Surveillance of hepatitis C Infection in France

1
Surveillance of hepatitis C Infection in France

• JC Desenclos,
• Département des Maladies Infectieuses
• Institut de Veille Sanitaire

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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

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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

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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
• ?

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Prevalence of HCV serum antibodies in 4 regions,
France, 1994
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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
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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

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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)

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Screening activity by quarter, RENAVHC network
(n257), France 2000
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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

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Newly referred HCV patients, pôles de référence,
2000 mode of discovery of HCV
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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
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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 gt100, gt 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
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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

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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
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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

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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

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Examples of notification of HCV iatrogenic
transmission since July 2001

• Outbreak in an haemodialysis center, 2001
• 22 new infections incidence 52person 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)

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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

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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

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HCV infection among HIV patients, France, June
2001
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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

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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)

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Death associated with chronic hepatitis per 100
000 population, by gender, France, 1979-1998.
Source CépiDC-INSERM
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Representative sample of death certificates with
mention of liver disease (N 360), France, 1997
Source CépiDC
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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
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Death rate associated to HCV infection by age
and gender, France, 1997
Death per 100 000
Age
Source CépiDC
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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

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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...