The European Journal of Public Health Advance Access originally published online on October 26, 2006
The European Journal of Public Health 2007 17(3):263-271; doi:10.1093/eurpub/ckl233
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Infectious and allergic diseases, cancer, and diabetes |
Screening campaign of hepatitis C among underprivileged people consulting in health centres of Lyon area, France
F. Sahajian1, P. Vanhems1, F. Bailly2, J. Fabry1, C. Trepo2, M. Sepetjan and Members of ADHEC1,*
1 Programme ADHEC, Laboratoire d'Épidémiologie et de Santé Publique Université de Lyon
2 Pôle de référence Hépatites C, Service d'hépato-gastroentérologie Hôtel-Dieu, Lyon, France
* Association for the Study of Hepatitis C Screening
Correspondence: Dr Frédéric Sahajian, ADHEC, Laboratoire d'Epidémiologie et de Santé Publique, Faculté de Médecine, Domaine Rockefeller, 8 avenue Rockefeller, 69373 Lyon Cedex 08, France, tel: +33 04 78 77 75 33, fax: +33 04 78 77 75 71, e-mail: sahajian{at}rockefeller.univ-lyon1.fr
Received September 22, 2005, accepted August 18, 2006
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Abstract |
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Background: A screening campaign for hepatitis C virus (HCV) infection was carried out in eight health centres of Lyon from June 2003 until March 2004. The population targeted for screening was underprivileged individuals without any social insurance, protected by Couverture Mutuelle Universelle or Aide Médicale Etat (AME), to estimate the prevalence of anti-HCV antibodies in this population and to identify associated risk factors. Methods: After training in HCV infection and screening, 43 general practitioners participated in the campaign. Information about patient socio-demographics and risk factors was collected prior to proposing screening serology. Blood samples were often taken in health centres. Follow-up of positive cases was organised via the Reference Centre of HCV Infection in Lyon with possible specialised consultations in health centres. Results: The average age of the 988 individuals in the campaign was 37 years; 51% were women; 54% had a foreign nationality; 21% lived in sheltered accommodation; 19% were lodged in third-party accommodation; 9% were homeless; and 57% possessed less than
562 (Revenu Minimum d'Insertion level). Screening was not proposed to nine patients because of medico-psychological problems. The acceptance rate for screening was 98.8% (967/979), and testing was carried out on 97.6% of these subjects (944/967). The prevalence of anti-HCV antibodies in the sample was 4.7% (44/944) (95% CI = 3.4–6.2). Nearly 80% of positive cases were unknown prior to the campaign. Multivariate logistic regression modelling identified lifetime injection drug use [odds ratios (OR) = 15.99; P < 0.0001], lifetime medical care in a foreign country (OR = 4.46; P = 0.001), and wearing tattoos (OR = 2.75; P = 0.048) as significant risk factors for carrying anti-HCV antibodies. Characteristics independently associated with HCV seropositivity were age between 40 and 49 years, AME benefits, and no social insurance. Conclusion: Wide acceptance of screening, high prevalence of anti-HCV antibodies (much higher than in the French population in general), a high proportion of positive cases unknown beforehand, and satisfactory follow-up of seropositive patients are all factors which support the need for a screening campaign targeting HCV infection in underprivileged persons living in France.
Keywords: hepatitis C, screening, underprivileged population
According to the World Health Organisation, there are more than 170 million chronic carriers of hepatitis C virus (HCV) in the world.1–3 In France, from a survey of those covered by the national insurance scheme (assurés sociaux du régime général), conducted in November 2004 by the Institut de Veille Sanitaire (INVS), the prevalence of anti-HCV antibodies in the general population was estimated to be 0.9%.4 This study was part of the national framework plan for HBV and HCV launched in February 2002,5 which primarily targeted the reinforcement of HCV screening and the reduction of HCV transmission, whose risk factors are now well known.6–9
In the underprivileged population, particularly among the homeless, the prevalence of anti-HCV antibodies is especially high. According to data from the American literature, it varies according to the samples studied, from 12 to 21% among street children,10,11 from 32 to 44% among homeless adults,9,12–14 up to 52.5% according to Stein and Nyamathi,15 and even up to 65% according to Riley et al.16 in a study carried out in San Francisco among homeless persons co-infected with human immunodeficiency virus (HIV). Moreover, Nyamathi et al.17 estimated this prevalence to be 22% among underprivileged adults living in sheltered accommodation or sleeping rough. Sherriff and Mayon-White18 determined the prevalence rate to be 26.5% among homeless adults in Oxford, England. Roy et al.19 estimated it to be 12.6% among street kids in Montreal, and Moses et al.20 reported a rate of 17% among homeless adults in Winnipeg, Canada.
