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)