Enjeux et difficultés de l'accès aux traitements pour la prise en charge de l'hépatite B chronique à Madagascar : étude qualitative auprès des soignants et personnes atteintes

OBJECTIVES

Madagascar faces many difficulties in accessing diagnosis and treatment of hepatitis B. The prevalence of chronic hepatitis B infection is estimated at 6.9%. The costs associated with screening and treatment are high and not easily accessible. This article proposes a reflection on the challenges and difficulties of access to diagnosis and treatment for patients with chronic hepatitis B.

METHOD

The "Neo Vac" study aimed to document the life paths of people living with chronic hepatitis B, their difficulties and their perceptions of HBV. Twenty-three semi-structured interviews were conducted in 2019 in Antananarivo with patients and gastroenterologists.

RESULTS

The study describes the numerous obstacles that mark the therapeutic pathways of chronic HBV patients. The first result indicates lack of knowledge of the disease by chronic HBV patients and the varied circumstances in which the disease is discovered. None of the persons interviewed had been screened on their own initiative, the screening having taken place during prenatal consultations or emergency hospitalizations or during a morbidity episode. The care pathway was characterized by doubt and anxiety due to lack of knowledge about the possible disease outcome and concern about the costs of care.

DISCUSSION

Little known by the population and health professionals, hepatitis B is rarely the subject of voluntary screening and is most often detected during an apparently unrelated health event. The exorbitant cost of treatment for patients, the cost of medical analyses and secondary costs, and the unavailability of follow-up tests outside the capital constitute barriers to access to care that are insurmountable for the majority of the Malagasy population.

CONCLUSIONS

This first qualitative study on the experiences of HBV-infected persons in terms of access to care and treatment in Madagascar underlines the extent to which access to treatment remains limited, due to the absence of a national policy for the prevention, screening and management of hepatitis B, which remains a highly neglected and unrecognized disease in Madagascar as well as internationally.

[Outcomes of cumulative transfers of fresh and frozen embryos in in vitro fertilization in women infected by hepatitis B virus]

OBJECTIVE

To assess the impact of hepatitis B virus (HBV) infection in women on in vitro fertilization (IVF) outcomes.

METHODS

An observational monocentric case-control cohort study conducted between 2012 and 2019 compared the outcomes of the first cycle of IVF between 64 woman infected with HBV and 128 seronegative controls. Frozen embryos transfers made within 18 months of the puncture were included. The exclusion criteria were severe infections, viral co-infection in women, any viral infection in their spouse, or lack of fresh embryo transfer. The matching was performed according to age, primary infertility or secondary, conventional or intracytoplasmic injection IVF technique and date of attempt. The main analysis focused on cumulative live births rates (LBR).

RESULTS

The clinical and ovarian stimulation characteristics were comparable except for a longer period of infertility in the HBV group. The LBR in the HBV group, when compared to controls, was not different after transfer of fresh (14.06 vs. 25.00% P=0.08) or frozen embryos (4.17 vs. 18.92% P=0.08), but significantly decreased in cumulative analysis (15.63 vs. 35.94% P=0.003). HBV infection was negatively associated with LBR in multivariate analysis OR=0.38 (95% CI 0.14-0.92) P<0.05. The implantation rate was lower in the HBV group versus controls, in fresh (14.89 vs. 27.72% P=0.02) and frozen (3.03 vs. 21.65% P=0.01) embryo transfers.

CONCLUSION

This study suggests a negative impact of HBV infection in women on the cumulative LBR after IVF.

[The recommendations of nephrologist are poorly followed by the primary care physician. The example of vaccination against hepatitis B]

The relationship between specialist physician and primary care physician (PCP) has been poorly evaluated in France. We have studied the application of a specialist's recommendation by the PCP. Vaccination against hepatitis B in patients with chronic renal failure was the follow-up marker. After consultation, the nephrologist wrote in his report to the PCP that the vaccination was recommended. At the next nephrological consultation, the patient was asked if the PCP had proposed vaccination. The clinical, biological characteristics and history of the patients were recorded as well as number and location of the PCP consultations. Five nephrology centers recruited 315 patients. In 61.6% (194/315) of the cases, the vaccination was not proposed by the PCP. Only the estimated GFR (lowest in vaccinated patients, 29.5 vs. 34.5mL/min/1.73m²), the delay between the two consultations of the nephrologist (shorter in vaccinated patients, 18.7 vs. 22.9 weeks) and the nephrologist's practice center (17.5 to 52% vaccination rate) are statistically significant in univariate analysis. In multivariate analysis, only the center effect persists. The lack of vaccination was argued by a letter from the PCP in 2 cases (1%). In the absence of a direct questioning of the PCP, the reasons for not following the recommendation remain unexplained. Overall, the recommendation of the nephrologist was little followed. Our study can contribute to the reflection on the shared follow-up of patients suffering from chronic diseases.