All these studies indicate strong exposure of underprivileged populations to HCV, due principally to an increased frequency of intravenous drug use (IVDU) or intranasal drug use, which constitutes a major risk factor for seropositivity according to most authors. Other associated factors are age over 18 years19,20 or age up to 41 years,17 wearing tattoos,15,19 alcohol consumption, a prison record, a long period of sleeping rough,15,17 prostitution,19 a history of sexually-transmitted diseases, sharing bathroom facilities (razors, toothbrushes), or needles during drug use.15
To our knowledge, in France, no published data exist regarding the prevalence of anti-HCV antibodies among the underprivileged. However, in its 2004 study,4 the INVS estimated this prevalence to be 2.65% among Couverture Mutuelle Universelle (CMU) claimants. Likewise, the risk factors of HCV seropositivity for people living in poverty in France are largely unknown. Nevertheless, significant transmission of this virus could be feared in this population, which is made up, in part, of ordinary migrants from countries strongly endemic in HCV (notably Africa and eastern Europe) and, in another part, of poor people living in collective accommodation (squatting or collectives) and susceptible to sharing bathroom facilities or paraphernalia where drug use is involved.
In this context, an HCV screening campaign was undertaken among underprivileged members of the public who consulted eight health centres in the Lyon region, to estimate the prevalence of anti-HCV antibodies and to identify associated risk factors.
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Materials and methods |
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Target population
This screening exercise was conducted in eight health centres in the Lyon region where a significant proportion of the clientele was constituted of patients in economically or socially underprivileged situations, due to poor housing conditions, low levels of income, or irregular employment. The heterogeneity of this population led us to choose the type of social security of the subjects as the common inclusion criterion for the campaign. Claimants of CMU (social insurance adapted for underprivileged people of French nationality) or Aide Médicale Etat (AME) (social insurance adapted for underprivileged people with no French nationality living in France), persons availing themselves of the general social security regime without complementary insurance as well as those deprived of social security coverage but able to claim one of these measures were included in the study. The exclusion criteria were: age <18 years old, and urgent care needed by the patient. When the context was not suitable (serious physical or psychological illness, language barriers), screening was not proposed.
Sample size
Sample size, n, was based on the expected prevalence (p) of anti-HCV antibodies of 0.10, with specified relative precision e of 0.02 and confidence level 
of 95%, according to n = pq(
/e)2, which, assuming 10% refusal, resulted in 900 enrolments.
Study inclusion procedures and constitution of the population sample
The eight participating centres did not receive the same number of underprivileged people. Two centres only accepted CMU and AME claimants or subjects not having any social security at all. In one low-activity centre in which few persons were seen (200 per year), systematic inclusion of all consultants could be achieved. In a high-activity centre in which more persons were seen (2000 per year), one in three persons consulting (the third, sixth, and ninth patients in each consultation) was randomly screened because the time needed for study completion did not permit us to include all patients. The six other centres accepted both underprivileged and non-underprivileged patients; after a preliminary review by reception personnel, all people consulting, who were CMU or AME claimants or those not having any complementary insurance, were included in the study. Thus, the number of subjects included from these six centres represented the number of all underprivileged patients seen at the centre during the study. The study sample was therefore made up of underprivileged subjects who were consulting and included in the 8 health centres by the 43 general practitioners (GPs) participating in the campaign.
Questionnaires and data collection
The campaign was conducted between 1 June 2003 and 31 March 2004. Towards the end of the medical consultation, by interview, the doctor who knew the patient's identity, would propose a written questionnaire to each participant included without noting patient identity. The doctor asked his/her patient to fill out an informed patient consent form before inclusion in the study. This anonymous questionnaire consisted of demographic variables (age, gender) and social variables (nationality, type of accommodation, type and amount of income, type of social security). The doctor collected hepatitis C risk factors for every patient (drug use, blood transfusion, history of surgery before 1992, presence of HCV-seropositive people among the subject's relatives or friends, wearing tattoos, medical care, or surgery abroad) as well as co-factors of the morbidity of infection (HIV and HBV seropositivity, alcoholism) before proposing to take a screening blood sample, most often in the health centre. In the consultation following the screening, the doctor would note in the questionnaire the initial and confirmed serology results as well as the confirmation eventually obtained by polymerase chain reaction (PCR) testing. Then, the doctor sent the anonymous questionnaire to the Coordinating Centre.
