1. Enhanced Hepatitis Strain & Surveillance System (EHSSS) in Review
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 Hepatitis Services
Follow up all identified acute HBV and HCV
Vancouver population 2010: 651,276
British Columbia population 2010: 4,523,995

3. Overview Between 2000-2010 HCV/HBV numbers decreasing
1123 individuals identified as of January 28, 2011
311 Acute HBV, 805 Acute HCV, 7 Acute HBV/HCV co-infection
HCV/HBV numbers decreasing
Numbers provided by Amanda Jan 28, 2011

4. Case Definitions Acute HBV Acute HCV
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 Corrections
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
Feb 2006 to Oct 2007 *
PHSA Laboratory Software Redesign
Lost data and communication linkages that allowed site investigator to detect
Acute HCV through seroconversion
Serologically indicative acute HBV
Nov 2007 Regained acute HBV and HCV identification and communication capacity
approx. 8 correction cases, 2010

6. Regional Health Authorities assuming EHSSS follow up for acute HCV
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
Interior health authority began following up acute HCV in spring of 2009 through public health nurses. Fraser HA has indicated it wants to begin following up the HCV cases – much larger case load.

7. Demographics For all mono-infected cases 2000-2010
n= 311 acute HBV, n= 805 acute HCV

8. Acute HBV Cases by Age
311 total cases Mean age for acute HBV 40.6 yrs in 2010
BC began grade 6 immunization program in 1996 of 11 year olds. In 2010 this cohort was 25 – at risk population changes and reduces over time

9. Acute HBV Cases by Gender
2010 is tied second lowest ratio of female:male since recording began
Infection predominates in males

10. Acute HBV Cases by Health Authority*
Vancouver Coastal 2010 population: 1,128,854
Vancouver aggregate 2010 population: 651,276 *
Vancouver Coastal Cases exclude the City of Vancouver (population of Vancouver was 651,276 in 2010, population of Vancouver Coastal was 1,128,854)

11. Acute HCV Cases by Age
Acute HBV identified at an older age ( younger ages protected by vaccine) compared to Acute HCV Mean age for acute HBV 40.6 yrs vs yrs for acute HCV in 2010

12. Acute HCV Cases by Gender
84% (62/74) of those 19 or under diagnosed with acute HCV are female

13. Acute HCV Cases by Health Authority*
1 case from Yukon in 2010
Fraser contains most of the federal and many of the provincial jails in BC where there is an opportunity to test for HCV among those with a chaotic and risk taking lifestyle prior to entry *
Vancouver Coastal Cases do not include City of Vancouver
† 7 cases not listed on chart originated in the Yukon

14. Acute HBV/HCV Co-infection
7 cases since 2000 (no new cases )
5 males yrs; 2 females yrs
5 cases in VIHA, 1 in Interior, 1 in Fraser
4 consecutive cases in Victoria from
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 2000-2010
Interviews
For all mono-infected cases for
n=183/311 acute HBV
n=201/805 acute HCV

16. Acute HBV Interviews by Year
Unable to locate includes missing, other and unable to locate for these next 2 slides

17. Acute HCV Interviews by Year
by delays in laboratory identification through seroconversion
For 2010:
27% (15/55) interview rate including those in corrections, otherwise 32% (15/47) cases interviewed. Tracking corrections as of 2008 in reason for not interviewed because we are not able to often access those tested in prison. Note also that cases are still open.
15% (8/55) Correction
42% (23/55) unable to locate
15% (8/55) refused
2% (1/55) language barrier
* Corrections tracked starting in 2008

18. Risk Factors For interviewed 2000-2010 acute HBV (n=183)
6 HBV interviewed in 2010
15 HCV interviewed in 2010
For interviewed
acute HBV (n=183)
acute HCV (n=201)

19. Acute HBV Risk factors 2000-10
In the previous 12 mo’s before diagnosis:
28% no risk factors identified (52/183)
44% only 1 risk factor identified (80/183)
41% - only sexual risk factors (75/183)
2% - only IDU (3/183)
1% - only NIDU (2/183)
5 Key risk factors analyzed include 1. injection drug use, 2. non-injection drug use, sex (3. hetero,4. homo & bi-sex), 5. incarceration
Combine Sexual risk factors in some analyses: for example here, for those with one risk factor, included in sexual risk factors is 4 homosexual only, 67 hetero and 4 cases of hetero and same sex combined
52/183, 28% = none

