In 2016, an estimated 135,700 people in the general population of mainland France were chronic carriers of HBV, of whom 17.5% (95% CI: 4.9–46.4) were unaware of their infection. In 2 to 10% of cases, these chronic carriers may develop cirrhosis or hepatocellular carcinoma in the medium to long term. Approximately 4% of people with chronic hepatitis B are estimated to be carriers of anti-HBV antibodies.
For Santé publique France, the challenge is to ensure the epidemiological surveillance of hepatitis B and Delta and to promote their prevention and screening, particularly by raising awareness among those at high risk of infection.

Epidemiological Surveillance of Hepatitis B

The epidemiological surveillance conducted by Santé publique France relies on long-term surveillance systems (mandatory reporting, networks of clinicians or medical laboratories), studies of the general population and exposed populations, analysis of medical-administrative databases (notably those of the Health Insurance system and the PMSI), and modeling. Santé publique France produces various epidemiological indicators: prevalence, incidence, screening activity, care, mortality, and vaccination coverage.

Prevalence

Estimates of the prevalence of chronic hepatitis B 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 using a random sample of social security beneficiaries and their dependents enrolled in the general social security system.

In 2016, a new estimate of the prevalence of chronic hepatitis B in the general adult population (ages 18–75) living in metropolitan France was conducted using BaroTest and the 2016 Health Barometer. BaroTest is a virological component of the 2016 Health Barometer, based on a self-collected blood sample applied to a filter paper at home, testing for HBV, hepatitis C virus (HCV), and human immunodeficiency virus (HIV). The 2016 Health Barometer is a telephone survey conducted among a representative sample of the population aged 15–75 residing in mainland France.

In specific populations

Prevalence estimates for chronic hepatitis B are also calculated for the following specific populations:

• Pregnant women based on 2011 data from the French Longitudinal Study from Childhood (ELFE) in maternity wards and the 2016 National Perinatal Survey (ENP),

• Afro-Caribbean individuals in the Île-de-France region based on the 2016 AfroBaromètre survey, a cross-sectional and anonymous survey conducted in community intervention sites run by the Afrique Avenir association, in open settings (train/subway exits, markets) or closed settings (nightclubs, community halls, hair salons, places of worship),

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

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

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

Diagnosis of Acute Hepatitis B

• Mandatory Reporting of Acute Hepatitis B

Mandatory reporting of acute hepatitis B was implemented in March 2003.

Its objectives are to describe the characteristics of newly infected individuals and to monitor their progression in order to assess the impact of prevention policies. It also aims to identify clusters of cases or unusual modes of transmission.

Any person in whom the following are detected for the first time must be reported:

• Anti-HBc IgM;

• HBsAg and total anti-HBc antibodies in the context of acute hepatitis B (significant elevation of ALT with or without jaundice), if anti-HBc IgM has not been tested;

The following should be excluded: chronic HBsAg carriage and reactivation of chronic hepatitis B with positive anti-HBc IgM.

The reporting form is carbonless, non-photocopiable, and non-downloadable (for reference, a sample is available here). Reporting entities must request the forms from the Regional Health Agency (ARS) in their area of practice.

The notification is initiated by the laboratory technician according to the criteria above. The prescribing physician then completes Sheet 2 of the form, indicating, if known, a history of chronic hepatitis B (with or without reactivation), and sends this Sheet 2 to the MISP of the ARS without filling out the other sections.

• Estimation of the number of acute hepatitis B diagnoses

Between 2004 and 2007, the number of acute hepatitis B diagnoses in France was estimated based on the number of cases reported under the DO and its estimated completeness rate in 2005.

Since 2010, due to the low coverage of the acute hepatitis B DO, the estimate of the number of acute hepatitis B diagnoses in France has been derived from the triennial LaboHep surveys, conducted among random samples of public and private clinical laboratories. This survey includes a section on the diagnosis of acute hepatitis B and a section on screening for anti-HCV antibodies and HBsAg

Monitoring of Hepatitis B Screening and Diagnostic Activities

Surveillance of screening activity currently relies on:

• The national LaboHep survey. This cross-sectional retrospective survey was established in 2010 to replace the RenaVHC/B network of volunteer laboratories. It is conducted every 3 years among a sample of participating clinical laboratories (LABM) selected at random from a survey frame comprising all laboratories (public and private). The indicators are estimated based on the random sample for all laboratories in France, taking into account the sampling plan and performing a post-stratification adjustment based on the activity of all French laboratories. The objective of this national survey is to estimate, for all of France, by region and by department, the number of samples collected for HBsAg testing and the number of samples confirmed positive for HBsAg for the first time in the laboratory during the year, and to describe the sociodemographic characteristics of individuals diagnosed as HBsAg-positive.

