ORIGINAL ARTICLE
Epidemiology of Crohn’s Disease in Québec, Canada
Anne-Marie Lowe, MSc,* Pierre-Olivier Roy, MD, MSc,† Michel B.-Poulin, DVM, PhD,†,‡
Pascal Michel, DVM, PhD,†,‡ Alain Bitton, MD,§ Laurie St-Onge, MSc,†,‡ and Paul Brassard, MD, MSc*,P
Background: Crohn’s disease (CD) is an idiopathic inflammatory
bowel disease (IBD). We aimed to determine the prevalence and
incidence of CD in Québec and characterize the demographic and
health-related factors associated with this disease.
Methods: We identified CD cases in the provincial administrative
databases for the years 1993–2002. The CD prevalence and inci-
dence rates were estimated respectively for the periods 1993–2002
and 1998 –2000. We validated the identified cases using clinically
confirmed IBD cases. Predictor variables of CD were analyzed using
the Poisson regression model to explain the variation in CD inci-
dence rates across Québec.
Results: In all, 21,172 patients fulfilled the CD case definition
for the period. The age and sex standardized average prevalence
rate for 1993–2002 was 189.7 cases / 100,000 population and the
age and sex standardized incidence rate of CD for the 1998 –2000
period was 20.2 cases / 100,000 person-years. The female/male
cases ratio among incident cases was 0.74 for the 0 –14-year-old
group, 1.30 for the 15– 64-year-old group, and 1.77 for the cases
older than 65 years old. After adjustment, independent predictors
of CD incidence were: incidence of 5 reportable enteric diseases,
proportion of individuals of Jewish ethnicity, and proportion of
immigrant people.
Conclusions: The identified predictors of CD explained 20% of
the regional variance in the incidence rate of CD in the Québec
Received for publication May 5, 2008; Accepted August 14, 2008.
From the *Faculty of Medicine, University of Montréal, Montréal, Qué-
bec, †Groupe de recherche en épidémiologie des zoonoses et sante publique
(GREZOSP), Faculté de médecine vétérinaire, Université de Montréal,
Saint-Hyacinthe, Québec, ‡Laboratory for Foodborne Zoonoses, Public
Health Agency of Canada, Saint-Hyacinthe, Québec, §Faculty of Medicine,
Division of Gastroenterology, McGill University Health Center (MUHC),
Montréal, Québec, PFaculty of Medicine, Division of Clinical Epidemiol-
ogy, McGill University Health Center (MUHC), Montréal, Québec, Canada.
Supported by a student fellowship of the Division of Clinical Epidemiol-
ogy, McGill University (to A.M.L.) and a New Investigator career award
from CIHR (to P.B.).
Reprints: Paul Brassard, Division of Clinical Epidemiology, McGill
University Health Center (MUHC), Royal-Victoria Hospital, 687 Pine
Ave. West, R4-29, Montréal, Québec, Canada, H3A 1A1 (e-mail:
paul.brassard@clinepi.mcgill.ca).
Copyright © 2008 Crohn’s & Colitis Foundation of America, Inc.
DOI 10.1002/ibd.20756
Published online 22 October 2008 in Wiley InterScience (www.
interscience.wiley.com).
Inflamm Bowel Dis ● Volume 15, Number 3, March 2009
population. Other factors such as genetic susceptibility to CD or
the effect of an environmental cause should be taken into con-
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sideration in the models to explain the residual variance.
(Inflamm Bowel Dis 2009;15:429 – 435)
Key Words: Crohn’s disease, incidence, prevalence, associated
factors, validation
T he inflammatory bowel disease (IBD) family comprises
Crohn’s disease (CD) and ulcerative colitis (UC).1 Since
its recognition in 1932, the etiology of CD is still unknown.
However, the most accepted paradigm is a multifactorial
cause involving a complex interaction between genetic com-
ponents of the host and an environmental trigger, possibly of
microbiological origin.2 CD appears to affect mostly people
from developed nations and the reported incidence suggests a
variation in the distribution of the cases,3 as well as a time
trend in occurrence.4 In Canada, CD epidemiological data
have recently been reported in 5 provinces for the time period
of 1998 –2000 and the global incidence of CD was estimated
to be 13.4 cases / 100,000 person-years.5 In Québec, despite
the fact that the prevalence of the principal genetic suscepti-
bilities in CD patients has recently been studied,6 the global
epidemiology of CD is not well characterized. The aim of this
study was to determine the prevalence and incidence of CD in
Québec and characterize the demographic and health-related
factors associated with this disease.
MATERIALS AND METHODS
Study Setting
In 2006 the Canadian province of Québec population
was 7,546,131.7 This province has a universal health insur-
ance plan managed by the Régie de l’assurance maladie du
Québec (RAMQ) and all residents of the province are eligible
for this healthcare service. The province territory is divided
into 166 local community service centers (CLSC) districts,
the smallest health-related geographical divisions in Québec.
Data Source and Case Definition
This population-based study was conducted using the
computerized provincial administrative databases that were
developed in the context of the universal insurance program.
These databases capture all physician visits, procedures, hos-
pitalizations, and vital status and include the RAMQ database
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Lowe et al
and Med-Echo system. The RAMQ database covers every
person under the public health insurance of Québec and
includes billing and diagnosis codes. The Med-Echo system
is a hospital database that contains information on all in-
hospital procedures as well as patient demographics, admis-
