2014 French guidelines for hepatitis B and C screening: a combined targeted and mass testing strategy of chronic viruses namely HBV, HCV and HIV.

BACKGROUND & AIMS: Worldwide and, to a lesser extent, in France, a minority of individuals infected with hepatitis B (HBV) and C (HCV) is aware of its status. Given the current availability of highly effective anti-HBV and anti-HCV agents, the high rate of undiagnosed people, associated with individual and community prejudices (liver disease worsening, persistence of a hidden transmission reservoir and medicoeconomic burden of delayed care), is unacceptable. METHODS: On the occasion of the first French general report on viral hepatitis, new recommendations for HBV and HCV testing were issued. We aim to introduce the new French strategy for HBV and HCV screening, and to describe the underlying epidemiological data. RESULTS: These recommendations comprise various items. First, the screening of chronic viruses, namely HBV, HCV and HIV, should be quasi-systematically combined. Second, the targeted screening of groups at risk of viral exposure must be strengthened. Third, routine testing for each of these three viruses should be offered at least once to men of 18-60 years old who had never been tested. In parallel, in pregnant women, in addition to HIV-HBV screening, currently recommended HCV testing should be routinely performed during the first trimester of pregnancy. In order to best achieve the target populations, community initiatives that propose testing actions should be encouraged, particularly those including rapid point-of-care tests. CONCLUSIONS: Overall, these recommendations aim to define a comprehensive testing strategy for chronic viral infections, emphasizing both targeted screening and mass screening and considering jointly HBV, HCV and HIV.

[Factors associated with investment in an office medicine project by general practice residents]. / Déterminants du projet d'installation en ambulatoire des internes de médecine générale.

OBJECTIVE: To identify thefactors associated with investment in an office medicine project by French general practice (GP) residents. METHODS: We conducted a national survey using a web-based self-administered questionnaire and analyzed the data collected by multiple logistic regressions. The dependent variable was "an office medicine project" The explanatory variables were both individual (socio-demographic and linked to training trajectories) and contextual (related to the available training programmes and the regional medical demography). RESULTS: The response rate was 48.5%. Out of the 1,695 residents of the study sample, 315 (18.6%) already had a project to setup an office practice during their third cycle ofmedical studies. The main factors associated with this project were (p < 0.05): to receive strong academic support, to live in a rural or semi-rural area, to work as a GP locum, to perform residency training in the same city as the medical training and to perform residency training in a region with a high percentage of GPs 55years and older. CONCLUSIONS: This study showed that a project to setup an office practice was influenced by both individual and contextualfactors. Special attention should be paid to the means and content of training to ensure better supportfor residents, which could make office general practice more attractive.

[Peer visits to community-based general practitioners and pediatricians as part of the "Antibiotics only when necessary" campaign in the Alpes-Maritimes district. Methodology, feasibility, and interest]. / Visites confraternelles aux médecins libéraux généralistes et pédiatres des Alpes-Maritimes lors de la campagne "Antibios quand il faut". Méthodologie, faisabilité et intérêt.

OBJECTIVES: As part of a public health campaign promoting prudent antibiotic use to combat bacterial resistance in southeastern France, a multidisciplinary group organized peer-conducted educational outreach (academic detailing) visits to all the community-based general practitioners and pediatricians in the district. The visits, which took place in 2000 and were repeated in 2003, were intended to provide epidemiological data and professional guidelines to these doctors. METHOD: A group of local experts created special academic detailing sheets based on French and international recommendations. Peers with similar experience received special training in the relevant scientific material and in communications skills and then visited the local physicians and discussed the detailing sheets. RESULTS: The project contacted 95% of the target doctors (1079/1174 in 2000 and 1119/1135 in 2003), 94% (1024/1079 and 1042/1119, respectively) of whom agreed to be visited. The visitors reported positive feedback in over 80% of cases. Many of the visited doctors showed keen interest that led to ongoing dialogue, including participation in a regional influenza surveillance program. A sample of the visited doctors received a questionnaire to evaluate the method in 2001: 93% of the responders endorsed the method and 92% requested for more recommendations and guidelines. DISCUSSION: Carefully prepared individual academic detailing visits conducted by peers succeeded in visiting nearly all the physicians in the district twice, two years apart, and provided them with useful support for implementing important guidelines in everyday practice. This method can be used to improve cooperation between healthcare providers and improve the quality of health care in France.