Public health impact of Infanrix hexa™ (DTPa-HBV-IPV/Hib) reimbursement: A study programme in France. Part 2: Evolution of the acceptability of infants' vaccination against hepatitis B in general and pediatric practices - the PRALINE study

BACKGROUND

The reimbursement of the hexavalent vaccine (Infanrix hexa™), comprising the DTPa-IPV-Hib components and the hepatitis B recombinant in a single vaccine, was approved in France in March of 2008. The impact of its reimbursement on physicians' decisions to vaccinate infants against hepatitis B was assessed in a study conducted with general practitioners and pediatricians.

METHODS

The PRALINE study (NCT01777074) was a national, cross-sectional, repeated study with two measurement periods (T1 and T2) that measured the changes in physicians' acceptance of hepatitis B vaccination of infants before and for the 3 years after the approval of the hexavalent vaccine reimbursement. Two patient registers were created for each measurement period to enroll the first 15 12- to 15-month-old infants and the first 15 24- to 27-month-old children seen by the practitioners. The proportion of eligible children receiving a hepatitis B vaccine for each physician's practice was calculated. Practitioners also answered a vaccination practice questionnaire via telephone interviews.

RESULTS

Across the two study periods, 418 general practitioners and 463 pediatricians were recruited and responded to the telephone interview on their vaccination practices. The overall number of children included in the study in both study periods reached almost 20,000. In the general practitioners group, there was a significant increase in the proportion of physicians "practicing hepatitis B vaccination" (i.e., at least 50% of eligible children receiving the initial hepatitis B vaccination) in children 24-27 months old (79% T2 versus 47% T1, P-value [P]<0.001). Similarly, the proportion of pediatricians initiating hepatitis B vaccination increased from 51% (T1) to 94% (T2) (P<0.0001). General practitioners offered hepatitis B vaccination to infants more systematically in the second study period (87% T2 versus 73% T1, P<0.001) and also suggested the use of the hexavalent vaccine to more patients after reimbursement (92% T2 versus 78% T1, P<0.0001). The proportion of pediatricians offering vaccination to every infant was high at T1 (94%) and remained steady (97%) with a high use of the hexavalent vaccine (94% T1 and 96% T2).

CONCLUSION

The PRALINE study shows a significant and immediate change in the hepatitis B vaccination practices of general practitioners and pediatricians following hexavalent vaccine reimbursement with a significant increase in hepatitis B vaccine coverage in infants.

[Hepatitis B and pregnancy. Part 2. Nine practical issues about delivery and neonatal care]

In France, the hepatitis B maternal-fetal transmission prevention strategy is based on serovaccination at birth. Serum therapy is to inject 30IU/kg of anti-HBs specific immunoglobulins of human origin in the first hours of life, which in practice corresponds to 1ml or 100IU. Vaccination should also be performed during the first hours of life, and a new injection should be performed at 1month and 6months. In infants less than 32weeks and/or less than 2kg, lower vaccine response leads to prescribe an additional injection at 2months. This serovaccination reduces the risk of mother to child transmission from 57 to 4 %. The failure risk factors of serovaccination are high maternal viral load (greater than or equal to 7 log) and/or the presence of HBeAg. The delivery route does not change the risk of maternal-fetal transmission of hepatitis B when serovaccination at birth was well conducted. Likewise, breastfeeding does not change the risk of maternal-fetal transmission of hepatitis B after serovaccination. It is recommended by WHO. During labor, the pH in utero should be done only when strictly necessary, the published data do not allow to conclude on the risk of transmission.

[Hepatitis B and pregnancy. Part 1. Thirteen practical issues in antenatal period]

In France, the prevalence of chronic hepatitis B is about 1% in pregnant women (usually asymptomatic carriers of HBsAg). The risk of maternal-fetal transmission of hepatitis B is particularly high when viral load measured by PCR is higher in mothers (above 7 log) or HBeAg is present. In case of maternal-fetal transmission of hepatitis B, the risk to the newborn of developing subsequent chronic hepatitis B is very high (90%), with long-term complications such as cirrhosis and hepatocellular carcinoma. The prevention of maternal-fetal transmission is based on systematic testing for hepatitis B during pregnancy, followed by serovaccination of the newborn at birth. If necessary, amniocentesis can be realised but will avoid the realization of a transplacental gesture. In case of high viral load, the establishment of a maternal antiviral treatment with lamivudine or tenofovir from 28SA can further reduce the risk of transmission. Given the low resistance it induces, tenofovir should be used preferentially.