sion, and discharge dates and up to 15 discharge diagnoses
codes according to the International Classification of Dis-
eases, Ninth Revision (ICD-9-CM).8 All databases were
linked through the use of a unique and anonymous identifier,
therefore creating a longitudinal history of each patient’s
clinical outcomes and healthcare utilization. The databases
covered the period from January 1st, 1993, to December 31st,
2002.
The basic epidemiological unit used in this study is the
medical contact or health system contacts. It was defined as
either a unique outpatient visit to a medical doctor related to
a CD diagnosis or a hospitalization. One hospitalization rep-
resented a continuous sequence of days related to a CD
diagnosis. Using the administrative definition developed in
Manitoba for IBD,5 we searched for the healthcare utilization
records for each individual with a healthcare contact for a
diagnosis of CD (ICD-9-CM;555.x) between the years 1993
and 2002, inclusive.9 The case definition included having at
least 5 health system contacts within the study period, or if
the individual was registered in the health system for less than
2 years, having 3 or more contacts. The validity of this case
definition has previously been shown.5 The age at diagnosis
of a case is the age corresponding to the first medical contact.
Case Validation
We attempted to clinically validate a portion of the
cases identified through the administrative databases for the
period 1993–2002. As a reference, we used a group of clin-
ically confirmed and well-characterized IBD cases (CD or
UC) identified between the years 1993–2001 in Montréal
through the gastroenterology units of 2 McGill University
Health Center (MUHC) hospitals.10 To compare the 2 groups
of cases, we used the RAMQ health insurance number
(NAM), which is a common identifier unique to each indi-
vidual in Québec. An authorization from the Commission
d’accès à l’information (CAI) and MUHC ethics approval
had been obtained as well as informed written consent from
the patients.
Prevalence and Incidence Rates
Age and sex standardized annual prevalence rates have
been calculated for the years 1993–2002, excluding from
computations the persons who died the previous year. Age
and sex standardized annual incidence rates were also calcu-
lated using the shorter period of 1998 –2000 in order to
differentiate incident from prevalent cases in the early years
and to account for the possibility of incomplete data in the
last years of data collection. Two different populations were
430
Inflamm Bowel Dis ● Volume 15, Number 3, March 2009
used as standards for this calculation: the mid-year 1996
Québec population and the combined 1996 populations of 5
other Canadian provinces (British Columbia, Alberta, Sas-
katchewan, Manitoba, and Nova Scotia). All standardization
used the direct method. The population data were made
available through the Québec Health and Social Services
Ministry (MSSS) and from Statistics Canada.
Predictor Variables
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Factors have been previously associated with CD in the
literature.11–14 We created a database with 7 of these associ-
ated variables including a measure for each of the 166 CLSC
areas of Québec. Ethnicity measures are the percentage of the
population reporting to be immigrants, of Jewish ethnicity,
and of Native American ancestry. Other measures were ma-
terial deprivation, number of prescriptions of oral contracep-
tives (OC) among women in the population, enteric infection
incidence rate, and smoking. The original data of variables
associated with ethnicity came from the 2001 Census of
Canada. We included the material deprivation variable in the
analysis knowing that health inequality can be determined by
material deprivation due to an increase of general suscepti-
bility to ill health.15 This measure is the combination of
estimates of material deprivation from the 2001 Census of
Canada smaller areas to get values equivalent to the larger
CLSC areas. The exposure to oral contraceptives among
women, defined as the average number of prescriptions
served per year, was determined by using period estimates
from IMS Health Canada and were applied ecologically to the
corresponding areas of CLSCs.16 Ecological measures of
enteric infection incidence rate (the combined incidence of all
cases of the 5 most frequent reportable enteric diseases, being
campylobacteriosis, salmonellosis, shigellosis, giardiasis, and
yersiniosis) per CLSC were obtained for the province from
the surveillance section of the Montréal-Regional health
board for the period 1995–2000. Finally, the measure of
smoking was created by applying rates from the larger areas
of Socio-Sanitary Regions (RSS) to the smaller CLSC areas
to get the estimated percentage of smokers. The RSS self-
reported smoking rates were obtained by the National Insti-
tute of Public Health of Québec (INSPQ).
Descriptive Statistical Models
The predictor variables and the age and sex standard-
ized incidence rates were modeled in uni- and multivariate
models. Incidence rate ratios (IRRs) were calculated follow-
ing the Poisson regression functionality of the GENMOD
procedure provided by SAS software (v. 9.1, SAS Institute,
Cary, NC). The generalized estimating equations (GEE) of
this procedure adjust for possible clustering effects as well as
for repeated measures. Ninety-five percent confidence inter-
vals (95% CI) were calculated. Statistical significance was
Inflamm Bowel Dis ● Volume 15, Number 3, March 2009 Epidemiology of CD in Québec