Implementation of the screening test
The serological screening tests were performed by the laboratories which normally undertake the biological examinations for each centre. Enzyme-linked immunosorbent assay (ELISA) and third-generation tests were used. When a positive result was obtained, a second ELISA was carried out on a second sample with a different method. If this produced a further positive result, a confirmation test by PCR was conducted.
Follow-up of patients screened
In each centre, feedback consultation was scheduled in the days following the screening by the same doctor who had seen the patient the first time. After a first positive screening test, the doctor again proposed to his/her patient a second screening test in the same laboratory for confirmation. PCR was done in cases where positive serology was confirmed. Depending on the results of this test, the doctor proposed the most suitable medical care plan possible in connection with the Lyon Reference Centre of HCV Infection. To coordinate this care plan and if the doctor and the patient so desired, a specialised consultation was arranged locally in the screening location by a Reference Centre hepatologist. All follow-up care was covered for patients by their insurance (CMU or AME).
Data and statistical analysis
Data analysis was not stratified by centre because of a low number of infected individuals in some centres. Analysis, therefore, proceeded with the data collected on subjects included in all eight centres. Quantitative data were coded and collected with the ACCESS program. The results of the screening test were analysed according to the social demographics and risk factors of the study sample. In univariate analysis, the Chi-square test was used to compare variables and test differences between proportions. Then, multivariate analysis was carried out by the descending logistical regression method, to identify factors independently associated with the presence of anti-HCV antibodies. Variables having a P-value <0.15 in univariate analysis were included in the model. Statistical analysis was performed with SPSS (Version 10.1). All tests were considered to be statistically significant above the 5% level.
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Results |
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Among the 988 patients included in the study, screening was not proposed to 9 of them due to an unsuitable situation (serious medical pathology or psychological condition, language barrier), 12 declined screening, and 77 had already been screened. In this last group, 9 were known carriers of anti-HCV antibodies, with screening having confirmed their seropositivity. The level of screening acceptance was, therefore, 98.8% (967/979). Sampling was actually undertaken in 97.6% of subjects (944/967) [95% confidence interval (95% CI) = 96.5–98.4]: 886 patients in the health centres and 58 in city laboratories. Six of the twenty-three patients who did not undergo the test had to initially present themselves at a city laboratory. The level of coverage was logically higher when the screening blood sample was collected on site (98.1 versus 90.6%; P = 0.0008). In our sample, the high acceptance rate among IVDUs can be explained by a high proportion of non-active users (13/16).
Among the 944 patients who underwent the screening test, 44 positive and 900 negative results were accounted for. The prevalence of anti-HCV antibodies among these 944 included and screened patients was 4.7% (44/944) [95% CI = 3.4–6.1%]. Moreover, 79.5% of seropositive patients were new cases identified during the campaign.
Screening realisation and social demographic characteristics of the 988 study subjects (table 1)
The level of blood sampling differed significantly by age. Those between the ages of 30 and 39 years underwent this sampling significantly less frequently than the other age groups (P < 10–6).
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Prevalence and crude odds ratios of HCV seropositivity according to the characteristics of the 944 subjects screened (table 2)
With univariate analysis, the characteristics significantly associated with HCV seropositivity were age between 40 and 49 and over 60 years, non-French nationality, homelessness, level of income from
0–562 per month, AME, and lack of social security. These results indicated a higher prevalence for more underprivileged individuals.
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Prevalence and crude odds ratios of HCV seropositivity according to risk factors for the 944 subjects screened (table 3)
With univariate analysis, the risk factors significantly associated with HCV seropositivity were IVDU, healthcare abroad, tattoos, and HBV seropositivity. The odds ratios (OR) of HCV seropositivity were 1.8 [95% CI = 0.2; 9.1] for French individuals with a previous history of healthcare abroad, and 2.5 [95% CI = 1.1; 6.6] for non-French individuals with a previous history of healthcare abroad.
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Characteristics and risk factors independently associated with HCV seropositivity among the 944 screened subjects (table 4)
With modelling by descending logistical regression, three characteristics of the screened subjects (age between 40 and 49 years, AME claimants, no social security) and three risk factors (current or previous IVDU, a previous history of healthcare abroad, wearing tattoos) were independently associated with HCV seropositivity.
