acknowledgements
 Thanks to Amanda Yu for her statistical
expertise and to our partners in public
health who conduct interviews on
behalf of the EHSSS
33