[Screening and hepatitis C management survey in general medicine in the Alpes-Maritimes and east Var area]. / Enquête de pratique en Médecine Générale sur le dépistage et la prise en charge de l'hépatite C dans les Alpes-Maritimes et l'est du Var.

BACKGROUND: This study was performed to assess screening and management of hepatitis C by community-based practitioners in the Alpes Maritimes district in the South of France and to compare their practices with the recommendations issued by the consensus conferences in 1997 and 1999. This information was to be used to adapt continuing medical education to the needs of practitioners in the area. METHOD: Two hundred and nineteen general practitioners who were members of eighteen continuing medical education associations accepted to complete a questionnaire containing eighteen closed questions. It was issued late 1999 during one of the monthly meetings and completed by all the participating physicians. RESULTS: Only 32% of general practitioners knew the conclusions of one of the two French and European consensus conferences concerning hepatitis C. General practitioner practices were in accordance with recommendations for targeted screening in case of transfusion before 1991 (88%), intra-venous drug use (94%) and increased ALT (91%); however intra nasal drug use (35%) and imprisonment (46%) were underestimated risk factors. Frequency of screening was correlated to duration of practice (P<0.01), size of practice (P<0.02) and follow-up of hepatitis C infected patients, regardless of treatment (P<0.03). Upon discovery of a positive HCV status, 80% of general practitioners prescribed initial investigations but these included costly and needless procedures such as hepatic imaging (56%), RNA quantification (39%) and viral genotype (6%). On the other hand, 79% general practitioners recommended a liver biopsy for patients with elevated transaminase levels. When transaminase levels were normal, only 13% requested qualitative detection of viral RNA. Generally, general practitioners were confused concerning the indications for qualitative or quantitative viral RNA investigations. Few general practitioners followed treated HCV-infected patients and renewed interferon therapy prescriptions. Condom use was advised by 56% of GPs for couples in which one of the partners had a positive HCV status. CONCLUSIONS: This study demonstrates the weak impact of consensus conferences on hepatitis C management for general practitioners in the Alpes Maritimes. It provides an opportunity to identify the need for specific training which will be developed within the Côte d'Azur Hepatitis C Network.

[Modalities of care in anti HCV positive patients identified in General Medicine in the Alpes-Maritimes district]. / Analyse de la prise en charge en Médecine Générale de malades identifiés comme positifs pour le virus de l'hépatite C dans le département des Alpes-Maritimes.

UNLABELLED: Little is known about the management of HCV infected patients after screening in general medicine. On May 2000, 75 General Practitioners (GP) from South Eastern France were involved in an HCV screening campaign. Fifteen per cent of 6321 patients seen during this period presented at least one of the following risk factors: blood transfusion before 1991, drug abuse, imprisonment. Among the 238 HCV positive patients, 9 new cases were reported. AIM OF THE STUDY: To describe the management of these patients. RESULTS: One hundred and fifty-nine of these 238 cases were studied (100 males and 59 females). Mean age was 42 +/- 12 years. Mean delay between contamination and the discovery of HCV positive status was 8 +/- 6 years. Main routes of infection were: drug abuse (78%), transfusion before 1991 (15%), imprisonment (7%). The GP performed the entire follow up of cases in 34%. The following investigations were performed: ALT dosage in 98% (elevated: 59%, normal: 41%), qualitative HCV RNA detection in 77% (positive 78%, negative 22%), quantitative HCV RNA detection in 27%. A liver biopsy was performed in 62 patients (39%). Among the 159 patients 39 (19%) were treated with Interferon (with or without Ribavirin). Treatment and liver biopsy were not performed for the following reasons: patient refusal (26%), normal ALT values (26%), HIV co-infection (27%), elderly patients (3%), decompensated cirrhosis (5%), drug abuse or excessive alcohol intake (12%). CONCLUSION: The main reasons that adequate management in hepatitis C patients failed was fear of liver biopsy and/or Interferon therapy, and a population difficult that was difficult to treat (HIV coinfected, drug abuse or chronic alcoholism), A better collaboration between general practitioners and specialists could help improve the management of these patients.

