Screening for hepatitis B, C and D in metropolitan France from 2016 to 2022: A map based on the National Health Data System with a focus on HDV screening

Screening for hepatitis B, C and D in metropolitan France from 2016 to 2022: A map based on the National Health Data System with a focus on HDV screening | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Screening for hepatitis B, C and D in metropolitan France from 2016 to 2022: A map based on the National Health Data System with a focus on HDV screening Céline Rigaud, Sandrine François, Paul Carrier, Véronique Loustaud-Ratti This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5662958/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Sep, 2025 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background According to the latest World Health Organization report, the incidence and mortality rates of viral hepatitis, including hepatitis delta infection, have increased in recent years. The simultaneous screening of these viruses and HIV remains important for containing their spread or eliminating them. Many treatments are now available that can either cure or limit the complications of these infections. Delta infection, which affects 5% of hepatitis B (HBV)-positive patients, is largely underestimated, whereas the prevalence of delta cirrhosis and hepatocellular carcinoma (HCC) is 3 to 5 times greater than that of HBV monoinfection. The real-life prevalence of hepatitis delta virus (HDV) in metropolitan France has rarely been studied. Methods This study aimed to determine the number of HCV, HIV, HBV and HDV screening tests performed from 2016–2022 based on data from the French National Health Data System. We compared the results of HDV Ab tests with the number of expected HDV Ab tests, which was calculated based on the estimate of positive HBV screening in France (0.7%). Results From 2016–2022, 28,314,766 anti-HCV Ab tests, 29,463,042 anti-HIV Ab tests, 28,898,177 HBs Ag tests, 162,055 anti-HDV Ab tests and 21,963 HDV RNA tests were performed. We observed an increase of 39%, 30%, 45%, 130% and 206% respectively, during this period. Fifty-five percent of the expected anti-HDV Ab tests were carried out in 2016, 69% were carried out in 2020, and 94.7% were carried out in 2022. However, with respect to two specific populations in 2022, only 0.26% of pregnant women and 26% of patients monitored for chronic HBV infection underwent an anti-HDV Ab test. The patients screened for HBs Ag, anti-HCV Ab, anti-HIV Ab and anti-HDV Ab were mainly in the Ile de France and Provence-Alpes-Côte d’Azur regions. A total of 41.7% of the patients tested for anti-HDV Ab and 51.8% of the patients tested for HDV RNA had a precarious profile. HDV screening test prescribers were hospital-based, and HBV, HCV and HIV test prescribers worked mainly in the private sector. Conclusion In total, HDV screening increased 2.3-fold from 2016 to 2022 but remained insufficient in some populations. Screening Hepatitis B Hepatitis C Delta hepatitis French National Health Data System Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction The World Health Organization (WHO) has set a goal of eliminating chronic hepatitis virus infections by 2030, with a 10% reduction in mortality, access to diagnosis for 90% of infected subjects and access to treatment for 80% of infected individuals [ 1 ]. Targeted strategies have been implemented, especially in high-income countries, but this objective has not been achieved for all countries. The number of deaths related to viral hepatitis is increasing: there were 1.3 million deaths related to viral hepatitis in 2022 (83% caused by hepatitis B virus (HBV) and 17% by hepatitis C virus (HCV)) versus 1.1 million in 2019, according to the latest WHO report [ 1 ]. Delta virus (HDV) affects approximately 5% of people with chronic HBV infection globally and is largely underdiagnosed, but it is still responsible for one million deaths annually [ 2 , 3 ]. In France, the number of HCV patients tested increased by 9% per year between 2014 and 2021 (except during the COVID-19 pandemic). However, a 69% decrease in direct-acting antiviral initiation has been observed since mid-2017. Even if the pool of patients to be treated probably decreases, it is still necessary to increase awareness among undiagnosed infected people [ 4 ]. Two studies recently reported the HBV positivity rate in France. (i) The 2021 LaboHEP survey [ 5 ] revealed a 25% increase in the number of HBs Ag performed compared with 2016, with a lower positivity rate in 2021 (0.69%) than in 2016. (ii) The CeGIDD 2022 survey [ 6 ] examined 529,453 consultations