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Surveillance of hepatitis C Infection in France

Surveillance of hepatitis C Infection in France. JC Desenclos, Département des Maladies Infectieuses Institut de Veille Sanitaire. Outline. Background Ongoing Surveillance HCV screening activity newly treated patients in reference centres blood donors & residual risk

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Surveillance of hepatitis C Infection in France

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  1. Surveillance of hepatitis C Infection in France JC Desenclos, Département des Maladies Infectieuses Institut de Veille Sanitaire

  2. Outline • Background • Ongoing Surveillance • HCV screening activity • newly treated patients in reference centres • blood donors & residual risk • indicators of arm reduction activities • nosocomial HCV infections • Repeated surveys • HIV-HCV co-infection • prevalence and % of HCV infected screened • HCV associated deaths • Other projects

  3. HCV national prevention and control plan • National plan initiated by the Ministry of Health • Planned at the regional level • Secondary and tertiary prevention • screening of at risk groups (goal : 70% in 2002) • early follow up, management and treatment • Primary prevention • blood (NAT, 2001) and organ donation safety • harm reduction policy among IV drug users • control of iatrogenic transmission • health care related (standard precautions…) • tattooing, piercing…

  4. 5 4 3 1 2 Epidemiolgical profile • Prevalence : 1.1%; 500 000 - 650 000 with HCV antibodies of whom 80% are HCV RNA+ (1994) • Source of past infection: • Blood transfusion : 1/3 • IV drug use : 1/3 • iatrogenic : ?? 10-15% • Genotype : • “0bservatoire VHC” • 2000-2001 • Incidence : • ?

  5. Prevalence of HCV serum antibodies in 4 regions, France, 1994 Fécamp: 1,9% Lyon : 1,3%

  6. Proportion of HCV positive subjects who knew their status when screened, Social security examination center, Région Centre, France, 1993-2000 % Year Source : Dubois et al, Concours Médical

  7. Objectives of HCV surveillance • Data for decision making • burden • trends • risk factors • Evaluate prevention and control programs • screening activities • blood safety • IVDU harm reduction • Disease control : outbreak detection, investigation and control • Link and interaction with public health research

  8. Surveillance of laboratory HCV antibody screening activity • RENAVHC : network of hospitals and public laboratories nationally distributed (N = 257) • Initiated in 2000 • Activity by quarter • monitor screening activities • number of serologic tests done and of positive • test confirmation activity • basic characteristics of positive tests • Analysis by quarter and region (n = 22)

  9. Screening activity by quarter, RENAVHC network (n=257), France 2000

  10. Newly referred patients in hepatitis C reference centers • 30 reference centers • hepatology or gastro-enterology centers • designated by the ministry of health • coordinate a regional network of clinical care, information, treatment, prevention, training… • National surveillance network • reference centers-InVS (23 in 2000; 25 in 2001) • trend overtime in patient characteristics • case definition : newly referred hepatitis C • data : clinical, epidemiological and virological

  11. Newly referred HCV patients, “pôles de référence, 2000” : mode of discovery of HCV

  12. Newly referred HCV patients, “pôles de référence, 2000” : clinical stage 9,8 * * 1991-1993 : 20%; F. Roudot-Thoraval et al. Hepatology 1997 ; 26 : 485-90

  13. 34* 38* Newly referred HCV patients, “pôles de référence, 2000” : source of infection Suspected source of Women Men infection n (%) n (%) Transfusion 359 46,2 281 27,1 IV drug use 183 23,2 518 49,5 Nasal drug use 37 5,1 131 4,1 Professional exposure † 35 4,5 20 1,9 Nosocomial exposure ‡ 146 18,4 136 12,9 Other factors ¶ 146 18,7 202 19,4 No risk factors 99 12,3 115 10,7 total >100%, > to more than 1 risk factorr; †health care related ; ‡ dialysis, surgery, endoscopy ; ¶ acupuncture, injections, piercing, sexual partner HCV+ * : in 1991-2003 : 34 and 25%, respectively HCV-HIV co-infection : 7%

  14. Surveillance of blood safety • Collaborative surveillance between blood centers & InVS • HBV, HCV and HIV markers • all donors • repeat donors • denominators • characteristics of positive patients • Incidence among repeat donors • Estimate of residual risk

  15. 6,0 5,0 4,0 3,0 2,0 HBV HIV 1,0 HCV 0,0 HTLV 1992-94 1993-95 1994-96 1995-97 1996-98 1997-99 1998-00 Source : GATT, InVS, INTS Incidence of HIV, HBV, HCV and HTLV among repeat blood donors, France, 1992-2000 Cases per 100 000 person year 3 years moving period

