Hepatitis C: Whats New? Naveed Zafar Janjua, MBBS, MSc, DrPH Senior - PowerPoint PPT Presentation

Hepatitis C: What’s New? Naveed Zafar Janjua, MBBS, MSc, DrPH Senior Scientist, Clinical Prevention Services, BCCCDC Clinical Assistant Professor, School of Population and Public Health, UBC

Outline • Overview • Global burden of HCV • Epidemiology of HCV in Canada • Epidemiology of HCV in BC • HIV/HCV co-infection/occurrence • HCV mortality • HCV Treatment update

Hepatitis C virus (HCV) • Discovered in 1989 is an RNA virus, transmitted mainly through blood with a large reservoir of chronic carriers worldwide • Major cause of post-transfusion hepatitis prior to 1992 • Major cause of chronic liver disease, cirrhosis, and hepatocellular carcinoma worldwide • Long latency period, most people not aware about their status until late stage disease • 2-3% of world population infected with HCV • ~1% (250,000-450,000) of Canadian population infected – lower than many other countries in the world • 1990-2015: estimated 4-fold increase in the number of patients diagnosed with HCV in Canada

Kamal 2008; Thein 2008; Maheshwari et al. 2010 Early treatment Most of new infections occur in prevent chronic HCV PWID infection Infections ~ 25% 25% Poorly Symptomatic Pegylated INF/Rib Clear tolerated and/or DAA Support cures ≈ 75% ? Combo DAA’s > 90% Pill 75% Chronic Alcohol Do nothing Obesity 15% to 25% Diabetes Prevent infections? cirrhosis, ESLD, HIV Harm reduction? HCC, transplant Older age TasP? Prevent complications? Males Decades

Global epidemiology of hepatitis C virus infection: New estimates of age ‐ specific antibody to HCV seroprevalence ≈ 185 M (2.8% (95% CI: 2.6%-3.1%)) Hanafiah et al. Hepatology 2013;57:1333–1342 http://onlinelibrary.wiley.com/doi/10.1002/hep.26141/full#fig3

Global epidemiology of hepatitis C virus infection: Genotype distribution

HCV Epidemiology in Canada: Reported cases by year 60 Male Female Total 50 Rate per 100,000 population 40 30 20 10 0 2005 2006 2007 2008 2009

HCV Epidemiology in Canada: Reported cases by sex and province, 2009 120 Female Male Total 100 Rate per 100,000 population 80 60 40 20 0 NL PE NS NB QC ON MB SK AB BC YT NT NU Canada Source: http://www.phac-aspc.gc.ca/sti-its-surv-epi/hepc/hepc_pt-eng.php

HCV rate by age in Canada, 2009 90 Female Male Total 80 70 Rate per 100,000 population 60 50 40 30 20 10 0 0-4 5-9 10-14 15-19 20-24 25-29 30-39 40-59 60+ Age (years)

Cumulative rate of reported acute HCV infection by age group and gender, EHSSS, Canada, 2004-2008 Differences from overall rate: younger age & more female in younger age group. Risk factors: Mainly IDU Source: Epidemiology of Acute Hepatitis C Infection in Canada Results from the Enhanced Hepatitis Strain Surveillance System (EHSSS). http://www.phac-aspc.gc.ca/sti-its-surv-epi/hcv-epi-eng.php

11 HCV in BC • 73,000 individuals reported with HCV – 25% clear – x % deceased – ~ 20,000 unknown • ~60,000 living with chronic HCV • >80% recent infections associated with IDU

HCV in BC and Canada by year 150.0 Rate per 100,000 population 100.0 50.0 0.0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 BC Hepatitis C Reports 3523 3043 2834 2907 2882 2508 2479 2218 1968 1885 BC Hepatitis C Rate 85.5 73.2 67.5 68.5 66.9 57.2 55.6 49.0 43.0 40.8 Canadian Hepatitis C Rate 46.8 45.2 40.4 36.9 36.6 35.8 33.2 31.1 28.8