in French STI clinics (which provide free information, screening and diagnosis for human immunodeficiency virus (HIV), viral hepatitis and sexually transmitted infections) and revealed an HBV screening rate of 34.7% and an overall positivity rate of 1.1%, which is higher than that in the general population but concerns specific patients (more often males and people born abroad) [ 6 ]. HDV is a small, defective RNA virus that depends on the expression of the HBs antigen (HBs Ag) of HBV for its structure and assembly. It uses the same entry mechanism as HBV to infect hepatocytes by binding to the sodium taurocholate cotransporter polypeptide [ 7 ]. Consequently, HDV screening requires adequate HBV screening. Chronic delta infection is the most serious form of hepatitis; at 10 years, the risk of cirrhosis is 57%, and the risk of hepatocellular carcinoma (HCC) is 15%, i.e., 3 to 5 times higher than the risks associated with HBV monoinfection [ 8 ]. In Europe, the estimated prevalence of anti-HDV antibodies (Ab) in the general population with positive HBs Ag is 3% (95% CI: 2.09–4.21), and 64% of these cases are positive for HDV RNA [ 2 ]. In France, few studies have examined the prevalence and profile of HDV patients specific populations [ 9 , 10 ]. European learned societies and the French High Authority for Health (HAS) recommend systematic screening for anti-HDV Ab for any new positive HBs Ag cases [ 11 , 12 ]. New therapeutic options, particularly the use of bulevirtide to treat HDV, are changing the management of these patients [ 13 ] and limiting the incidence of complications such as cirrhosis and HCC. The objective of this study was to provide a map of viral hepatitis and HIV screening in France between 2016 and 2022 based on the French National Health Data System (SNDS), with a focus on delta hepatitis, as the prognosis of delta hepatitis has recently changed with the availability of new treatments. Methods Data sources The SNDS combines data from the Program for the Medicalization of Information Systems (PMSI), the National Inter-Regime Information System of the Health Insurance (SNIIRAM) and data related to causes of death [ 14 ]. The screening data from 2016 to 2022 for HBV (HBs Ag), HCV (Ab), HIV (Ab) and HDV (anti-HDV Ab and HDV RNA) in metropolitan France come from the inter-regime consumption database (DCIR), which contains data on biology procedures performed in city laboratories as well as in private establishments, and from the database of hospitalizations in Medicine, Surgery and Obstetrics (PMSI-MCO), which contains data on procedures and outpatient consultations in public establishments. Additional processing was applied to remove outpatient consultations of public establishments submitted to the DCIR (filter DPN_QLF ≠ 71). Only test reimbursement data were available in the dataset; test results were not available. Screening tests The codes of the Nomenclature of Medical Biology Acts (NABM) used for the HBV, HCV, HIV and HDV tests are described in Table 1 . Table 1 List of NABM codes Test Title of the act NABM Code HBs Ag HEPATITIS B VIRUS (HBV) : SD : HBS Ag by immune-enzymologic assay IEA 0322* SEROLOGICAL STATUS SCREENING AND/OR DIAGNOSIS OF HEPATITIS B. - HBS Ag - ANTI-HBS Ab – ANTI-HBC Ab 4500 HEPATITIS B (HBV) RECENT INFECTION:AG HBS + AC ANTI-HBC IGM BY IEA 4710* SEROLOGICAL STATUS MONITORING OF CHRONIC HEPATITIS B - HBS Ag - HBE Ag - Ab 4711 SEROLOGICAL STATUS PREGNANCY MONITORING HBS Ag 4715 HCV Ab SEROLOGICAL STATUS ANTI-VHC Ab. 3784 HIV Ab SEROLOGICAL STATUS HIV 1 and HIV 2 INFECTION 388 HDV Ab SEROLOGICAL STATUS ANTI-DELTA IgG OR TOTAL ANTI-DELTA Ab 1740 HDV RNA DETECTION-QUANTIFICATION OF HDV RNA 4119 *removed on 01/02/2019 Study population The profile of the patients tested was described using the SNDS variables (see Additional data 1). Public health publications usually use the term “precarious profile” to indicate vulnerable people living in social insecurity. In the SNDS, individuals are identified by special health insurance dedicated to people in difficulty. The precarious population included patients benefiting from either complementary universal medical coverage (CMUc), complementary health assistance (ACS) or supplementary health insurance (C2S). The analyses were carried out on people under 60 years of age because other allowances can be allocated to elderly people with low resources. The populations benefiting from state medical aid (AME) or a provisional social security registration number (NIR) are people who recently arrived in metropolitan France (immigrant population) and who are newly affiliated with the French health