  16. Residual risk of transmission of blood-borne viruses per million blood donations, 1992-2000(Transfusion; 2002, in press) Risk per 1 000 000 9,0 8,0 7,0 6,0 5,0 4,0 3,0 HBV 2,0 HCV 1,0 HIV HTLV 0,0 1992-94 1993-95 1994-96 1995-97 1996-98 1997-99 1998-00 3 years moving period Source : GATT, InVS, INTS

  17. Harm reduction activities : SIAMOIS • National data-base, stratified by district • Delivery indicators • number of syringes sold • number of steribox kit sold • amount of subutex sold • methadone • Impact indicators • overdose deaths • arrests for drug offense • National and local monitoring • Sharp drop in 1ml syringe sale in last year

  18. Notification of nosocomial infection events • Introduced in 2001 • Nosocomial sentinel events • based on criteria; no positive nor negative list • HCV and HBV infection following medical care • Notification • to local district health offices • inter-regional nosocomial coordination centers • national coordination : RAISIN-InVS

  19. Examples of notification of HCV iatrogenic transmission since July 2001 • Outbreak in an haemodialysis center, 2001 • 22 new infections; incidence : 52%person years • 3 genotypes • major breaches in hygiene procedures • case-control study: infection associated with : • care by a nurse who had just cared for an HCV+ patient • not to dialysis on a machine used previously by an HCV positive patient • Seroconversions associated with : • endoscopy (1) • inappropriate use of a glucometer (1)

  20. Surveys • Seroprevalence and behavioral surveys of IV drug users (InVS, INED, ANRS) • multi-city (5 to 6 large urban area) • cluster (multi site) probability sample • blood (finger) taken for HIV, HCV and HBV • questionnaire • pilot done in Marseille (April 2002) • Prevalence of HIV-HCV co-infection • National seroprevalence survey

  21. HIV-HCV co-infection • National probability sample of HIV wards • one day survey (June 2001) • in- and out- HIV positive patients • basic epidemiological and clinical characteristics • Results • N = 1744 • co-infecion : 28% (25-30 000 patients) • Among HCV patients, HIV infection : 7% • New survey planned in 2003 • hepatitis B markers • include hepatology wards

  22. % HCV infection among HIV patients, France, June 2001

  23. Population survey • Aim : evaluate HCV prevention plan • prevalence by age (18-80), gender, region (5 inter-regions) and social status (low vs others) • % of HCV+ subjects who knew HCV status • % of HCV+ patient that are taken in charge • Stratified probability cluster sample of social security affiliated • N = 15 000 • HCV and HBV • Planned for last quarter of 2002

  24. Mortality associated with hepatitis C • Vital statistics • Specific viral hepatitis included in 10th ICD • Not available in the 9th ICD: • chronic hepatitis • cirrhosis • carcinoma • Survey of death certificates (CépiDC-InVS) • retrospective survey of certifiers and medical records • random sample of certificates with mention of liver conditions and HIV • done in 1997 and planned in 2003 for (HCV and HBV)

  25. Death associated with chronic hepatitis per 100 000 population, by gender, France, 1979-1998. Source : CépiDC-INSERM

  26. Representative sample of death certificates with mention of liver disease (N = 360), France, 1997 Source : CépiDC

  27. Estimate of the number of deaths associated with HCV in 1997 • By applying sampling fraction • Deaths : 1 837, 95% CI : 1 740 - 1 930 • Death per 100 000 : 3,2; 95% CI : 2,9 - 3,3 • Initial versus associated cause of death : • initial : 630 • associated cause : 1207 • major role : 564 • not major : 643 • Total : 1837 Source : CépiDC

  28. Death rate associated to HCV infection by age and gender, France, 1997 Death per 100 000 Age Source : CépiDC

  29. Disease registries • Cancer registriy (Francim) • all cancers (liver cancer included) • covers 10 districts (12% of population) • certified, coordinated and funded jointly by InVS and INSERM • being strengthened to monitor long term trends • Cirrhosis registry • no registry in France • interaction between HCV, HBV and alcohol

  30. Public health research conducted under the auspices of ANRS • Case control study of HCV seroconversions • plan to include 70 cases and 280 controls • ongoing • Cohort study of HCV- intravenous drug users • north and east of France • one year follow up • basic incidence rate : ~ 10% person year • Sociological research : perception, barriers to screening, follow up, treatment; quality of life... • Cost-efficacy studies...

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