A national cross-sectional study among drug-users in France: epidemiology of HCV and highlight on practical and statistical aspects of the design.

BACKGROUND: Epidemiology of HCV infection among drug users (DUs) has been widely studied. Prevalence and sociobehavioural data among DUs are therefore available in most countries but no study has taken into account in the sampling weights one important aspect of the way of life of DUs, namely that they can use one or more specialized services during the study period. In 2004-2005, we conducted a national seroepidemiologic survey of DUs, based on a random sampling design using the Generalised Weight Share Method (GWSM) and on blood testing. METHODS: A cross-sectional multicenter survey was done among DUs having injected or snorted drugs at least once in their life. We conducted a two stage random survey of DUs selected to represent the diversity of drug use. The fact that DUs can use more than one structure during the study period has an impact on their inclusion probabilities. To calculate a correct sampling weight, we used the GWSM. A sociobehavioral questionnaire was administered by interviewers. Selected DUs were asked to self-collect a fingerprick blood sample on blotting paper. RESULTS: Of all DUs selected, 1462 (75%) accepted to participate. HCV seroprevalence was 59.8% [95% CI: 50.7-68.3]. Of DUs under 30 years, 28% were HCV seropositive. Of HCV-infected DUs, 27% were unaware of their status. In the month prior to interview, 13% of DUs shared a syringe, 38% other injection parapharnelia and 81% shared a crack pipe. In multivariate analysis, factors independently associated with HCV seropositivity were age over 30, HIV seropositivity, having ever injected drugs, opiate substitution treatment (OST), crack use, and precarious housing. CONCLUSION: This is the first time that blood testing combined to GWSM is applied to a DUs population, which improve the estimate of HCV prevalence. HCV seroprevalence is high, indeed by the youngest DUs. And a large proportion of DUs are not aware of their status. Our multivariate analysis identifies risk factors such as crack consumption and unstable housing.

Harm reduction interventions, behaviours and associated health outcomes in France, 1996-2003.

AIMS: To track the effect of the French harm reduction programme targeted at intravenous drug users (IDUs) and associated health outcomes. MATERIAL: Since 1996, we have collected monthly sales of sterile syringes and substitution treatments (buprenorphine high dosage and methadone) sold to IDUs in the 23 000 pharmacies in France and collated these figures in a single data base (SIAMOIS). To this data base we have also added the number of syringes distributed through community associations, as well as methadone treatments prescribed in public drug dependence clinics. METHODS: For the period 1996-2003 we analysed syringe sales and prescribed substitution treatments as indicators of access to harm reduction services. We compared variations of these figures over time with trends in health outcome indicators [annual number of fatal overdoses, hepatitis C virus (HCV) and human immunodeficiency virus (HIV) prevalence among intravenous drug users], risk behaviour indicators (rate of syringe sharing or rate of syringe re-use) and legal indicators (heroin and cocaine use-related arrests). FINDINGS: The number of sterile syringes sold or distributed to IDUs increased from 1996 to 1999 (+ 21%) and then decreased dramatically from 1999 to 2003 (-40%). In 2003, we estimated that more than 100,000 drug users used substitution treatments. Between 1996 and 2003, a decrease in syringe sharing and syringe re-use was observed, HIV prevalence among IDUs decreased from 40% to 20% and HCV prevalence remained high (60-70%). From 1996 to 2003, arrests due to heroin use declined (from 17 328 to 4025) and deaths due to overdoses also decreased (from 465 to 89), whereas arrests for cocaine use increased from 1184 to 2511. CONCLUSION: Our results indicate that, since 1996 in France, IDUs have had greatly improved access to sterile syringes and substitution treatments. The decrease in syringe sharing and re-use practices and of HIV prevalence during the same time period indicates that the harm reduction policy implemented in France has had a positive impact. However, because of the persistent sharing and re-use of syringes and a remaining high HCV prevalence in IDUs, efforts to facilitate access to sterile syringes must continue, and targeting of at-risk groups must be improved. Behavioural surveys associated with HIV and HCV seroprevalence data are needed to further assess prevention of blood-borne infections among IDUs in France.

[Harm reduction policy related to drug use: the needles exchange programs]. / Politique de réduction des risques : programmes d'échange de seringues.