system. In two populations of interest, pregnant women (NAMB code 4715) and patients followed for chronic hepatitis B (NABM code 4711), we identified HBs via Ag tests associated with anti-HDV Ab (NABM code 1740) screening tests (Table 1 ). Patients who received at least one treatment delivery during the period 2016–2022 were considered under treatment. Long-term illness (Affection Longue Durée = ALD) is a financial scheme set up by the French health insurance system, allowing 100% coverage of health care costs related to the treatment of an illness whose severity and/or chronic nature require prolonged care and costly treatment. These patients can be identified using CIM10 codes for a given pathology (see Additional data 1). Ethical-legal aspects The Limoges University Hospital has permanent access to the SNDS according to the decree of the Official Journal No. 0150 of June 30, 2021. Access and use of these data were performed in compliance with the SNDS security framework, and the personnel concerned received mandatory training and were authorized to extract SNDS data. This project was evaluated and approved by the Limoges University Hospital and then registered in the Health Data Hub directory (No. F20231116101028). Analyses The data are expressed as numbers, percentages or rates. Duplicates (patients who had several tests in a year) were removed using the unique anonymized beneficiary identifier of each patient. For each screening test, we described the distribution by age and sex. The data were extracted and analyzed with SAS guide v8.0. The number of expected anti-HDV Ab tests was calculated from the HBs Ag positivity rates of the Labohep 2013 [ 15 ] and Labohep 2021 [ 5 ] surveys (0.8% and 0.7%, respectively) and the number of HBs Ag tests extracted from the SNDS. For women undergoing pregnancy monitoring, the number of expected HDV Ab tests was calculated using the prevalence of chronic HBV carriage estimated at 0.8% in the 2016 National Perinatal Survey [ 16 ]. To describe the geographical distribution of screening tests, the number was reported to the population living in each administrative region in metropolitan France (source INSEE). Comparisons were performed via the χ 2 test and the Mann‒Whitney test for categorical and continuous variables, respectively. Statistical analysis was performed with R V4.4.3 (R foundation for statistical computing). Values of p < 0.05 were considered statistically significant. Results Number of tests performed and number of tests expected From 2016–2022, 28,898,177 HBs Ag tests, 28,314,766 HCV Ab tests, 29,463,042 HIV Ab tests, 162,055 HDV Ab tests and 21,963 HDV RNA tests were performed in metropolitan France. More specifically, 16,355,991 patients benefited from HBs Ag tests (1.7 tests per patient), 24,361,337 patients benefited from HCV Ab tests (1.2 tests per patient), 17,482,079 patients benefited from HIV Ab tests (1.7 tests per patient), 150,165 patients benefited from HDV Ab tests (1.08 tests per patient), and 14,529 patients benefited from HDV RNA tests (1.5 tests per patient). Between 2016 and 2022, the number of tests performed increased by 45% for HBs Ag tests, 39% for HCV Ab tests, 30% for HIV Ab tests, 130% for anti-HDV Ab tests, and 206% for HDV RNA tests. However, in 2020, there were decreases in HBs Ag, anti-HCV Ab, anti-HIV Ab and anti-HDV Ab screening because of the COVID-19 pandemic (changes of -5.9%, -5.9%, -9% and − 4.9%, respectively, compared with the previous year), whereas the gradual increase in HDV RNA tests remained constant. The same variations were observed for the number of patients tested for HDV Ab and HDV RNA (Figs. 1 and 2 ). Figure 3 shows the evolution of the number of HDV Ab tests expected versus the number of HDV Ab tests performed per year. Fifty-five percent of the expected anti-HDV Ab tests were carried out in 2016 (14,280 vs. 25,887 expected), 69% of the expected anti-HDV Ab tests were carried out in 2020 and 94.7% of the expected anti-HDV Ab tests were carried out in 2022 (32,871 vs. 34,714 expected). The gaps from 2021–2022 were significantly lower than those from 2016‒2020 (p = 0.0476). The observed differences between the expected and performed values for the years 2016 and 2022 were highly significant (p = 0,025). The ratio of HBs Ag tests to the number of inhabitants in each French region was greater in Ile de France (IDF) than in Provence-Alpes-Côte d'Azur (PACA) and then in Occitanie , without any change in trend since 2016. The same regional distribution was observed for the anti-HCV Ab and anti-HIV Ab tests (Supplementary Data S2). With respect to the anti-HDV Ab tests, the