TABLE 1. Yearly Age and Sex Standardized* Prevalence and

Incidence Rates of Crohn’s Disease in Québec, 1993-2002 and
1998-2000
Prevalence Incidence
Year (per 100,000) (per 100,000)

1993 82.6 N/A

1994 116.2 N/A
1995 139.8 N/A

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1996 169.3
1997 187.7
1998 202.6
1999 225.0
2000 242.8
2001 260.2
2002 270.4
Average 189.7
*The reference population used to standardize is Quebec 1996.
defined at the P 0.05 level. Interaction terms were also tested
in the final model.
RESULTS
Number of Cases Identified and Validation
From January 1st 1993 to December 31st 2002, there
were 72,570 medical contacts related to CD. During the same
period, 21,172 patients fulfilled the CD case definition and
were still alive in 2002, while 890 patients who had fulfilled
the CD case definition died during the period. The encrypted
patient identifier was absent for 3535 medical contacts. The
case validation included 55 patients with consent, 32 CD and
23 UC. The observed sensitivity was 97% and specificity was
83%.
Prevalence and Incidence of CD in Québec
The point prevalence for the year 2002 was 270 cases
/ 100,000 population. The average period prevalence rate for
1993–2002 was 189.7 cases / 100,000 population (Table 1,
Figure 1) For the 1998 –2000 period, the age and sex stan-
dardized average incidence rate of CD was 20.2 cases /
100,000 person-years, rate standardized with the Quebec
population. The incidence was 20.1 cases / 100,000 person-
years when using the combined populations of 5 other Cana-
dian provinces as the reference population.
N/A
N/A
20.6
20.3 FIGURE 1. CD standardized prevalence rate (per 100,000).
19.8
N/A
N/A old. The overall distribution of CD cases by age and sex is
20.2 presented in Figure 2.
Data Modeling
The crude estimates of IRR for each variable are dis-
played in Tables 2 and 3. Crude CD incidence rate ratio was
maximal in the age group 20 –29 years old. The other vari-
ables associated with CD in univariate models are: a high
proportion of immigrants, a high proportion of Jewish indi-
viduals, prescriptions of oral contraceptives, incidence of 5
reportable enteric diseases, Native American ancestry, and
material deprivation (Table 3). After adjustment, independent
predictors of CD incidence were: a high proportion of immi-
grant people, a high proportion of Jewish individuals, and the
incidence of 5 reportable enteric diseases. None of the inter-
action terms from the final model were significant. The value
of the pseudo-R2 of the reduced Poisson regression model
was 0.20.
DISCUSSION
Across the years included in the study period, the
population-based standardized prevalence rate of CD follows