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Medical care of seropositive patients in the 6 months following screening (table 5)
After the screening test, 44 confirmed seropositive patients accepted and underwent the PCR test for confirmation of HCV infection. This test gave a positive result in 24 cases. Six months after screening, six patients were lost to follow-up (two of them were foreign patients who had returned to their country of origin), but 86% of seropositive patients, that is 38 out of 44 patients, had benefited from regular medical follow-up carried out jointly by their GP and a hepatologist from the Lyon Reference Centre of HCV Infection. In 13 patients, interferon-alpha2b and ribavirine treatment was started as soon as possible in the Reference Centre. In the present study, we do not have the outcome after treatment was started.
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Discussion |
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This study aimed to identify the determinants of HCV seropositivity among underprivileged individuals consulting in health centres. Its internal validity was satisfactory with a high response rate and good participation, but external validity needs to be discussed since this population is not automatically representative of all underprivileged people in France. Reliability is difficult to estimate because few studies have been performed in this population, and we hope to repeat the investigation under similar conditions to confirm these first results.
Our study sample comprised underprivileged people who consulted GPs in health centres. Their reasons for medical consultations were all kinds of diseases observed in general practice. The prevalence of anti-HCV antibodies can be generalised only for those consulting in such health centres and who had social insurance. Inference to all underprivileged people (i.e. including those who do not have access to health centres and hence to healthcare) might be questionable.
The prevalence of anti-HCV antibodies in the underprivileged population (4.7%) screened in this campaign is clearly more than 
1% estimated for the general population in France.4,21 Likewise, this prevalence is more than the 2.65% estimated among CMU claimants in the survey conducted by Meffre et al.4 in 2003–2004 from a national sample of social security claimants referred to the Centres d'Examens de Santé (CES). To our knowledge, this latter study was the only one performed and published in France regarding HCV screening of the underprivileged. Nonetheless, in Colombes, a study on the global health of Sonacot residents22 noted 0.9% HCV-positive serology, previously unknown among these residents, and 3.7% HBV seropositivity versus 2.9% in our campaign (P = 0.87).
Abroad, screening studies of impoverished people essentially concerned homeless populations and recorded anti-HCV antibody prevalence between 12 and 52.5%,9–15 much greater than that found in our campaign. In an investigation of vulnerable adults staying in sheltered accommodation, Nyamathi et al.17 likewise reported a clearly increased prevalence (22%). Our study participants might be less underprivileged than in other locations. For example, in US studies, underprivileged persons did not have social insurance and access to healthcare. This can explain the lower rate of anti-HCV infection in our present study population compared with the results obtained of US investigations.
One of the probable causes of this massive HCV contamination among the most impoverished could, as Beech et al.11 and Stein and Nyamathi15 reported, be due to the sharing of paraphernalia by drug users (straws, syringes) or bathroom equipment (razors or toothbrushes), more widespread among the underprivileged than in the general population and often connected to the lack of income as well as a frequently collective lifestyle.
Around 80% of infected cases detected in our campaign were unknown before to be carriers of anti-HCV antibodies. This proportion is much higher than one (46%) estimated by Meffre et al.4 among claimants of CES. Among the clientele of GPs in city practices, most screenings23–26 likewise found a small percentage of patients previously unknown to be carriers of anti-HCV antibodies (from 4 to 25%). A seropositive subject who ignores his status cannot take preventative measures for non-transmission of HCV. In addition, transmission might be facilitated in cases of higher viraemia expected in non-treated individuals. Such a hypothesis highlights the need for innovative and appropriate measures to cut transmission in that population.
In our study, the prevalence of nasal drug consumption or by injection (4%) was comparable with that estimated in France at CES by Meffre et al.4 among Revenu Minimum d'Insertion (RMI) claimants (3%), but clearly more weakly than abroad in samples of homeless populations: 20–53%.13–15,17–18 The prevalence of anti-HCV antibodies among the drug users of our sample is 13% globally, 37.5% among IVDUs, and 9.3% among ‘sniffers’. These prevalences are less for the most part than those estimated in all other studies: 16.3% according to Desai et al.14 among all drug users; 26.5% according to Roy et al.,19 53% according to Stein and Nyamathi,15 55% according to Meffre et al.4 in French CES, 56% according to Sherriff and Mayon-White,18 77% according to Nyamathi et al.,17 86% according to Rosenblum et al.13 among IVDUs; and 19.8% according to Roy et al.19 among ‘sniffers’. However, as all these authors emphasise, intravenous drug addiction is found to be the leading seropositivity risk factor (OR = 15.99).