regional distributions were somewhat different: IDF, PACA and Auvergne-Rhône-Alpes were the most important prescribers (Fig. 4 ). However, when the regional HBs Ag positivity rates estimated from the 2021 LaboHep survey[ 5 ] were used to calculate the number of expected HDV Ab tests, almost no regions (except Bretagne , Corse and Hauts de France ) reached the target of 100% of the tests expected in 2016 (Table 2 ). In 2021, the majority of regions improved, but some, such as Centre Val de Loire , IDF, and Grand Est , had not yet achieved these objectives. Finally, Hauts de France , which had achieved these objectives in 2016, no longer met them in 2021. Table 2 Calculations of HDV Ab tests expected in 2016 and 2021 by region 2016 2021 Region Nb of HBs Ag Positivity rate (%) HBs Ag + * Nb of HDV Ab expected Nb of HDV Ab carried out Percent of tests performed relative to expected tests (%) Nb of HBS Ag Positivity rate (%) HBs Ag + * Nb of HDV Ab expected Nb of HDV Ab carried out Percent of tests performed relative to expected tests (%) Auvergne-Rhône Alpes 340,880 0.56 1,909 1,351 71 528,339 0.44 2,325 3,451 148 Bourgogne Franche Comté 104,441 0.62 648 244 38 149,373 0.41 612 709 116 Bretagne 124,169 0.44 546 690 126 197,541 0.41 810 1,013 125 Centre-Val de Loire 92,346 0.74 683 413 60 152,371 0.92 1,402 790 56 Corse 17,341 0.12 21 86 413 23,777 0.2 48 99 208 Grand Est 276,636 0.46 1,273 892 70 375,956 0.5 1,880 1,514 81 Hauts de France 264,045 0.31 819 893 109 393,704 0.51 2,008 1,564 78 Ile de France 791,636 1.44 11,400 4,339 38 1,104,013 1.32 14,573 8,908 61 Normandie 140,161 0.47 659 399 61 209,928 0.3 630 833 132 Nouvelle Aquitaine 269,624 0.47 1,267 885 70 407,074 0.45 1,832 1,927 105 Occitanie 301,231 0.57 1,717 1,531 89 463,632 0.49 2,272 2,113 93 Pays de Loire 146,953 0.54 794 545 69 239,128 0.47 1,124 1,543 137 Provence-Alpes-Côte d'Azur 364,074 0.48 1,748 1,444 83 444,597 0.57 2,534 2,711 107 *positivity rates are from the LaboHep 2021 study[ 5 ] Description of the people screened Between 2016 and 2022, the individuals who were screened for HBV were mainly women between 21 and 40 years old (sex ratio = 0.54), with a median age of 34 years. The sex ratios were 0.62 and 0.60 for the HCV Ab and HIV Ab screening tests, respectively, with median ages of 34 and 33 years (see distribution of age/sex in Additional Data S1). For the anti-HDV Ab test, the sex ratios were 1.4 and 1.6 for HDV RNA, with median ages of 40 and 41 years, respectively (Fig. 5 ). Among the patients tested for anti-HDV Ab, 41.7% had a precarious profile, 14.5% had received a provisional NIR, and 8.3% benefited from AME. A total of 51.8% of patients tested for HDV RNA had a precarious profile, 18.7% had provisional NIR, and 12.9% benefited from AME. The percentages of prisoners (almost exclusively men) screened for anti-HDV Ab and HDV RNA were 2.2% and 2.8%, respectively (Fig. 6 ). Patients tested for HDV RNA used opioid substitution therapy 4 times more frequently than patients screened for anti-HDV Ab (2.9% vs. 0.7%), with a majority of men (sex ratio = 11) being 2 times more likely to use antidepressants (28.5% vs. 11.5%). Similarly, patients tested for HDV RNA were more likely to be HIV-infected (7.7% vs. 4.1%), with a sex ratio of 1.9, and to be on HBV and/or HDV treatments (9.8% vs. 0.3% for interferon and 39.1% vs. 15.8% for nucleoside analogue treatments (NUCs)). Among patients tested for HDV RNA (N = 6619) from 2019–2022, 9.7% were treated with bulevirtide. Finally, long-term disease status was twice as common for people who had an HDV RNA test than for those screened for anti-HDV Ab (Fig. 6 ). Evolution of HDV screening in two populations of interest According to the coding for pregnancy monitoring, in 2016, 0.05% of HBV screenings were followed by an HDV test, versus 0.26% in 2022. When calculating the number of expected HDV Ab tests based on the prevalence of chronic HBV, estimated at 0.8% from the 2016 National Perinatal Survey[ 16 ], only 7.1% of the expected HDV Ab tests were performed. In 2022, however, there was a clear increase of 37.4% compared with 2016. Among patients monitored for chronic hepatitis B in 2022, 26% benefitted from an HDV Ab test, compared with 17.2% in 2016. Profile of prescribers While the coding available in the SNDS makes it possible to differentiate employees of public establishments from private practitioners, the specialties can be correctly extracted for private practitioners only, with the specialties of public employees being coded incorrectly (by default, two-thirds are coded in general medicine). The majority of the prescribers of HBs Ag tests were