Age and Sex in CD

The mean age of diagnoses for CD cases was 38.7 years
old, ranging from 1 year old to 84 years old. For the 1998 –
2000 period, the female/male cases ratio among the incident
cases was 0.74 for the 0 –14-year-old group, 1.30 for the
15– 64-year-old group, and 1.77 for cases older than 65 years FIGURE 2. Distribution of CD cases by age and sex.

431
Lowe et al
TABLE 2. Crude Incidence Rate Ratios (IRR), Univariate Model
Analysis for Age and Gender Variables
Predictors Incidencea Crude IRRb
Age
0-19 13.9 Ref.c
20-29 35.5 2.64
30-39 24.3 1.62
40-54 21.7 1.52
⬎55 20.6 1.50
Gender
Male 18.50 Ref.c
Female 27.90 1.95
a
Average incidence of CD, by 100,000 person-years.
b
Incidence rate ratio (IRR) calculated using as a dependant variable the crude
incidence of CD.
c
Referent category.
a positive trend, increasing from 1993 to 2002 (Fig. 1). The
population-based standardized point prevalence of 2002 in
the province of Québec (270 cases / 100,000 population) is
among the highest reported.17 The case definition was highly
sensitive and specific, suggesting that almost all CD cases
were identified from the database and the rate of false-
positives was low. These 2 measures were comparable to
those obtained by Bernstein et al,5 reinforcing the validity of
the case definition provided by these authors. However, our
validation has its own limitations, principally due to the very
small numbers of clinically identified cases in our cohort and
the fact that the MUHC is a tertiary care center where the
diagnosis may be more accurate than in the community,
therefore overestimating the sensitivity and specificity.
Age is an important predictor for CD and the incidence
rate ratio for the 20 –29-year-old group is higher than what is
observed for the same age group in the province of Mani-
toba,11 but is consistent with previous reports.5,18,19 When
comparing women to men the incidence rate ratio is 1.95, an
observation that seems to be slightly higher than what was
previously reported.18,20 We also observed a geographic vari-
ation in the incidence of CD in Québec; however, since no
spatial analysis was performed in this study, specific geo-
graphical patterns or trends were not characterized.
A recent study compared the prevalence of CD from 5
Canadian provinces.4 There appeared to be west-to-east geo-
graphical variation: the prevalence of CD in 2000 was esti-
mated to be 233.7 cases / 100,000 population in British
Columbia and 318.5 cases / 100,000 population in Nova
Scotia.4 Our findings are concordant with this increasing
west-to-east geographical variation, as our results, using the
same case definition, showed a point prevalence of 270 cases
/ 100,000 population in Quebec.4 The standardized incidence
rate is 20.1 cases / 100,000 population over a similar obser-
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Inflamm Bowel Dis ● Volume 15, Number 3, March 2009
vational period to what has been reported for the other Ca-
nadian provinces, which makes it the second highest rate
among the 6 provinces for the 1998 –2000 period (Nova
95% CI Scotia’s reported incidence rate for CD being 20.2 cases /
100,000 population).4
Even if the data suggest a high burden of CD in
Canada, such a conclusion cannot be achieved at this point, as
2.34-2.93
population-based studies like those done in Canada are
1.44-1.82
known to be more sensitive than hospital-based studies, since
1.39-1.66
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they include both outpatient visits and hospitalizations.5
1.36-1.64
Comparing these results with those from hospital-based stud-
ies done in other geographical areas such as Spain21 or
1.68-2.27
Singapore22 would not take into account that these studies
may have underestimated their prevalence.
However, even though population-based studies are
more sensitive, we believe that the present prevalence esti-
