1. PREVAC B Management 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

2. 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)

3. 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

4. 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’)

5. 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)

6. 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?

7. 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)

8. 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)

9. 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

10. Results Preventive 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

11. 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

12. HBV markers prevalences –HBV carriers 11% –HBV Contact non-carriers 36 % –Vaccinated 28% –No marker 25%

13. HBV prevalences

14. Anti HBc Antibody alone: an issue for managing prevention of HBV What’s the problem? Your patient has one of the following results 1.Hbs AG neg, anti HBs AB neg, anti HBc AB pos 2.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

15. 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

16. 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

17. 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.

18. Thank you for your attention