[Factors related to screening of hepatitis C virus in general medicine]. / Facteurs associés à la proposition du dépistage de l'hépatite C en médecine générale.

UNLABELLED: Despite the high prevalence of hepatitis C in France ( approximately 1.2%), a large proportion of people infected with hepatitis C virus (HCV) are not known aware of their status. The objective of this study was to investigate the factors related to screening in general medicine. MATERIAL AND METHODS: Three hundred and one general practitioners were interviewed by phone in South-Eastern France about their HCV screening practices, knowledge of the epidemic, of the natural course of the disease, and opinions about health care for people infected with HCV. RESULTS: While general practitioners often offered HCV screening to intravenous drug users, screening for people who had received blood transfusion, and identification of risk factors among patients were not satisfactory. Multivariate analysis showed that certain characteristics in general practitioners were negatively and independently related to the frequency of HCV screening, especially: general practitioners older than 40 (odds-ratio: 3.12), general practitioners who did not care for intravenous drug users (odds-ratio: 2.24) and did not prescribe human immunodeficiency virus tests (odds-ratio: 5.55). Other characteristics such as awareness of the course of hepatitis C and health care were also associated with HCV screening. Conversely knowledge of the size of the epidemic was not related to better HCV screening practices. CONCLUSION: Our study shows that knowledge about the size of the epidemic and the natural history of hepatitis C, HCV screening practices and investigation of risk factors among patients are not satisfactory among South-eastern French general practitioners. Although HCV screening and health care must be improved among intravenous drug users, hepatitis C should not be considered as a disease of injecting drug users only by general practitioners and the population. Efforts should be made so that hepatitis C is recognized as a global public health issue, and training of general practitioners should be improved to investigate risk factors and offer HCV screening instead of merely dramatizing the situation.

["Antibiotics only when necessary" campaign in the Alpes-Maritimes district: no negative impact on invasive infections in children in the community 1998-2003]. / Campagne "Antibios quand il faut" dans les Alpes-Maritimes: absence d'impact sur l'incidence des infections invasives dues aux bactéries respiratoires communautaires chez l'enfant, 1998-2003.

OBJECTIVES: A multidisciplinary group (for the study and prevention of infections in children, GEPIE) conducted a local public health campaign to improve antibiotic prescribing in pediatric outpatient care in the Alpes-Maritimes district. This campaign included peer-conducted academic-detailing (educational outreach) visits in 2000 and 2003. Practitioners often report during both focus groups and the GEPIE visits that they prescribe antibiotics because of a fear of subsequent complications. This study therefore sought to explore the trends in invasive diseases related to bacterial respiratory pathogens. METHODS: A retrospective survey examined the incidence in the district of invasive infections due to Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, and Neisseria meningitidis from 1998 through 2003 among children aged 1 month to 15 years. All local laboratories were asked for all reports of blood cultures (as well as spinal, synovial, pericardiac, peritoneal, and pleural fluid cultures) positive for these bacteria in the study population over the study period. Resistance and serotype data were recorded. RESULTS: Over the 6-year study period, there were 113 cases of invasive infections: 64% due to S. pneumoniae, 26% to N. meningitidis, 6% to H. influenzae, and 4% to S. pyogenes. There was no statistically significant difference in the annual average incidence rate before and during the campaign. The overall incidence rate was 11.2 cases per 100,000; meningitis accounted for 4.2, and invasive pneumococcal diseases 7.2 (42.7 per 100,000 children younger than 2 years). Pneumococcal resistance rates to penicillin and erythromycin did not change significantly. DISCUSSION: Two local cross-sectional studies at daycare centers in 1999 and 2002 showed a 9% reduction in the proportion of children who received antibiotics. The stability of invasive infection in children and of bacterial resistance during the campaign is reassuring. The campaign's risk/benefit ratio appears positive. CONCLUSION: These results encourage continuing promotion of rational antibiotic prescribing and ought to allay practitioners' fears about the consequences of prescribing antibiotics less often.