In the general population of mainland France in 2016, approximately 133,000 people had chronic hepatitis C (the virus was present in their blood), of whom 26,000 (19%) were unaware of their infection. HCV screening and prompt initiation of treatment are therefore major challenges in the effort to eradicate the disease.
The role of Santé publique France is to ensure the epidemiological surveillance of hepatitis C and to promote prevention and screening, particularly by raising awareness among people at high risk of infection.

Epidemiological Surveillance of Hepatitis C

The epidemiological surveillance conducted by Santé publique France is based on:

• long-term surveillance systems (in collaboration with clinical laboratories),

• studies of the general population and exposed populations,

• analysis of medical-administrative databases (particularly those of the Health Insurance system and the PMSI),

• modeling.

Santé publique France produces various epidemiological indicators: prevalence, incidence, screening and diagnostic activity, care, and mortality.

Prevalence Surveillance

Estimates of the prevalence of chronic hepatitis C are conducted in the general population and in specific populations.

• In the general population

In 2004, a national prevalence survey of hepatitis B and C was conducted in the general adult population (ages 18–80) in metropolitan France among a random sample of social security beneficiaries and their dependents enrolled in the general social security system.

In 2011, the prevalence of hepatitis C was estimated using modeling in the general metropolitan population aged 18–80.

These prevalence data were updated for the year 2016, thanks to the BaroTest study, which involved offering participants in the 2016 Health Barometer a screening for hepatitis B and C using a self-administered blood sample taken at home. The 2016 Health Barometer is a telephone survey conducted among a representative sample of the population aged 15–75 residing in metropolitan France.

• In specific populations

Estimates of chronic hepatitis C prevalence are also calculated for the following specific populations:

• Drug users, based on the 2011–2013 ANRS-Coquelicot survey. This cross-sectional, anonymous epidemiological survey was conducted among drug users (DU) recruited from specialized facilities. The survey was carried out in five metropolitan areas (Lille, Strasbourg, Paris, Bordeaux, Marseille) and two departments (Seine-et-Marne, Seine-Saint-Denis).

• Men who have sex with men (MSM) frequenting gay social venues, based on the 2015 Prévagay survey. This anonymous cross-sectional survey was conducted among MSM frequenting bars, saunas, and backrooms in five French cities (Paris, Lille, Lyon, Montpellier, and Nice) in 2015.

• The hospital population based on data from the Information Systems Medicalization Program (PMSI).

Monitoring of Hepatitis C Screening and Diagnostic Activities

Monitoring of hepatitis C screening activity currently relies on:

The national LaboHep survey: This retrospective cross-sectional survey was established in 2010 to replace the RenaVHC/B network of volunteer laboratories. It is conducted every 3 years using a sample of clinical laboratories selected at random from a survey frame comprising all public and private laboratories. Indicators are estimated for the whole of France based on the random sample, taking into account the sampling plan and performing post-stratification weighting based on the activity of all French laboratories. The objective of this national survey is to estimate, at the national level, by region, and by department, the number of anti-HCV antibody serology tests performed and the number of anti-HCV antibody serology tests that were positive for the first time in the laboratory during the year, and to describe the sociodemographic characteristics of individuals diagnosed as anti-HCV antibody positive.

• Analysis of health insurance reimbursement data: these data come from the SNDS (National Health Data System), which provides data from all health insurance schemes across France. The data used to monitor anti-HCV antibody screening activity pertain exclusively to laboratory tests performed on an outpatient basis or during hospitalization in a private for-profit healthcare facility (they do not cover tests performed in public healthcare facilities during hospitalization or outpatient visits).

• Activity data from CeGIDDs (Free Centers for Information, Screening, and Diagnosis of HIV, Viral Hepatitis, and STIs), which since January 1, 2016, have included CDAGs (Anonymous and Free Screening Clinics) and Ciddists (Centers for Information, Screening, and Diagnosis of Sexually Transmitted Infections).

In addition to these screening activity data, general population surveys (Health Barometer, KABP) allow for estimating the proportion of people with a reported history of screening.
Furthermore, prevalence surveys allow for estimating the proportion of infected individuals who are aware of their infection versus those who are not.