private practitioners (63%), followed by practitioners employed by public institutions (25%) and practitioners employed by private institutions (only 4%). In 8% of the cases, the prescribers were not specified. Private practitioners were composed of 56.6% of general practitioners (37% of total prescribers), followed by gynecologists (20.3% of private practitioners, 13.4% of the total), hepato-gastroenterologists (2.3% of private practitioners, 1.4% of the total), nephrologists (2.1% of private practitioners, 1.3% of the total) and various specialties (up to 11.6%). In 10% of the cases, the specialties were not specified. The profiles of prescribers of the HCV Ab and HIV Ab tests were very similar, with more than 60% of the tests being prescribed by private doctors, followed by practitioners in public institutions. General practitioners and gynecologists were the most involved (see details in Additional data S3). The trend was reversed for anti-HDV Ab, with 57.8% of practitioners working in public institutions and 33.5% being private practitioners. Employees of private institutions represented only 3.1% of the anti-HDV Ab prescribed, and 5.6% of the prescribers were not specified. Sixty-nine percent of private practitioners were general practitioners (23.1% of all prescribers), followed by hepato-gastroenterologists (24%, 8% of all prescribers). Gynecologists represented only 1.5% of private practitioners (0.51% of the total), and other specialties represented 5.5%. Employees of public institutions generated 80.5% of HDV RNA prescriptions, and private practitioners generated 13.3%. Employees of private institutions represented only 2.5% of the total HDV RNA prescribed, and in 3.7% of the cases, the prescribers were not specified. Private practitioners were composed of hepato-gastroenterologists, 52% (i.e., 7% of total prescribers), followed by 40% of general practitioners (5% of the total). Gynecologists accounted for only 2% of private practitioners (0.3% of the total). Six percent of private practitioners belonged to other specialties (Fig. 7 ). Discussion The WHO and European and American societies have issued recommendations on screening for hepatitis delta in at least every patient identified as HBsAg + to be repeated in case of risk factors. This is a crucial strategy for preventing a high incidence of cirrhosis and HCC in this population. A recent Spanish study of patients hospitalized for HDV between 1997 and 2018 revealed that while this number has remained stable over time, liver-related events and CHC linked to HDV are increasing in this population, whereas severe acute hepatitis is decreasing [ 17 ]. Currently, the underdiagnosis of HDV is concerning as new antiviral drugs are approved, including bulevirtide [ 13 ], which has been shown real-life efficacy for preventing liver-related events [ 18 ]. Is hepatitis Delta screening sufficient? There was a clear increase in HBV and HDV screening in 2022 compared with 2016, despite a decline in HBV screening in 2020 due to the COVID-19 pandemic. The availability of Bulevirtide in France for HDV infection, first under nominative Temporary Authorization for Use (early 2019) then cohort (September 2019) and then under Marketing Authorization (July 2020), has clearly encouraged health care professionals to screen for HDV 1.8 times more often in 2022 than in 2016. However, specific populations, such as pregnant women and patients monitored for chronic hepatitis B, remain largely underscreened (0.8% and 26%, respectively). Considering the chronic hepatitis B population, the High Authority of Health of France [ 12 ] recommends not only screening for delta Ab upon the first detection of an HBsAg + result but also offering annual HDV screening in cases of repeated or persistent exposure to a risk of superinfection (e.g., regular travel to endemic areas, drug users, and populations at sexual risk). Migrant HBV patients may travel frequently within their country of origin. On average, we can estimate that delta Ab should be repeated every 2 to 3 years, and in the global population of HbsAg + patients, the number of tests carried out should exceed 100% of the tests expected. When examining the association between the number of tests carried out and the number of inhabitants by region, we found that the IDF, Auvergne-Rhône-Alpes and PACA regions were the most efficient in terms of the absolute number of HBV, HDV Ab and HDV RNA prescriptions. The population density in these regions, the high proportion of migrants and drug users, can explain the reinforcement of screening earlier than in other regions of France (e.g., the