Public health impact of Infanrix hexa (DTPa-HBV-IPV/Hib) reimbursement: A study programme in France. Part 1: Evolution of hepatitis B vaccine coverage rates in infants aged less than 27 months, in the general population - the PopCorn study

BACKGROUND

Reimbursement of the hexavalent vaccine (Infanrix hexa) comprising the DTPa-IPV-Hib components and the hepatitis B valence in a single vaccine was decided in March 2008 in France. The impact of its reimbursement on the hepatitis B vaccine coverage rate was assessed in a study conducted in the general population prior to and after implementation of the reimbursement policy.

METHODS

The PopCorn study (NCT01782794) was a national, cross-sectional and repeated study, with four assessment periods over 3 years, from 2009 to 2012, to assess the hepatitis B vaccine coverage in 12- to 15- and 24- to 27-month-old children, vaccinated between 2007 and 2011 and selected by the quota sampling method. Face-to-face interviews were conducted at their homes and vaccination status was collected using their child's health record. Parents were also interviewed on their perceptions and acceptance of hepatitis B vaccination. Three indicators were calculated to assess hepatitis B vaccination coverage: proportions of infants with at least one dose before 6 months of age, with at least two doses before 6 months of age and with a complete schedule at 24 months of age.

RESULTS

A total of 4903 children were enrolled in the study. An overall significant increase (P-value [P<0.05]) of the three indicators of interest over the four periods of time was observed for both age groups. The proportion of children receiving hepatitis B vaccination before 6 months increased from 21% at baseline (before vaccine reimbursement) to almost 75% at the last assessment period in 2012. More than 60% of 24- to 27-month-old children received a complete schedule in 2012 compared to 33% at baseline. No significant increases in the proportions of parents "favourable" and "moderately in favour" of hepatitis B vaccination were observed across the four evaluation periods (respectively, 17-22% and 48-50%, P=0.09).

CONCLUSION

The rapid increase of hepatitis B vaccination coverage suggests a significant change in hepatitis B vaccination practice related to the hexavalent vaccine's reimbursement. This change was observed in a context of stability regarding parents' perceptions and acceptance of hepatitis B vaccination and of coverage rates for other infant vaccinations.

Prevalence of hepatitis B virus serologic markers in pregnant patients in Antananarivo, Madagascar

BACKGROUND AND OBJECTIVES

Hepatitis B virus (HBV) infection is a major public health problem in Madagascar. Its severity is related to the risk of chronicity, especially in case of neonatal contamination. Our objectives were to investigate the prevalence of HBV infection among pregnant patients at the Befelatanana obstetrics and gynecology teaching hospital department (BOGTH) by detecting HBsAg and to evaluate the risk of HBV mother to child transmission by screening for HBeAg.

METHODS

We conducted a 6-month prospective study in the BTHOGD from February 2012 to July 2012. All pregnant patients consulting for antenatal care were screened for HBV serologic markers.

RESULTS

The prevalence of HBsAg was 1.9% (20 out 1050 screened patients). The average age was 26.51 years (25-30 years). Most patients tested were unaware of their hepatitis B status and only 0.38% had been vaccinated before pregnancy. Only 1 (5%) of the 20 patients with HBsAg was positive for HBeAg.

CONCLUSION

Hepatitis B is very frequent in pregnant patients in Madagascar and it is recommended that all pregnant patients be routinely screened for HBsAg. This screening of maternal infection would allow applying prophylactic measures to neonates to decrease the risk of disease chronicity.

Evolution of hepatitis B vaccine coverage rates in France between 2008 and 2011

High vaccine coverage rates were reached for hepatitis B vaccination in teenagers nearly two decades ago (1995), but controversy sharply decreased the rate of vaccination in France, requiring high remobilization in its favor and careful monitoring of vaccine coverage rates. We report the results of Vaccinoscopie(®) survey which has monitored the yearly evolution of vaccine coverage rates since 2008.

METHOD

A representative national sample of 5250 mothers was recruited in 2011: 3000 mothers of infants (1000 for each of the following age range: 0-11 months, 12-23 months, and 24-35 months of age) and 2250 mothers of teenagers. They all answered a self-administered questionnaire on the Internet and reported all vaccinations included in their child's health record.

RESULTS

In 2011, 82.4% (CI 95%: 77.6-87.1) of infants 6-8 months of age were given hepatitis B vaccination before six months of age and 71.9% (CI 95%: 66.3-77.5) of children 24-26 months of age were fully immunized before 24 months of age. France should reach its objectives for infants thanks to the hexavalent vaccine, but this is not the case for teenagers since in 2011, at 14-16 years of age, only 55.4% (CI 95%: 53.3-57.4) had started their vaccination schedule and 37.4% (CI 95%: 35.4-39.4) were fully vaccinated.

CONCLUSION

This recent data, specially concerning teenagers, should lead to corrective measures rapidly to reach vaccine coverage targets for this vaccination.