20. Acute HBV Risk factors 2000-10
In previous 12 mos before diagnosis:
28% had risk factor combinations (51/183)
11% - NIDU & sexual risk factors (21/183)
5% - IDU, NIDU & sexual risk factors (9/183)
3% - IDU, NIDU, sex & incarceration risk factors
(6/183)
3% - IDU & sexual risk factors (5/183)
2% - IDU, NIDU & incarceration (4/183)
(Other risk factors or combinations = 3% (6/183))
Drugs and sex in combination = 35/183, 19%

21. Acute HBV Risk factors 2000-10
In the previous 12 mos before diagnosis:
16% - injection drug use (30/183) – in cases was single risk factor
7% - incarcerated – all in combination with drug use 13/183 (10 IDU & NIDU, NIDU only)
In only 3 cases was IDU a single risk factor – for the other 27 it was reported along with other risk factors
All those who had been in prison in the previous 12 months also had drug risk factors
Many have multiple risk factors and they are ongoing so pts are eligible for vaccine but there are missed opportunities

22. Acute HBV Risk Factors 2000-10
Lifetime risk factors:
(85%)
NIDU = Non injection drug use
IDU = Injection drug use
Same sex only 4 women and all also had heterosex contact.
Men in same sex were same only and 13 bisex
Percentages are percentage of cases reporting for that risk factor.
(40%)
(26%)
(24%)
(13%)
Different = sex with different gender; Same sex = sex with same gender

23. Acute HBV IDU Proportions

24. HBV Risk Factors
52 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
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
No case in but 2 cases in 2009 – one had injections for non-health professional in last 6 mo in India for fever (included in medical exposure), one had no risk factors at all
No change for 2010

25. Acute HCV Risk factors 2000-10
In the previous 12 mo’s before diagnosis:
No risk factors identified (11%, 22/201)
Only 1 risk factor identified (20%, 40/201)
6% - injection drug use only (13/201)
9% - only sexual risk factors (18/201)
4% - non-injection drug use only (8/201)
<1% - incarceration only (1/201)
Versus HBV where only 1 risk factor identified accounted for 44% total cases and 41% of those total cases - only sexual risk factors

26. Acute HCV Risk factors 2000-10
In the previous 12 mo’s before diagnosis:
70% - injection drug use (139/201)
(13/201 cases = single risk factor)
15% - had been incarcerated (30/201)
(1/30 case = single risk factor)

27. Acute HCV Risk Factors Lifetime risk factors: (93%) (82%) (81%) (35%)
men who have sex with men exclusively (3) or in combo with diff sex 14; 26 female bi sex
Percentages are percentage of cases reporting for that risk factor.
(35%)
(21%)

28. HCV Risk Factors
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
1 case in 2008 but declined sex risk factor Q
1 case 2010

29. HBV & HCV Multiple Risk Factors
Number of participants reporting lifetime multiple risk factors for IDU, NIDU,
Different-Sex, Same-Sex and Incarceration:
40%
36%
31%
19%
16%
19%
For 2010, HBV 16 have no risk factors, HCV 5 have no risk factors
Number of risk factors increases and number of single risk factors decreases when considering lifetime risk factors.
Percentages are percentage of HCV or HBV cases reporting each number of risk factors.
12% 8% 6% 1%

30. HBV & HCV Multiple Risk Factors
Lifetime risk factor combinations 1
Risk Factor 2
Risk Factors 3 4
HBV
Sex n=79/183
43%
NIDU & Sex n=20/183
11%
IDU, NIDU & Sex
n=16/183 9%
IDU, NIDU, Incarceration & Sex n=23/183
13%
HCV
Sex n=12/201 6%
IDU & Sex n=19/201
IDU, NIDU & Sex n=76/201
38%
IDU, NIDU, Incarceration & Sex n=61/201
30%
Increased % of acute HCV cases with multiple risk factors

31. Summary Acute Hepatitis B Identified acute cases decreasing
Sexual exposure most predominant risk factor
Vaccination of those at risk in prison is important
Age associated with younger immunized.
Vaccination in prison is important - In BC have free vaccination program in prison where IDU can be accessed if they have been missed before but are also other community opportunities

32. Summary Hepatitis C Virus
Identified acute cases now decreasing for last 2 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 report prep, & our partners in public health who conduct interviews on behalf of the EHSSS