1. Enhanced Hepatitis Strain & Surveillance System (EHSSS) in Review 2000-2009 BCCDC Hepatitis Services Site Site Investigator: Liza McGuinness

2. 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. 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

4. 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. 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. 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. 7 For all mono-infected cases 2000-2009 n= 305 acute HBV, n= 748 acute HCV

8. 8 Acute HBV Cases by Age

9. 9 Acute HBV Cases by Gender Infection predominates in males

10. 10 Acute HBV Cases by Health Authority * * Vancouver Coastal Cases exclude the City of Vancouver

11. 11 Acute HCV Cases by Age

12. 12 Acute HCV Cases by Gender 83% (54/65) of those 19 or under diagnosed with acute HCV are female

13. 13 Acute HCV Cases by Health Authority * * Vancouver Coastal Cases do not include City of Vancouver † 6 cases not listed on chart originated in the Yukon

14. 14 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. 15 For all mono-infected cases for 2000-2009 n=177/305 acute HBV, n=185/748 acute HCV

16. 16 Acute HBV Interviews by Year

17. 17 Acute HCV Interviews by Year * Includes 5 cases still in follow up

18. 18 For interviewed 2000-2009 acute HBV (n=177) and HCV (n=185)

19. 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

20. 20 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 (O ther risk factors or combinations = 7/177, 7%; No risk factors = 52/177, 29%)

21. 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. 22 Acute HBV Risk Factors 2000-09 Different = sex with different gender; Same sex = sex with same gender Lifetime risk factors:

23. 23 Acute HBV IDU Proportions

24. 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. 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. 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. 27 Acute HCV Risk Factors Lifetime risk factors:

28. 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. 29 HBV & HCV Multiple Risk Factors Number of participants reporting lifetime multiple risk factors for IDU, NIDU, Different-Sex, Same-Sex and Incarceration:

30. 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=76/177 43% NIDU & Sex n=18/177 10% IDU, NIDU & Sex n=16/177 %9 IDU, NIDU, Incarceration & Sex n=21/176 12% HCV Sex 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

31. 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. 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. 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