development of numerous reception centers for migrants or drug users and offsite screening). However, the same IDF region, as well as Centre Val de Loire , Grand Est and Hauts de France , still demonstrates insufficient screening compared with the “expected HDV tests”. The people screened for HBV were mostly women between 21 and 40 years old, as already described by Tamandjou et al. [ 19 ]. On the other hand, patients screened for HDV were mostly men, with a peak between 31 and 40 years of age. The majority of these patients were precarious or recently affiliated with the Primary Health Insurance Fund by a provisional NIR or benefited from AME and were more likely to be infected with HIV. In France, very few studies are available on the prevalence and profile of HDV patients, and these studies are heterogeneous and not comparable. An old survey of blood donors from 1997–2011 reported a prevalence of 1.98%, with 22.9% positive RNA [ 9 ]. Data from a survey conducted by Santé Publique France on people diagnosed with HBV between 2008 and 2012 revealed a 6% rate of HDV coinfection, of which 62.5% had a replicative profile and a quarter originated from a country with high endemicity for HDV [ 10 ]. Finally, a national study of a targeted population of 1,112 HDV-infected patients with advanced disease referred to university hospitals revealed a median age of 36.5 years, 68.6% male, with geographical origin as the main risk factor (74.2% of the cases), followed by a history of intravenous drug use (15.8%), iatrogenic or nosocomial contamination (5.5%) and sexual transmission (4.5%). Viral coinfections were frequent, with HIV coinfection found in 9% of the cases [ 8 ]. Who prescribes screening tests today? The majority of screening tests for hepatitis B and C and HIV are prescribed by general practitioners or obstetricians-gynecologists (60%). The screening rate for these three viruses is continuously increasing, indicating ongoing surveillance in our territory. Since 2024, in addition to screening for HIV, screening for hepatitis B has been available without a prescription for those under 26 years of age in all laboratories (decree 2024). Only screening for hepatitis C, which is curable, remains problematic, as HCV affects specific populations (e.g., drug users and individuals transfused in the 1980s) who are often distant from health care pathways. In this particular case, "outreach" screening initiatives are necessary [ 20 ]. General practitioners are the primary actors in HBV screening but are also involved in anti-HDV Ab screening. However, a significant proportion of these practitioners work part-time in public institutions. Specialists working in a public institution are the main prescribers of HDV RNA tests. Owing to the complexity of the management of HDV, patients are referred primarily to hospital centers. Additionally, access to HDV treatments in France involves a multidisciplinary consultation meeting in reference centers. Finally, paramedical staff are needed for therapeutic education. Interestingly, the management of HDV in public and mainly in university referral hospitals promotes the declaration of HDV and HBV as long-term diseases by general practitioners. Obstetricians-gynecologists have very little involvement in HDV screening, but HBV screening is recommended for pregnant women in the first trimester of pregnancy: 0.26% of prescribed HBs Ag tests are followed by an anti-HDV Ab test only (i.e., 7.1% of the expected tests carried out in 2022, with an increase of 37.4% compared with 2016). There is no pregnancy monitoring code for HDV in the SNDS. Thus, it can be assumed that pregnant women who tested positive for HBs Ag were either not systematically referred to a specialist or were referred, but the test prescribed by the specialist was not coded during pregnancy monitoring. A specific survey on the matter would be welcome. Furthermore, only a quarter of the patients monitored for chronic HBV infection benefited from HDV screening. We can therefore assume that despite the recommendations of learned societies [ 11 ] and the French High Authority for Health [ 12 ], an insufficient number of repeated HDV tests are performed in chronic HBV patients, who are at risk of Delta superinfection, especially when migrant patients repeatedly stay in endemic countries of origin. Solutions to strengthen screening A first solution would be to strengthen HDV Reflex Testing (RT) in laboratories with the registration of this RT at the official nomenclature in the event of screening of a first positive HBs Ag test. This practice already exists in many university hospital