According to the results of our multivariate analysis, healthcare received abroad, whatever the nationality of individuals (principally Eastern Europe and Africa), constituted the second greatest risk factor strongly associated with seropositivity (OR = 4.46). This factor is not presented as evidence in any of the HCV screening studies carried out among impoverished populations. The result nevertheless seems to confirm the following observations: in a survey among the homeless in Bedford (Massachussetts), Desai et al.14 reported a five times greater risk of seropositivity among Vietnam veterans (half of whom had been injured and had received care) compared with those who had never fought. Moreover, in the general population in America, Chou et al.9 noted a two times lower risk of seropositivity among white or hispanic Americans compared with black people or people from other ethnic minorities, likely to have stayed or received care in their country of origin.
According to multivariate analysis, wearing tattoos (OR = 2.75) represents the third risk factor associated with seropositivity. This finding is similar among street children in Montreal,18 and likewise among homeless adults in Los Angeles.15 In addition, Ko et al.27 observed a significant increase in risk when the person producing the tattoo was not professional. Such unlicensed practices are certainly very frequent among impoverished subjects, particularly the homeless, often living in collective situations under very tenuous hygiene conditions.
Even though it was connected to HCV seropositivity in univariate analysis, blood transfusion before 1992, alcohol consumption, and HBV seropositivity, unlike other studies,15,17 were not independently associated with the presence of anti-HCV antibodies, according to multivariate analysis. In fact, blood transfusion and HBV seropositivity appear to be strongly linked with healthcare abroad, alcohol consumption, and IVDU.
Other results of multivariate analysis revealed that men, the 40- to 49-year-old age group, AME claimants and the absence of social security among the subjects screened constituted the characteristics independently associated with HCV seropositivity. It is particularly noteworthy in their study of RMI claimants, in France, that Meffre et al.4 recorded the highest prevalence of anti-HCV antibodies (7%) among men aged 40–49 years. Several of the pre-cited studies abroad gave similar results for males17 and the elderly.12,14,17,19,20 This was not the case for AME, a framework which does not exist abroad. As AME is reserved for foreign nationals living in France, there is an evident statistical connection between these two variables which explains why foreign nationality is not to be found in our final model, even though it represents a very strong risk factor for HCV seropositivity compared with that for French nationals. Moreover, Meffre et al.4 likewise noted the highest risk among foreign nationals compared with French RMI claimants.
The absence of social security constitutes the fourth characteristic associated with seropositivity. In our model, this variable appears to be statistically connected to lack of income and homelessness, significant factors in univariate analysis not found in the final model. Such a result is not surprising because the absence of social security very often reveals a very precarious social and economic situation in a person's domestic life. In fact, in France, all impoverished people can claim this protection on condition of satisfying the necessary steps, of presenting themselves and making claims at associated or institutional social services. It therefore appears that the prevalence of anti-HCV antibodies and the risk of seropositivity are most significant for the most vulnerable subjects. In their studies, Meffre et al.4 confirmed this hypothesis by noting that prevalence is clearly higher in cases of social vulnerability (3.5 times higher among impoverished people claiming CMU than among non-claimants). Similarly, Chou et al.9 estimated this risk of seropositivity to be three times higher among Americans living below the poverty line compared with those living above it and among unemployed people compared with working people.
Even if our sample was small, follow-up of the 44 positive patients in our campaign appeared to be satisfactory, since 86% of them could benefit from regular medical follow-up adapted to their situation. In this group, all infected patients (PCR-positive) had access to a hepatologist. Because of the study, efficient collaboration was implemented between GPs and specialists. After the identification of infected persons, optimal follow-up was organised by specialists. However, we cannot assume that such access to care is provided outside the context of an epidemiological study.