Data on the Management of Chronic Hepatitis C

• Data on Long-Term Conditions (ALD)

Individuals with chronic hepatitis B or C virus infections may, under certain conditions, be eligible for the Long-Term Illness (ALD) program under the health insurance schemes as ALD 6. This program allows, upon request by the treating physician and as part of a treatment protocol, exemption from the copayment for procedures and services required for the treatment of the condition.
Viral hepatitis C confirmed by the presence of hepatitis C virus (HCV) RNA in serum is eligible for exemption from the copayment, provided that:

• an indication of an initial assessment of the severity of the condition;

• the need for antiviral treatment or long-term follow-up.

The exemption is granted for an initial period of five years, renewable for 10-year periods if the patient receives antiviral treatment. The onset of serious sequelae, where a causal link to the treatment is established, results in the reinstatement of the copayment exemption.

Analyses of the number of people covered under ALD 6 for chronic hepatitis C (code B182) as of December 31 of a given year are conducted using individual data from the National Health Data System (SNDS)

• Data on treatment with direct-acting antivirals

Since late 2013, the treatment of chronic hepatitis C has undergone a major therapeutic shift with the introduction of direct-acting antivirals (DAAs), which achieve a cure rate of over 95% in patients, with a better safety profile and shorter treatment durations than previous therapies. Following the announcement in May 2016 by the Minister of Health regarding universal access to these DAAs, the French National Authority for Health (HAS) issued a favorable opinion in December 2016 recommending the extension of DAA treatment to asymptomatic patients with fibrosis stage F0 or F1. Treatment for patients with milder disease aims to slow the progression of liver fibrosis, prevent its complications, avoid extrahepatic manifestations, and limit viral transmission.
Data from the National Health Data System (SNDS) allow for an estimate of the number of HCV treatment initiations with second-generation DAA since 2013. These data include reimbursement data across all insurance schemes. The data do not allow for distinguishing between treatment initiations in the various French overseas departments (DOM).

• National Surveillance of Chronic Hepatitis C via Reference Centers and Voluntary Networks

This surveillance system, based on a network of voluntary reference centers, was established in 2000 to monitor chronic hepatitis C. It ended on December 31, 2007, to make way for surveillance of chronic hepatitis B (from 2008 to 2012).

The main objective of this surveillance was to describe the epidemiological, clinical, biological, and virological characteristics of individuals newly diagnosed with chronic hepatitis C by the reference centers (university hospital hepatology departments).

A case was defined as a patient over the age of 18 consulting or being hospitalized for the first time (first contact) for positive anti-HCV antibodies at the participating reference centers and hepatitis networks.

Surveillance involved the collection of epidemiological, clinical, biological, and virological data via a questionnaire

Mortality Surveillance

• In 2004–2005, a national survey was conducted using a random sample of death certificates obtained from certifying physicians to estimate hepatitis C-related mortality in mainland France in 2001.

• Analysis of data from the Medical Information Systems Program (PMSI) allows for the estimation of in-hospital mortality associated with hepatitis C.

Other data sources

• Epidemiological surveillance of blood donors

• Surveillance of healthcare-associated infections

Prevention measures against hepatitis C

There is no vaccine against hepatitis C. It is therefore important to protect yourself from blood-borne transmission and avoid rough sexual intercourse, which can lead to hepatitis C. The main preventive measures remain:

• strict aseptic practices during medical and dental care,

• risk reduction among people who use drugs: no sharing of equipment (syringes, snorting straws, crack pipes, cotton swabs), use of sterile, single-use injection kits, injections in safer consumption rooms, use of opioid substitution therapy…,

• the use of new, single-use, disposable needles, as well as the disinfection and sterilization of all equipment during tattooing, piercing, and acupuncture sessions,

• do not share personal hygiene items (razors, toothbrushes, nail clippers, etc.) as they may contain microdroplets of blood invisible to the naked eye.

Information for the general public:

• http://www.soshepatites.org/

• www.hepatites-info-service.org and its hotline 0 800 845 800

• Bilingual health booklets