Integrating Prevention, Control and Therapy for Viral Hepatitis: The Canadian Model

1. 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

4. 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.

5. 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

6. Control Strategies - D • Treat and cure the infection • Screening • Diagnosis • Contact Tracing • Non-curative treatment which eliminates infectiousness

7. Model for an Integrated Hepatitis Approach Consistent screening/ testing supplemented by epidemiological studies Information on drivers of incidence. Link test results to clinical follow-up and management records Modification of prevention programming Integrated prevention and care management Measure outcomes Improvements in Process Prevention & and Care Research Updated & evaluated guidelines for prevention and management

8. National Level Organizations • Health Canada • Canadian Viral Hepatitis Network • Canadian Liver Foundation

9. National Level Links: Canada Health Promotion and Programs Branch Hep Compensation Dept Health Protection Branch Blood Regulation Organ Regulation 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

10. 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

11. 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

12. 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

13. Acute Hepatitis B Incidence 2000 *Data from 4 sites, 11% of Canadian population

14. Acute Hepatitis C Incidence – 2000* *Data from 4 sites, 11% of Canadian population

15. 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

16. Ethnicity of Hepatitis B and C *Vancouver cases April 1, 2000-March 31, 2001

17. Surveillance for Viral Hepatitis andEmerging 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

18. Clinical Data Laboratory Data • Population Health/ • Policy Requirements • prevalence • natural history • intervention • effectiveness • economic burden Vital Statistics Billing Data Integrated Approach Required Knowledge (Scrambled Data)

19. representation from provinces/territories, non-government organizations, Statistics Canada, • CIHI, academics/clinicians and the Centre for Infectious Disease Prevention & Control Technical Working Group Secretariat Support • data & data management expertise • statistical expertise Population & Public Health Working Groups • provided by Health Canada Infectious Diseases Expert Advisory Groups • input on issues and priorities to Steering Committee/Working Groups Canadian Viral Hepatitis Network

20. Canadian Liver Foundation • Established 1969 • supports research • public information and education • living with liver disease programs • help-line • pamphlets • awareness programs

22. 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

23. Was a Centre for Excellence the Answer?

24. British Columbia Centre for Disease Control

25. 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

26. Hepatitis A Prevention • Hygiene • Food Inspection • Travel Advisories • Immunization • High Risk (MSM, IDU) • Chronic Liver Disease • Targeted Blitzes • Contacts and Outbreak Control

27. Hepatitis A in Canada and B.C. Rate per 100,000 population

28. Reported Hepatitis A Vancouver 1997-2001 – Risk Factors MSM Vaccination Campaigns SROs IDUs Dr. Patricia Daly

29. 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

30. Hepatitis B in Canada and B.C. Rate of Acute Disease per 100,000 population

31. Hepatitis B Age-group 11-20 Cases of Acute Disease per 100,000 population

32. Antenatal Seroprevalence of Anti-Hep B core, 1999 Percent Reactive

33. Geometric Mean Titre for anti-HBs by Age

34. Hepatitis C Prevention • Blood screening • Harm Reduction • street nurses • NEP (no parephenalia stuff) • No safe injection sites but starting

35. Hepatitis C in Canada and B.C. Rate per 100,000 population

36. Vancouver Injection Drug User Cohort

37. 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

38. Hepatitis B Therapy • Lamivudine still not curative • coverage for one year (case by case review thereafter) • e ag pos and pre-core mutants

39. 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

40. 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

42. 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

43. 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?

44. Acknowledgements • Mel Krajden, Gail Butt, Warren Hill • Tony Giulivi, Leslie Forester • Patricia Daly