PREVAC BManagement of hepatitis B prevention among migrants

AUBERT Jean-Pierre, DI PUMPO Alexandrine, SANTANA Pascale, MAJERHOLC Catherine, PY Anne-Marie, TAULERA Olivier, WAJSBROT

Alain, GERVAIS Anne, PETREQUIN Cécile

Dept of General Practice, University Paris VII, Paris, France

WONCA Europe, Istanbul, Sept 3, 2008

Background (1)

• In France (INVS 2004)

• Among people with Social Security:

• HBs AG carriers– 0,65 % general population– 5 % people born in Africa– 1 % people born in Asia

• Anti HBc AB carriers– 7 % general population– 50 %people born in Africa– 29 % people born in Asia

• Nothing is known about people without social security

• …but those people attend GPs (they can have consultations for free)

Background (2)

• Behaviour of GPs and hospital doctors regarding hepatitis B prevention is not well known

• Some datas are available, related to hepatitis B vaccination

• But… vaccination is just a part of prevention skills

What is prevention of hepatitis B?

1. People who carry no hepatitis B marker have to be vaccinated

2. everybody should receive information about this disease and its transmission– …BUT …– The messages to deliver differ from one group to another:

• HBs AG carriers (‘HB carriers’)• People with no HBV marker (‘HB free’)• People protected against HBV, by vaccination or infection) (‘HB

protected’)

How to manage HBV prevention?

• Three main serologic groups of people in theory….• ….but actually numerous serologic profiles• ….54 different serologic profiles can be found in

medical files• Development of an internet program,

– to help doctors manage prevention,

– To help doctors decide wich prevention skill has to be used

• internet-accessible information leaflets for patients, related to the serologic profile (uploaded by doctor)

Endpoints

• Main endpoints– Is it possible for GP to manage complete HBV prevention

strategies among migrant people coming from subsaharian Africa and Asia, with help of an internet-based program?

– What are the factors that influence such strategies?

• Secondary endpoints– What are HBV markers prevalences among those

populations?

Method

• 26 GP investigators

• All of them related to health networks

• All of them working in northen Paris and

north-east suburb (high rates of migrants)

• data prior to 31/12/2007 are presented

(preliminary results)

Inclusion/exclusion criteria

• Inclusion criteria

• Born in subsaharian Africa, or Asia

• Age >18• To assess one of the

investigators between 5/11/2007 and 29/2/2008

• Exclusion criteria

• If HIV carrier: Not to be immuno depressed (CD4 cells count<350/mm3)

PREVAC B: GP Patients

• 373 GP patients, among them:– 61% women– 83% born in subsaharian Africa (17% Asia)– 24% no social security– 50% less than 7 years of school 15% no

school at all

ResultsPreventive skill

• application of preventive skill:– 63% patients– 92% exluding missing results

Information

• Leaflets given to– 61% patients– 89% exluding

missing results

• 74% HBV carriers• 100% vaccinated people• 54% patients with anti HBc alone• 82% HBV contact, non-carrier• 74% no HBV marker

Results

Screening before study• 41% patients had been screened for HBV before study

Vaccination before study• 49% patients that required vaccination had been vaccinated before the

study• Thus 51% actually required vaccination ….

During study• 12% patients who required vaccination refused it• Vaccination was actually started for 75% of patients who required it

• Predictive factor for failure of vaccination strategy– Social precarity p=0,02

• Predictive factor for success– High level of education (college, university) p=0,01

HBV markers prevalences

– HBV carriers• 11%

– HBV Contact non-carriers

• 36 %

– Vaccinated • 28%

– No marker • 25%

HBV prevalences

21%

18%

13%

9%

8%

6%

5%

4%

0% 10% 20% 30%

Mali n=57

Asia n=45

Ivory Coast n=39

Congo n=39

Other francophone Af …

Cameroun n=33

Other non francoph Af …

Senegal n=27

HBV carriers prevalences related to country of birth

Anti HBc Antibody alone: an issue for managing prevention of HBV

What’s the problem?

• Your patient has one of the following results1. Hbs AG neg, anti HBs AB neg, anti HBc AB pos2. Hbs AG neg, anti HBs AB not given, anti HBc AB pos

• There is no consensus within guidelines– Vaccinate or not vaccinate (one-shot)?

How did we solve the problem?

• We decided to give the investigator the choice

• Case 1 : make an injection or consider the patient protected• Cas 2: complete serology or consider the patient protected

What do doctors do?

• Facing isolated anti HBc AB (n=28)– 14% complete serology

– 32% decide the patient is protected

– 47% vaccinate

– 7% missing data

one vaccination

shot47%considered

protected32%

Missing datas7%

complete serology

14%

isolated anti HBC AB among GP n=28

Predicitive factors of contact

• Africa/ Asia p=0,002

• Mali, Ivory Coast, Congo/other countries in Africa p=0,0002

• Age more than 40 p=0,04

• Less than 5 years of school p=0,01

Conclusion

• With help of an internet-based program, GP can manage full prevention of hepatitis B transmission.

• preliminary results• 41% patients screened before study• Among patients whose serology requires

vaccination, only one out of two had actually started vaccination

• Isolated anti HBC AB requires clear guidelines• Prevalences of HBV carriage is quite superior to

available datas when EVERY MIGRANT is included.

Thank you for your attention