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Hepatitis C Prevention, Support and Research Program
Health Canada

Get the Facts: Mid-term evaluation report

I. The Problem: Hepatitis C in Canada

In this section is a brief overview of hepatitis C as a threat to public health in Canada.

Hepatitis C: the virus

Hepatitis C is a disease of the liver caused by the hepatitis C virus (HCV). The World Health Organization estimates that as much as 3% of the world population is infected with HCV and that there are more than 170 million people worldwide who have chronic hepatitis C and are carriers. Many infected people have no symptoms and are unaware of their condition; they are at risk for chronic liver disease, cirrhosis and even liver cancer. Progression of the disease is slow. Because many HCV-infected people are in the 30-49 age group, the number of deaths due to HCV could increase significantly over the next two decades.¹

In Canada, the estimated prevalence of HCV-infected people is 240,000, or 0.8% of the population. Of these people, approximately 70% - more than 170,000 people - are unaware that they have been infected, and yet they may be carriers of the virus. The infection is newly diagnosed in an estimated 3,000 to 8,000 people each year.

Canada’s rate compares with 0.9% in the European Community and an estimated prevalence of 0.3% to 1.0% in the United Kingdom. In the United States, hepatitis C has been identified as the most common blood-borne infection with an estimated prevalence of 1.8%, or 3.9 million people.²

According to the Population and Public Health Branch of Health Canada, the highest incidence of HCV diagnosis occurs among people aged 20 to 49 years of age, and incidence is higher among males.

Hepatitis C infection is classified in two stages: acute and chronic. In the acute stage, symptoms may appear six to seven weeks after initial exposure; however, 60% to 70% of people in the acute stage have no symptoms, or symptoms are so mild that they are unaware of the infection. An important characteristic of hepatitis C infection is the fact that in a high proportion of infected people (75% to 85%) the acute infection progresses to chronic infection, which is associated with slowly progressing liver disease; serious effects of the disease may not appear for decades after the initial infection. Twenty percent of chronically infected people will develop cirrhosis or scarring of the liver, which can lead to liver failure.³ A proportion of chronically infected people will develop liver cancer.

Hepatitis C is spread most commonly by direct blood-to-blood contact with an infected individual. Injection drug use is the major mode of transmission of HCV in Canada. The virus is transmitted through transfer of infected blood in the sharing of needles, syringes or other drug paraphernalia.⁴ A person can become infected after a single event of drug use.

Between 1960 and 1992, an estimated 90,000 to 160,000 Canadians were infected with hepatitis C through infected blood or blood products. Hemophiliacs were particularly at risk for HCV. Since implementation of universal blood screening, this risk has been substantially reduced; risk of infection currently is one in 500,000 units.⁵

Risk of transmission through sexual activity is low, but people who have multiple partners face an increased risk of infection. Vertical transmission of HCV, from mother to baby, occurs in less than 5% of cases, and increases where the viral load in the mother is high, and when the human immunodeficiency virus (HIV) is also present.⁶ Health care providers who may be exposed to blood in the workplace are at risk for HCV infection, but the prevalence of the disease at present as documented is no greater than in the general population. HCV infection has been reported through other means of exposure, such as use of contaminated devices used in tattooing, body piercing and electrolysis.⁷ Household contact (sharing toothbrushes and other items that might be contaminated with infected blood) is considered a possible, but low, risk. A significant number of cases of hepatitis C occur in people who have no known risk factors.

Injection drug use is the primary risk factor and has been documented as the factor in 60% of the newly infected cases reported between 1999 and 2001. In Canada, approximately 25% of people who inject drugs report that they were incarcerated at the time they first injected drugs; the prevalence of hepatitis C infection in Canada’s federal correctional facilities is estimated to be between 25% and 40%.⁸

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Table 1.
Primary risk factors for acute hepatitis C cases, 1999-2001

Risk factor	%
Injection Drug Use	60.6
Unknown	13.3
Others	12.8
Health Care Acquired	6.4
Other Subcutaneous	3.7
Sexual	3.2

Source: Enhanced Hepatitis Surveillance System, Health Canada

Note. 2001 data preliminary. Sexual includes sex with hepatitis C carriers. Health care acquired includes blood transfusion, blood product, hemodialysis, hospitalization, history of surgery, organ transplant, history of dental visit. Others includes drug snorting, blood contact, hepatitis C carrier in family, institution associated, and incarceration. Other subcutaneous includes tattooing, body piercing, acupuncture.

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A number of people infected with hepatitis C are also infected with hepatitis B or HIV/AIDS. As of December 1999, more than 11,000 Canadians were co-infected with these viruses.⁹ The hepatitis C and B viruses and HIV are all blood-borne pathogens and share similarities in modes of transmission, except that sexual transmission is a stronger risk in hepatitis B and HIV. Hepatitis C is estimated to be 10 to 15 times more likely than HIV to be transmitted through contact with infected blood.¹⁰ Risk is considered to be present for all three viruses to varying degrees in these situations: sexual contact, mother-to child, occupational exposure (such as needle stick), sharing injection equipment, unsterile procedures that involve piercing the skin such as tattooing and body piercing, and use of unsterile equipment in medical or other procedures.