Excluding the four subjects who were lost to follow-up, all patients presenting an indicated need for treatment were treated. This result is much better than that reported by Hall et al.28 who, during a study in San Francisco, noted that only 6% of impoverished patients infected by HCV and eligible for treatment were actually treated. No other studies conducted abroad on the medical care of impoverished patients, consecutive to positive HCV screening, were found in the literature. Similarly, to our knowledge, no French data have been published on this theme. The only studies available concern impoverished subjects screened during blood donation or in city practices. Thus, Bonaguidi-Magniaux et al.29 and Julien30 estimated that the follow-up of ill people screened during blood donation was clearly insufficient. In the practices of GPs, Frère et al.31 and Ouzan et al.32 noted a mediocre standard of follow-up explained, in part, by the lack of training of those involved in screening with regard to HCV infection and also, in part, by the fear of hepatic biopsy and of treating seropositive patients. On the other hand, in our study of urban medicine,33 we established that satisfactory care of seropositive patients is achieved by effective communication between the person being screened and the specialist, notably with training specially tailored for GPs and in function of the healthcare network model. In our model, the training of participating doctors by Pole de Reference hepatitis C specialists on the one hand, and by local consultations in the presence of GPs and hepatologists on the other hand facilitated this functioning within the network and reasonably explained why our results (86% of seropositive patients in care) were close to those (93%) we obtained earlier,33 even though the two populations were very different.
This study shows that the prevalence of anti-HCV antibodies appears to be clearly higher among subjects in vulnerable situations consulting in health centres than in the general French population or in other subpopulations (clientele of town doctors, CES claimants). According to our results, prevalence was higher among the most impoverished subjects (homeless or foreign nationals) who cumulated the most frequent different risk factors. These findings underline the need for a screening campaign for HCV infection in underprivileged persons. The history of HCV transmission and infection in this population is not well known. To obtain more knowledge on this issue, we suggest that transversal studies be conducted by cohort investigation to describe the natural history of HCV infection in this population (C13). Until then, appropriate prevention measures should be proposed to underprivileged IVDU and to non-IVDU populations. Difficulties could be due to finding the right and adapted means of sharing information to prevent HCV transmission.
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Acknowledgments |
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We thank the 43 GPs and the 988 patients who accepted to participate in this Hepatitis C screening campaign among the underprivileged. We likewise thank the Caisse Nationale d'Assurance Maladie and the Direction Regionale de l'Action Sanitaire et Sociale Rhône-Alpes for their financial support. The editorial assistance of Ovid Da Silva and Ian Russell is acknowledged.
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1 World Health Organisation. Weekly Epidemiological Record. Hépatite C: prévalence mondiale, n. 46 (1997) Geneva: World Health Organisation. 341–8.
2 Global Surveillance and Control of Hepatitis C. Report of a WHO consultation organized in collaboration with the Viral Hepatitis Prevention Board, Antwerp, Belgium. J Viral Hepat (1999) 6:35–47.[CrossRef][Web of Science][Medline]
3 World Health Organisation. Hepatitis C. Fact Sheets. No. 164 (2000) Geneva: World Health Organisation.
4 Meffre C, Le Strat Y, Delarocque-Astagneau E, et al. Estimation des taux de prevalence des anticorps anti-VHC et des marqueurs du virus de l'hépatite B chez les assures sociaux du regime general de France métropolitaine, 2003–2004 (2005) Rapport préliminaire de l'Assurance Maladie et l'Institut de Veille Sanitaire, Paris, Janvier.
5 Plan national hépatites virales B et C (2002–2005). Secrétariat d'Etat à la Santé (dossier de Presse). (2002) Paris. 20 février.
6 Hépatites virales: dépistage, prévention, traitement. (1997) (Expertise collective). Paris. Edition INSERM, Mars.
7 Center of Disease Control. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR (1998) 47:1–39.[Medline]
8 EASL International Consensus Conference on Hepatitis C. Consensus statement. J Hepatol (1999) 30:956–61.[CrossRef][Medline]
9 Chou R, Clark EC, Helfand M. Screening for hepatitis C virus infection: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med (2004) 140:465–83.