mation likely underestimated the true prevalence of CD in
Québec. Indeed, more patients may have been identified as a
CD case if the period of study (actually 10 years) would have
been longer (only 25% of patients with at least 1 CD medical
contact were defined as CD cases). Also, 3535 medical con-
tacts did not have an encrypted medical identifier. These were
likely noncitizens of Québec and thus need not be considered
in this study, but there could also be some data collection
error that resulted in a lack of identifier. Economou and
Pappas23 recently published a global map of CD based on
assembled incidence data from the literature, from 1990 on-
ward. Based on their results, the CD incidence in Québec
would be one of the highest reported so far in the literature.
However, even though the majority of the published results
are standardized for age and sex, we believe that it can be
misleading to compare results of incidence between countries
without taking into account the ethnic composition of the
populations. Indeed, our results support the predictive roles of
ethnicity in the development of CD.14,24
We determined that in Québec, a strong proportion of
immigrants in a population is associated with lower incidence
rates of CD. This supports the hypothesis raised by Bernstein
et al4 about British Columbia’s low incidence and prevalence
rates of CD, the province’s population being constituted of
26% visible minority compared to 10% in Québec for the
same census year.25 This phenomenon could reflect a partic-
ular distribution of genetic susceptibilities in certain groups.
Indeed, since the beginning of the 1960s the country of origin
of the majority of new immigrants coming to Canada changed
from Western Europe to Asia and Africa and certain poly-
morphisms in the NOD2/CARD15 gene are associated with
this disease in Caucasians, but not in some Asian and African
populations.26 –29 We also observed an association between a
high incidence of CD and a high proportion of Jewish people
in the population. It has been observed that CD incidence is
generally higher in the Ashkenazi Jewish population when
compared to any other reference group. This is believed to be
Inflamm Bowel Dis ● Volume 15, Number 3, March 2009 Epidemiology of CD in Québec

TABLE 3. Crude and Adjusted IRR, Univariate and Complete Multivariate Models Analysis for Demographic and Health-related
Variables
Predictors
CLSC n Ave. Incidencea Crude IRRb Adjusted IRRc 95% CI

Immigration (%)
0-10 127 23.0 Ref.
11-62 39 20.1 0.87 0.76 0.69 0.85
Jewish descent (%)

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0-1 152 22.3 Ref.
2-19 11 21.2 0.95 1.02 0.87 1.21
20-59 3 28.7 1.28 1.70 1.30 2.21
Oral contraceptives (28
days prescription/year)
0-3 28 21.6 Ref.
⬎4 101 24.0 1.11 1.05 0.95 1.17
Incidence 5 enteric diseases
(100,000/pers-years)
1-6 15 19.0 Ref.
7-14 60 22.6 1.19 1.23 1.04 1.46
15-100 91 23.0 1.21 1.18 1.0 1.40
Smoking (%)
⬍26 85 22.9 Ref.
⬎26 81 21.8 0.96 N/A N/A N/A
Aboriginal (%)
⬎3.6 21 15.4 Ref.
0.6-3.5 43 22.9 1.49 1.02 0.86 1.22
0-0.5 102 23.6 1.53 0.95 0.79 1.15
Material deprivation
1. Low material deprivation 4 22.4 1.19 0.92 0.71 1.18
2. 24 23.8 1.26 0.89 0.77 1.04
3. 51 22.7 1.21 0.90 0.79 1.03
4. 59 23.1 1.23 0.85 0.75 1.0
5. Strong material
deprivation 28 18.8 Ref.
a
Incidence of CD standardized for age and sex with the Québec 1996 population/100,000 person-years.
b
Incidence rate ratio (IRR) of univariate models in which the dependent variable is CD incidence, standardized for age and sex with the Québec 1996
population.
c
IRR of the complete multivariate model in which the dependent variable is CD incidence, standardized for age and sex with the Québec 1996 population,
adjusted for: immigration, Jewish ethnicity, incidence of 5 enteric reportable diseases, Native American ancestry, and material deprivation.

