1. Enhanced Hepatitis Strain & Surveillance System (EHSSS) in Review 2000-2011 BCCDC Hepatitis Site Site Investigator: Liza McGuinness

2. 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. 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

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 (Interior, Fraser)  Future: federal & provincial corrections re: information access

7. 7 For all mono-infected cases 2000-2011 n= 319 acute HBV, n= 853 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 * * Van Coastal cases exclude City of Vancouver (population 651,048 in 2011)

11. 11 Acute HCV Cases by Age

12. 12 Acute HCV Cases by Gender 82% (55/67) 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 † 8 cases not listed on chart originated in the Yukon

14. 14 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. 15 For all mono-infected cases for 2000-2011 n=191/319 acute HBV n=220/853 acute HCV

16. 16 Acute HBV Interviews by Year

17. 17 Acute HCV Interviews by Year * Corrections tracked starting in 2008

18. 18 For interviewed 2000-2011 acute HBV (n=191) acute HCV (n=220)

19. 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) o41% - only sexual risk factors (79/191) o2% - only IDU (3/191) o1% - only NIDU (2/191)

20. 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) (O ther risk factors or combinations = 4% (8/191))

21. 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. 22 Acute HBV Risk Factors 2000-11 Different = sex with different gender; Same sex = sex with same gender Lifetime risk factors: (84%) (39%) (26%) (24%) (14%)

23. 23 Acute HBV IDU Proportions

24. 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. 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. 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. 27 Acute HCV Risk Factors Lifetime risk factors: (92%) (82%) (81%) (38%) (20%)

28. 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. 29 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. 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% HCV Sex 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. 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 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. 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