10 Ogilvie EL, Veit F, Crofts N, Thompson SC. Hepatitis infection among adolescents resident in Melbourne Juvenile Justice Centre: risk factors and challenges. J Adolesc Health (1999) 25:46–51.[CrossRef][Web of Science][Medline]
11 Beech BM, Myers L, Beech DJ. Hepatitis B and C infections among homeless adolescents. Fam Community Health (2002) 25:28–36.[Web of Science][Medline]
12 Cheung RC, Hanson AK, Maganti K, et al. Viral hepatitis and other infectious diseases in a homeless population. J Clin Gastroenterol (2002) 34:476–80.[CrossRef][Web of Science][Medline]
13 Rosenblum A, Nuttbrock L, McQuistion HL, et al. Hepatitis C and substance use in a sample of homeless people in New York City. J Addict Dis (2001) 20:15–25.[Web of Science][Medline]
14 Desai RA, Rosenheck RA, Agnello V. Prevalence of Hepatitis C virus infection in a sample of homeless veterans. Soc Psychiatry Psychiatr Epidemiol (2003) 38:396–401.[Web of Science][Medline]
15 Stein JA, Nyamathi A. Correlates of hepatitis C virus infection in homeless men: a latent variable approach. Drug Alcohol Depend (2004) 75:89–95.[CrossRef][Web of Science][Medline]
16 Riley ED, Bangsberg DR, Guzman D, et al. Antiretroviral therapy, hepatits C virus and AIDS mortality among San Francisco's homeless and marginally housed. J Acquir Immune Defic Syndr (2005) 38:191–5.[CrossRef][Web of Science][Medline]
17 Nyamathi AM, Dixon EL, Robbins W, et al. Risk factors for hepatitis C virus infection among homeless adults. J Gen Intern Med (2002) 17:134–43.[CrossRef][Web of Science][Medline]
18 Sherriff LC, Mayon-White RT. A survey of hepatitis C prevalence amongst the homeless community of Oxford. J Public Health Med (2003) 25:358–61.
19 Roy E, Haley N, Leclerc P, et al. Risk factors for hepatitis C virus infection among street youths. CMAJ (2001) 165:557–60.
20 Moses S, Mestery K, Kaita KD, Minuk GY. Viral hepatitis in a Canadian street-involved population. Can J Public Health (2002) 93:123–8.[Web of Science][Medline]
21 Désenclos JC, Dubois F, Couturier E, et al. Estimation du nombre de sujets infectés par le VHC en France, 1994–1995. BEH (1996) 5:24–7.
22 ARES 92. Intérêt d'un 
parcours santé
proposé aux résidents d'un foyer Sonacotra. BEH (2004) 43:205–6.
23 Pradat P, Caillat-Vallet E, Sahajian F, et al. Prevalence of hepatitis C infection among general practice patients in the Lyon area, France. Eur J Epidemiol (2001) 17:47–51.[CrossRef][Web of Science][Medline]
24 Altman C, Lesiour A, Dunbavand A, et al. Dépistage des malades à risque d'infection virale C en médecine générale. Gastroenterol Clin Biol (1999) 23:359–62.[Web of Science][Medline]
25 Czernichow P, Torre JP, Goria O. Dépistage ciblé de l'hépatite C en France par les médecins généralistes. Gastroenterol Clin Biol (1998) 22:28.
26 Ouzan D, Hofliger P, Cavailler P, et al. 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. Gastroenterol Clin Biol (2003) 27:90–3.[Web of Science][Medline]
27 Ko YC, Ho MS, Chiang TA, et al. Tatooing as a risk of hepatitis C virus infection. J Med Virol (1992) 38:288–91.[Web of Science][Medline]
28 Hall CS, Charlebois ED, Hahn JA, et al. Hepatitis C virus infection in San Francisco HIV-infected urban poor: high prevalence but low treatment rates. J Gen Intern Med (2004) 19:357–65.[CrossRef][Web of Science][Medline]
29 Bonaguidi-Magniaux M, Pillette C, Oberti F, et al. Le suivi des donneurs de sang ayant une sérologie du virus de l'hépatite C positive et de leurs receveurs est insuffisant. Gastroenterol Clin Biol (1996) 20:663–8.[Web of Science][Medline]
30 Julien AM. Suivi médical des donneurs de sang porteurs d'anticorps contre le virus de l'hépatite C. Gastroenterol Clin Biol (1996) 20:657–8.[Web of Science][Medline]
31 Frère T, Verneau A, Besson I, et al. Prise en charge de l'infection par le virus de l'hépatite C dans la région Poitou-Charentes. Gastroenterol Clin Biol (1999) 23:887–91.[Web of Science][Medline]
32 Ouzan D, Cavailler P, Hofliger P, et al. 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. Gastroenterol Clin Biol (2003) 27:376–80.[Web of Science][Medline]
33 Sahajian F, Bailly F, Caillat-Vallet E, et al. Prise en charge médicale des maladies séropositifs pour le virus de l'hépatite C. Gastroenterol Clin Biol (2001) 25:262–7.[Web of Science][Medline]
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