mostly due to their genetic susceptibility to CD.30 –32 In
Montréal, the CLSC with the second highest incidence rate
reported in the province is also the one that covers the
neighborhood where the Jewish Communities (i.e., Ashke-
nazi and Sephardic) are principally established.33
Known genetic polymorphisms explain only about 20%
of the associated risk of CD.34 Therefore, other factors, ge-
netic and/or environmental, could contribute to CD suscepti-
bility. The concept of an environmental trigger in the etiology
of this disease is supported by the increased development of
CD in the new immigrant generations. Indeed, it has been
observed that the incidence of CD increases in groups of
people who moved from countries where CD is rare to
developed countries where it has a high incidence.34 –36 Also,
it is known that the CD prevalence is higher in North Amer-
ican Jewish people compared to Israeli Jews.37
A positive association maintained after adjustment has
also been found between CD and the cumulated incidence
rates of 5 enteric reportable diseases. This result is opposite to
what was found by Green et al11 in Manitoba. Our measures
cover a recent past and not the events of childhood of the
population. Therefore, we cannot involve the “hygiene hy-
pothesis” in our interpretation.38,39 On the contrary, we pos-
tulate that our finding is more likely a proxy of a current

433
Lowe et al
environmental factor. Finally, our final model explains about
one-fifth of the variance of CD incidence; therefore, we
believe that spatial analysis of the distribution of CD cases in
Québec would help explain a larger spectrum of the variance.
Such precision would help elucidate if there is residual vari-
ance that could be explained by environmental factors. Our
team is currently conducting such an analysis.
In this study an effort was made to keep the interpre-
tation of the results at the population level in order to avoid
the introduction of an “ecologic bias,” which means inferring
the results to the individual level. However, some limitations
have been identified. An information bias may have been
introduced since regional estimates have been used to get
information for the CLSCs territories, transferring data from
larger territories to smaller ones. Also, we measured the
exposure to variables for the study period and not during
childhood, and perhaps the degree of exposure varies be-
tween the CLSC or some factors may have delayed effects on
the individuals. Moreover, it is possible that some cases
moved from one area to another during the study period. We
increased the intragroup homogeneity of the variables in-
cluded in the study by using CLSC since the variables have
greater chances to be uniformly distributed in these territo-
ries. When doing inter-CLSC comparisons, an effect of clus-
tering might have occurred due to the fact that similar people
have tendencies to live in same areas, although we structured
and analyzed our data to take into account this effect. It
would also be interesting to establish the geographical repar-
tition of the genetically susceptible people to CD in Québec.
That could help explain the results obtained in this study for
the ethnicity-related variables.
In summary, our results show that demographic and
health-related characteristics can partially explain the varia-
tion in the incidence of CD in Québec and that further
investigations need to be done to elucidate the residual vari-
ation.
ACKNOWLEDGMENTS
We thank Dr. Paul Rivest of the Montréal Regional
Health Board, Simon Mélançon (MSSS), and Anne-Maxime
Dagenais from IMS Health Canada for contributions to the
set-up of the datafile as well as Sarah Vahey for statistical
expertise.
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