Age distribution of HCV cases in BC, 2012 125.0 Rate per 100,000 population 100.0 75.0 50.0 25.0 0.0 <1 1-4 5-9 10-14 15-19 20-24 25-29 30-39 40-59 60+ Hepatitis C Rate - Female 18.9 2.3 0.9 0.0 8.2 28.1 43.3 38.3 43.6 20.8 Hepatitis C Rate - Male 4.4 1.1 0.0 0.8 4.2 21.5 37.6 63.1 100.0 50.4 Hepatitis C Rate 11.5 1.6 0.4 0.4 6.1 24.7 40.4 50.5 71.6 34.8 Hepatitis C Reports - Female 4 2 1 0 11 45 70 117 303 113 Hepatitis C Reports - Male 1 1 0 1 6 37 63 187 677 243 Hepatitis C Reports 5 3 1 1 17 82 133 304 982 357

HCV cases in BC by HSDA, 2012 H SDA H ealth Service Delivery Area C ases R ate 11 East Kootenay 38 47.1 12 Kootenay Boundary 23 28.7 48.5 39.7 13 Okanagan 161 45.4 N 14 T hompson Cariboo Shuswap 94 41.9 21 F raser East 188 65.1 22 F raser North 208 33.4 43.4 23 F raser South 257 34.8 31 Richmond 37 18.5 21.7 32 Vancouver 339 49.5 41.9 33 North Shore/Coast Garibaldi 63 21.7 63.4 41 South Vancouver Island 137 36.4 S outhwestern BC In set 21.7 47.1 63.4 33.4 28.7 42 Central Vancouver Island 135 50.6 21.7 45.4 65.1 50.6 49.5 43 North Vancouver Island 77 63.4 # 18.5 # 34.8 51 Northwest 30 39.7 52 Northern Interior 63 43.4 R ates per 100,000 p opulatio n by H SDA 50.6 53 Northeast 35 48.5 18.5 39.7 65.1 36.4 Note: Map classification by Jenks natural breaks method. 21.7 50.6

HCV Sero-conversions: Opportunities for Prevention of Transmission

HCV Rate/100,000 in BC & Canada, 1992-2012 Seroconversion Rate/100,000 in BC (M24 Window) 200 10.0 1,270,188 individuals 180 9.0 73,663 anti-HCV+ Rate per 100,000 population (8,425 seroconverters) 160 8.0 (4,308 M24) 140 7.0 120 6.0 100 5.0 80 4.0 60 3.0 40 2.0 20 1.0 0 0.0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Canada 5 6 10 48 42 65 76 64 58 54 51 47 45 40 37 37 36 33 31 29 BC (lab) 40 59 90 125 141 186 150 119 97 91 88 78 68 63 68 64 61 57 50 45 44 Acute M24 0.1 0.7 2.3 2.8 3.4 5.6 6.3 6.6 7.0 6.9 7.7 6.7 5.9 5.5 6.9 5.6 5.5 4.5 3.7 3.1 3.3

HCV Rate/100,000 in BC and Canada Sero-conversion rate BC 100 9 1,219,593 individuals 90 8 72,684 anti-HCV+ 80 8,181 seroconverters 7 Acute rate per 100,000 population Rate per 100,000 population 2013-03-19 70 6 60 5 50 4 40 3 30 2 20 1 10 0 0 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Canada rate 51 47 45 40 37 37 36 34 32 29 BC rate 88 78 68 63 68 64 62 56 50 45 44 Acute 24 M 7.7 6.7 5.9 5.5 6.9 5.6 5.5 4.5 3.7 3.1 3.1 Acute 12 M 4.2 3.7 3.0 2.5 3.4 2.5 3.1 2.3 1.8 1.6 1.2

HCV incidence rate/100 PY among repeat anti-HCV testers, BC, 2000-2011 Overall BC Males Females 1 HCV seroconversions per 100 person-years 0.5 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year

HCV incidence rate/100 PY among repeat anti-HCV testers by age group, BC 15-24 years 25-34 years 35-44 years 45-54 years 55+ years 1.6 1.4 HCV seroconversions per 100 person-years 1.2 1 0.8 0.6 0.4 0.2 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year

