Hepatitis C

        and      

Migrants

Kevin Pottie MD, CCFP, MClSc FCFP Associate Professor, Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa Institute of Population Health and CT Lamont Centre for Research on Primary Health Care on behalf of the Canadian Collaboration for Immigrant and Refugee Health

Hepatitis C Screening Guidelines for Migrants 1. Burden of hepatitis C in immigrant populations 2. Screening and morbidity 3. Recommendations 4. Clinical considerations

Pottie, Greenaway, Feightner et al. CMAJ 2011

  WHAT  IS  THE  BURDEN  OF  HEPATITIS  C  IN   IMMIGRANT  POPULATIONS?    •  Recent  increases  of  incidence  and  deaths  in  part  due  to  

importation  of  virus  by  immigrants  from  endemic  regions  

•  Seroprevalence  of  chronic  infection  in  the  immigrant   population  estimated  to  be  about  3%  (v.  0.8%  in  the   general  Canadian-­‐born  population)   –  Rates  of  up  to  18%  in  certain  populations  

•  Mortality  from  viral  hepatitis  and  hepatocellular   carcinomas  greater  among  immigrants  than  in  the   Canadian-­‐born  population   Pottie K, Greenaway C, Feightner J, et al . Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011

  WHAT  IS  THE  BURDEN  OF  HEPATITIS  C  IN   IMMIGRANT  POPULATIONS?    •  The  majority  of  immigrants  acquire  infection  through  

unsafe  injections  or  other  medical  procedures,  rather  than   through  injection  drug  use  

•  Immigrants  are  more  likely  to  have  concurrent  infection   (e.g.,  with  hepatitis  B  or  HIV),  which  increases  the  risk  of   progression  of  chronic  hepatitis  C  virus-­‐associated  disease  

Pottie K, Greenaway C, Feightner J, et al . Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011

Hepatitis C Screening Guidelines for Migrants 1. Burden of hepatitis C in immigrant populations 2. Screening and morbidity 3. Recommendations 4. Clinical considerations

Pottie, Greenaway, Feightner et al. CMAJ 2011

  DOES  SCREENING  FOR  HEPATITIS  C  VIRUS   DECREASE  MORBIDITY?    •  Detection  and  treatment  before  development  of  cirrhosis  is   important  

–  Sustained  virologic  response  (SRV)  in  higher,  which  is  associated   with  improved  clinical  outcomes   –  treatment  is  better  tolerated  in  absence  of  cirrhosis  

Pottie K, Greenaway C, Feightner J, et al . Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011

  DOES  SCREENING  FOR  HEPATITIS  C  VIRUS   DECREASE  MORBIDITY?    Immigrant  populations  show:    

•  Increased  likelihood  to  be  eligible  for  treatment   –  decreased  comorbidities  such  as  substance  abuse  and  psychiatric   illness  

•  More  favorable  response  to  treatment  than  the  general   Canadian  population   –  Predominance  of  genotype  3  infection  amongst  South  Asians   •  Genotypes  2  and  3  respond  most  favorably  to  treatment  

–  Asians  (Non-­‐South)  showed  highest  SVR  rate  in  response  to  PEG/ RIB  treatment,  independent  of  viral  genotype   Pottie K, Greenaway C, Feightner J, et al . Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011 Pattullo V, Heathcote J, Wong D. Superior reponse to pegylated interferon and ri bavirin in Asians with chronic hepatitis C. Hepatol Int 2010;4:723-31.

Hepatitis C Screening Guidelines for Migrants 1. Burden of hepatitis C in immigrant populations 2. Screening and morbidity 3. Recommendations 4. Clinical Considerations

Pottie, Greenaway, Feightner et al. CMAJ 2011

CCIRH  RECOMMENDATION   Screen for antibody to hepatitis C in all immigrants and refugees from regions with an expected prevalence of disease ≥ 3% (  

If the result is positive, refer to a colleague with expertise in managing patients with hepatitis C virus infection. Pottie, Greenaway, Feightner et al. CMAJ 2011

  ESTIMATED  WORLDWIDE  PREVALENCE  OF   HEPATITIS  C  

World Health Organization. Hepatitis C – global prevalence (update). Wkly Epidemiol Rec 1999;74:425-7.

Hepatitis C Screening Guidelines for Migrants 1. Burden of hepatitis C in immigrant populations 2. Screening and morbidity 3. Recommendations 4. Clinical Considerations

Pottie, Greenaway, Feightner et al. CMAJ 2011

CLINICAL  CONSIDERATIONS   •  Barriers  to  uptake  of  screening   –  Low  knowledge  of  hepatitis  C  in  immigrants  

•  Barriers  preventing  primary  care  physicians  from   recommending  screening   –  Little  experience  treating  patients  who  test  positive   –  Not  routinely  asking  patients  about  risk  factors  on   initial  visit   –  Failure  to  order  appropriate  diagnostic  tests  and   correctly  interpret  results  

 

Pottie K, Greenaway C, Feightner J, et al . Evidence Based Clinical Guidelines for Immigrants and Refugees. CMAJ 2011

Recommendations of Other Groups

Neither Canadian nor US guidelines identify immigrants as an at-risk group that should be targeted for screening.

CCIRH Guidelines highlight the potential benefits of routine hepatitis C screening for at-risk immigrant groups.

CCIRH  KEN   Thank you! Questions? Discussion Canadian Collaboration for Immigrant and Refugee Health Knowledge Exchange Network http://www.ccirhken.ca/ (physician friendly region checklist, case based Cochrane podcasts, e-learning, decision aids)