How Canada Tracks the Infection

In Canada, viral hepatitis incidence and prevalence data are collected through both routine and enhanced surveillance as well as through targeted studies of specific populations and groups at risk of contracting viral hepatitis.

The routine collection of data on viral hepatitis, including hepatitis C, is achieved through a national surveillance system. Health Canada’s National Notifiable Disease Reporting System regularly reports on diseases under national surveillance. Between 1992 and 1998 there was a dramatic increase in the number of reported cases due to increased reporting by provinces and territories. This was likely due to increased awareness and testing as well as access to federal transfer payments to cover 50% of the look-back, trace-back studies. The vast majority of these cases are those chronically infected as opposed to acutely infected. The completeness of notifiable disease reporting varies over time and by province or territory.

Due to limitations in the National Notifiable Disease Reporting System, an enhanced sentinel site surveillance system for acute hepatitis B and C was established in 1998. The enhanced surveillance began with two sites and at the time of this report, had expanded to seven sites across the country covering approximately 16 % of the population. The sentinel sites contribute data on acute and chronic hepatitis B and C infections, risk factors associated with infection and genotype information.

There is no vaccine available to prevent hepatitis C. Treatment is available for patients, usually through drugs such as a combination of interferon and ribavirin. The treatment regimen and duration of treatment depends upon the virus type (there are six types of hepatitis C virus). Research findings indicate that today, treatment can result in sustained viral suppression for approximately 40% to 80% of patients.

The Economic Burden to Canada

Documented health costs due to hepatitis C are high and rising quickly. For example, treatment with the ribavirin/interferon alfa-2b combination can cost up to $30,000 per course of treatment for an infected person. In 1998, the average cost of a liver transplantation performed in Ontario was $121,732, but costs could range up to more than $600,000.¹¹ Using the average cost above, the 217 liver transplants for hepatitis C in Canada in 1998 cost $26 million. From 1998 to 2008, the need for liver transplants is expected to triple.

There are only limited data on direct costs, but studies from other countries suggest that there may be costs associated with detecting the infection, managing and treating hepatitis, and managing associated or resulting conditions such as liver cancer and liver transplants, and, finally, providing terminal care.¹²

Indirect costs associated with hepatitis C represent productivity losses due to premature mortality, reduced work performance or absenteeism from work due to sickness or the effects of treatment, and missed days of work for family or friends who are providing care for the infected person. It is estimated that there will be added pressure on Canada’s social support systems because of hepatitis C; there are already indications that infected individuals are relying on permanent disability pensions as a source of primary income.

Personal costs may be significant as well; individuals report that hepatitis C results in a notable and negative effect on quality of life as a result of stigmatization and the physical symptoms of the disease.

Focus of Prevention Efforts

Injection drug use is the primary risk factor for new infections of hepatitis C. A review of the literature has identified research gaps in several areas, such as understanding the root cause of injection drug use, evaluation of harm reduction programs, and understanding which prevention interventions are the most effective for groups at risk for HCV infection.

Key Points

• Hepatitis C has already been diagnosed in tens of thousands of Canadians.

• Many people have been infected and are unaware that they have the infection; they have the potential, however, to transmit it to others.

• The majority of people with hepatitis C infection progress to a chronic or lifelong infection, and some develop serious liver disease over several decades after the initial infection.

• The cost of treating people with hepatitis C and their long-term health problems is estimated to be significant.

• Injection drug use is the most common risk factor among newly diagnosed cases of hepatitis C.

• Prevention is key: targeting people at risk is required to slow the spread of hepatitis C significantly.

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1. World Health Organization, Hepatitis C. Fact Sheet No 164, Geneva: WHO,1997.
   
   
2. J. Frankish, G. Moulton, B. Kwan, M.D. Waters, et al., Hepatitis C prevention: an examination of current international evidence. Hepatitis C Division, Hepatitis C Prevention, Support and Research Program. 2001, p.3.
   
   
3. S. Zou, S., M. Tepper, A. Giulivi, Viral hepatitis and emerging blood-borne pathogens in Canada, Canada Communicable Disease Report. Vol 27S3, September 2001.
   
   
4. Ibid
   
   
5. L. Cranston, Building a better blood system for Canadians. Canadian Journal of Public Health, 2000, Vol. 91: Supplement 1. P. S41.
   
   
6. Canadian Association for Study of the Liver, Management of Viral Hepatitis, Proceedings of 1999 consensus conference, 2000, p. 12.
   
   
7. S. Zou, M. Tepper, A. Giulivi, Current Status of Hepatitis C in Canada, Canadian Journal of Public Health., 2000, Vol 91: Supp. 1, p.S4.
   
   
8. Correctional Service Canada, 1995 National Inmate Survey, 1996.
   
   
9. R.S. Remis, et al. Estimating the number of people co-infected with hepatitis C and human immunodeficiency virus. Report to Health Canada, 2001.
   
   
10. T. Heintges, J.R. Wands. Hepatitis C virus:epidemiolgy and transmission, Hepatology, 1997, 26:521-526.
    
    
11. Canadian Journal of Surgery, 2002, Vol 45 (6), pp 425-434.
    
    
12. A. Sheill, M. Law, The cost of hepatitis C and the cost-effectiveness of its prevention. Health Policy. 2001,S8:121-131

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