HCV Related Mortality: Hazard ratios between HCV serological groups MNR vs. SNR REAC vs. SNR SERO vs. SNR SERO vs. MNR SERO vs. REAC Cause of Death HR (95% CI) HR (95% CI) HR (95% CI) HR (95% CI) HR (95% CI) All Age <40 2.07 (1.82-2.36) 7.25 (6.54-8.06) 7.52 (5.85-9.52) 3.62 (2.79-4.65) 1.03 (0.80-1.31) Age ≥40 1.42 (1.36-1.49) 2.39 (2.27-2.51) 3.36 (2.49-4.41) 2.36 (1.75-3.11) 1.41 (1.04-1.85) Liver related 2.72 (2.34-3.14) 9.62 (8.55-10.87 ) 5.10 (2.30-9.62) 1.88 (0.85-3.55) 0.53 (0.24-0.99) Drug related 2.62 (2.11-3.25) 13.70 (11.76-16.13) 20.83 (15.15-28.57 ) 8.00 (5.71-11.11) 1.54 (1.12-2.05) HIV related 83.33 (40.00- 52.63 (11.49- 17.54 (3.62- Female 3.03 (0.90-9.52) 0.64 (0.16-1.75) 200.00) 200.00) 71.43) Male 1.77 (1.11-2.74) 12.05 (9.09-16.13) 10.87 (5.24-20.41) 6.17 (2.84-12.35) 0.90 (0.44-1.63) Drug related mortality higher in sero-converters (acute HCV) Liver related mortality higher in first time reactors (chronic HCV)

HCV Related Mortality: Standardized Mortality Ratios Author SMR (95% CI) All-cause Liver-related Drug-related Country 3.1 16.8 19.3 HCV mono-infected (3.0-3.2) (15.4-18.3) (18.1-20.5) Amin Australia (2006) 5.6 32.9 24.7 HCV/HBV co-infected (4.8-6.6) (23.1-46.7) (18.2-33.5) 5.8 35.5 20.7 HCV mono-infected (5.6-6.0) (32.9-38.3) (18.9-22.7) Duberg Sweden (2008) 8.5 46.2 27.6 HCV/HBV co-infected (7.3-9.8) (31.5-62.3) (19.6-39.6) 4.9 20.0 23.5 HCV mono-infected (4.6-5.1) (17.9-22.2) (21.3-25.7) McDonald Scotland (2008) 32.9 34.8 36.6 HCV/HIV co-infected (29.2-37.0) (23.3-50.0) (25.2-51.4) 4.8 24.0 20.4 All HCV reactive (4.6-5.0) (22.2-25.9) (18.8-22.0) Yu 4.7 24.3 19.5 REAC- chronic HCV Canada (2013) (4.5-4.8) (22.4-26.2) (17.9-21.1) 10.2 13.1 38.1 SERO- Acute (8.5-12.0) (5.6-25.7) (29.0-49.1) Source: Yu A et al. BMC Public Health 2013; 13:291

2000-2011 EHSSS BC • 179/220, 81% reflect PWID (ever) • 83/220, 38% report previous incarceration • Nationally (2004-2009) Incidence/100,000 was 14.0 in Aboriginal people vs 2.2 in non-Aboriginal people

HCV co-infection in the HIV positive population in BC HIV +ve Linkable i.e. (First +ve HIV cases from 1995-2011) personal identifiers 7304 5934 (81%) Linked to combined Not linked to combined HCV dataset HCV dataset 4438 (75%) 1496 (25%) HIV+/HCV+ HIV+/HCV- 2082 (47%) 2356 (53%) HCV+ 1 st → HIV+ HIV+ & HCV+ HIV+ 1st → HCV+ 1070/2082 (51%) 487/2082 (23%) 525/2082 (25%) Median 3.6 yrs Median 1.7 yrs +/- 2 wks Buxton et al. BMC Public Health 2010;10:225, * data as of 2012-01-09