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• Analysis of health insurance reimbursement data. This data comes from the SNDS (National Health Data System), which provides data from all health insurance plans across the entire country. The data used to track HBsAg screening activity pertain solely 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, whether during hospitalization or in outpatient settings).

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

In addition to these screening activity data, surveys of the general population (Health Barometer, KABP) and specific populations (AfroBarometer 2016) allow for estimating the proportion of people who reported a history of screening.
Surveys such as the ELFE (French Longitudinal Study from Childhood) maternity ward survey or the ENP (National Perinatal Survey) help document the
frequency of prenatal hepatitis B screening (mandatory screening). Prevalence surveys help estimate the proportion of infected individuals who are aware of their status.

Estimation of HBV Vaccination Coverage

Estimates of vaccination coverage in the general population and in specific populations are based on surveys and analysis of SNDS data.

Data on the management of chronic hepatitis B

• Data on Long-Term Conditions

Individuals with chronic hepatitis B or C virus infection may, under certain conditions, qualify for the Long-Term Conditions (ALD) program under the health insurance schemes as part of ALD6 (active chronic liver diseases and cirrhosis). This program allows, upon request by the treating physician and within the framework of a treatment protocol, exemption from the copayment for procedures and services required for the treatment of the condition.

Chronic viral hepatitis B cases that test positive for HBsAg and meet the following criteria are eligible for exemption from the copayment:

• Signs of active viral replication: HBV DNA > 2,000 IU/ml or even an occasional elevation in transaminase levels

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

The exemption is granted for an initial period of two years, renewable if the patient receives antiviral treatment.

Download:

• HAS, Procedures and Services for Long-Term Conditions No. 6, Chronic Hepatitis B, May 2016

Analyses of the number of people eligible for ALD 6 for chronic hepatitis B (codes B180, B181) as of December 31 of a given year are based on individual data from the SNDS (National Health Data System).

• Hospitalization Data

Analysis of data from the Medical Information Systems Program (PMSI) enables monitoring of hospital morbidity associated with chronic hepatitis B: trends in the number of people hospitalized with a diagnosis of chronic hepatitis B, their sociodemographic characteristics, the frequency of their complications (cirrhosis, hepatocellular carcinoma), and comorbidities identifiable in the PMSI.

• National surveillance of chronic hepatitis B through reference centers and voluntary hepatitis networks

This surveillance, based on the surveillance network of voluntary reference centers (established in 2000 for hepatitis C surveillance), collected data on 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 B by the reference centers.

A case was defined as a patient over 18 years of age presenting for the first time (initial contact) for HBsAg-positive status on or after January 1, 2008, at participating reference centers and hepatitis networks.

It involved the collection of epidemiological, clinical, biological, and virological data via a questionnaire and a virological component consisting of the submission of specimens to the National Reference Center (CNR) for hepatitis B, C, and Delta.

The objective of this virological surveillance was to map HBV genotypes in France and to assess the prevalence of primary HBV resistance to antivirals.

An epidemiological surveillance program on the consequences of hepatitis B

Santé publique France, in collaboration with the cancer registry network (Francim) and the National Cancer Institute (Inca), conducts epidemiological surveillance of primary liver cancer. This type of cancer (hepatocellular carcinoma) can be a complication of chronic liver disease caused by HBV.

Mortality

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

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

Other data sources

• Epidemiological surveillance of blood donors

• Surveillance of healthcare-associated infections

Prevention efforts against hepatitis B and D

Santé publique France helps promote vaccination through various tools (website, promotional campaigns, brochures, etc.). An informational website on the different vaccinations available in France has been launched to provide reliable, scientifically validated answers to questions the public and healthcare professionals may have on the subject.
A section dedicated to hepatitis B vaccination is available in two separate areas: one is intended for the general public and the other for healthcare professionals, to better support them in their practice.

• Information for the general public:

  • vaccination-info-service.fr/Diseases-and-their-vaccines/Hepatitis-B

  • http://www.soshepatites.org/

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

  • “Hepatitis B: 5 Good Reasons to Get Vaccinated”

  • “Understanding Vaccination 2015”

Campaigns aimed at promoting sexual health have also been launched by Santé publique France.

• Information for healthcare professionals:

  • http://professionnels.vaccination-info-service.fr/Maladies-et-leurs-vaccins/Hepatite-B

  • Weekly Epidemiological Bulletin, June 2, 2022, Special Issue: Health Recommendations for Travelers, 2022