In several developed countries, needles exchange programs (NEPs) are a key preventive tool in harm reduction policy related to drug use. Many studies about NEP show it reduces HIV infections related to syringes sharing when part of others preventive actions. NEPs seem to have no impact on HCV transmission. Furthermore, young drug users, who are at high risk for HIV and HCV infections, are not attending NEPs very often. Trying to maintain high accessibility to sterile syringes, efforts must be stressed on hard-to-reach populations such as young injection drug users (IDU), focusing on their social network. Emphasis must also be put on prevention of unsafe sexual intercourse, often related to syringe sharing, which must be more prevented. Finally, design of assessment studies should be improved.

Introduction of SARS in France, March-April, 2003.

We describe severe acute respiratory syndrome (SARS) in France. Patients meeting the World Health Organization definition of a suspected case underwent a clinical, radiologic, and biologic assessment at the closest university-affiliated infectious disease ward. Suspected cases were immediately reported to the Institut de Veille Sanitaire. Probable case-patients were isolated, their contacts quarantined at home, and were followed for 10 days after exposure. Five probable cases occurred from March through April 2003; four were confirmed as SARS coronavirus by reverse transcription-polymerase chain reaction, serologic testing, or both. The index case-patient (patient A), who had worked in the French hospital of Hanoi, Vietnam, was the most probable source of transmission for the three other confirmed cases; two had been exposed to patient A while on the Hanoi-Paris flight of March 22-23. Timely detection, isolation of probable case-patients, and quarantine of their contacts appear to have been effective in preventing the secondary spread of SARS in France.

[An inter-laboratory study of anti-HCV antibody detection in saliva samples]. / Etude inter-laboratoires de la détection des anticorps anti-VHC sur prélèvements salivaires.

AIM: The purpose of this study was to evaluate the efficacy of anti-hepatitis C virus (HCV) antibody detection in the saliva samples of 108 drug users in an inter-laboratory study. METHODS: Between January and June 2001, 108 subjects in Lille, Metz and Lens received a test to detect anti-HCV antibodies in their saliva. Two consecutive saliva samples were taken in each subject (Salivette system, Sarstedt). An HCV serology (Axsym HCV 3.0, Abbott) was also performed and serum HCV RNA detection by Amplicor HCV 2.0 (Roche) was performed when HCV serology was positive. Sixty three patients had a negative HCV serology, 45 had a positive HCV serology, and 31 of these had positive HCV RNA as well. Tests for the detection of the anti HCV antibody in saliva samples were performed as a blind study in both the Lille and the Thionville laboratories. RESULTS: The sensitivity of saliva anti-HCV antibody tests was respectively 71% (32/45) and 78% (35/45) in Lille and Thionville. In the event of positive HCV viremia, the sensitivity was respectively 90% (28/31) and 93% (29/31). The specificity was respectively 97% (61/63) and 98.5% (62/63). Results from the two laboratories agreed for 101 saliva tests while discrepancies were found in 7 (Kappa Concordance Coefficient: 0.85). CONCLUSIONS: This study confirms, in a large, unselected population sample, that anti-HCV antibody detection tests in saliva allow the detection of 90% of viremic HCV-antibody-positive patients with excellent specificity. The simplicity and reproductibility of this technique makes it a precious tool for epidemiological studies.

Travel agents and the prevention of health problems among travelers in Québec.

BACKGROUND: Among the factors influencing travelers to seek preventive health advice before departure, the travel agent's recommendation plays an important role. The objective of our study was to document the practices and needs of travel agents in Québec (Canada) in relation to the prevention of health problems among travelers. METHODS: In June 2000, a cross-sectional descriptive survey was carried out among travel agents from all travel agencies in Québec. One agent per agency was asked to answer our questions. Data were collected using a 32-item telephone questionnaire. RESULTS: Altogether, 708 travel agents from the 948 agencies contacted answered our questionnaire (participation rate: 75%). Most respondents (81%) believed that the travel agent has a role to play in the prevention of health problems among travelers, especially to recommend that travelers consult a travel clinic before departure. Although over 80% of the agents interviewed mentioned recommending a visit to a travel clinic before an organized tour to Thailand or a backpacking trip in Mexico, less than half said they make the same recommendation for a stay in a seaside resort in Mexico. The majority of respondents were acquainted with the services offered in travel health clinics, and these clinics were the source of travel health information most often mentioned by travel agents. However, nearly 60% of the agents questioned had never personally consulted a travel clinic. When asked about the best way to receive information about travelers' health, more than 40% of respondents favoured receiving information newsletters from public health departments regularly whereas 28% preferred the Internet. CONCLUSION: Despite the limits of this study, our results should help the public health network better target its interventions aimed to inform travel agents on prevention of health problems among travelers.