centers, including the National Reference Center for hepatitis viruses, but is not currently applicable to the private sector. Several publications on RT have flourished in the literature [ 21 – 23 ] and show the effectiveness and profitability of screening in detecting HDV-positive patients [ 24 ]. A recent Spanish study demonstrated that RT performed at 100% reduced liver-related events and mortality by 35% in HDV patients and was cost-effective [ 25 ]. However, in this model, with respect to the Spanish population, the number of HDV tests prescribed spontaneously to HBs Ag patients was very low (< 10%), which helped to demonstrate the cost-effectiveness of RT. Thus, cost-effectiveness studies in countries with a low prevalence and an already acceptable screening of HDV are still essential [ 26 ]. Development of new solutions for offsite screening Pending HDV rapid diagnostic tests, detection of viral DNA or RNA could be carried out from a single blotting paper sample (dried blood spot test) in the event of positive HBs Ag, anti-HIV Ab, anti-HCV Ab or anti-HDV Ab tests. Dried blood spot tests are being developed [ 27 ] and are currently validated by the National Reference Center for hepatitis viruses. These tests are particularly suitable for migrant patients [ 28 ]. Finally, optimizing screening involves raising awareness about HDV screening among certain specialties, such as obstetricians-gynecologists, and repeating targeted screening in patients monitored for hepatitis B (treated or not treated with NUCs). Limitations of the study The use of individual data from the SNDS, which covers almost the entire population in metropolitan France over six years, was an important strength of this work. However, the main limitation also comes from the use of SNDS data, which do not allow us to calculate the positivity rate of the prescribed screening tests, particularly the HBV tests. We therefore had to estimate the number of positive HBV tests from the estimated HBV positivity rates in France [ 5 , 16 , 29 ] to calculate the number of HDV screening tests that should have been prescribed. Furthermore, certain data, such as those from CeGIDD, are not transferred to the SNDS (mandatory anonymization procedure for individuals undergoing screening). To our knowledge, in 2022, the number of HBs with Ag tests performed in CeGIDDs was 141,989 according to Tamandjou et al. [ 19 ], but the rate of HDV screening remains unknown. Similarly, it is not possible to extract the biological tests carried out during hospital stays in public institutions from the SNDS. However, HDV Ab screening tests during hospitalization represent a minority of all HDV screening practices. Notably, SNDS data only allow us to identify recent migrant patients through the provisional NIR or the AME. Because this SNDS database is based solely on reimbursement rates for medical tests and procedures, patients' place of birth and origin are not accessible at all. However, some patients of foreign origin who have been in France for a long time may not be included in provisional NIRs or AME. Finally, it would be useful to improve the coding of the specialties of prescribers, particularly in public institutions, to better map screening data from the SNDS and the future National Biology Data Warehouse, LABOé-SI [ 30 ]. Conclusion Between 2016 and 2022, we observed a clear increase in screening tests for HCV, HBV and HIV viruses. Overall, the prevalence of HBV screening, which is key for HDV screening, increased by 45%. Over the same period, the number of anti-HDV Ab prescribed increased 2.4 times. The availability of bulevirtide at the end of 2019 clearly increased HDV screening dynamics. However, significant work remains to be done, particularly in pregnant women and in chronic hepatitis B patients treated with NUCs. Raising awareness among prescribers about the proper targeting of populations at risk of HDV remains essential. Helpful solutions can also be proposed, such as HDV Reflex Testing by laboratories at the first diagnosis of HBs Ag + and the dissemination of blotting techniques (authorizing the performance of PCR on the same sample), particularly in migrant reception facilities. Abbreviations Ab: antibody ACS: complementary health assistance Ag: antigene ALD: affection longue durée = long-term illness AME: state medical aid BLV: bulevirtide C2S: supplementary health insurance CeGIDD: free information, screening and diagnosis centers for human immunodeficiency virus, viral hepatitis and sexually transmitted infections CMUc: complementary universal medical coverage DCIR: inter-regime consumption database IDF: Ile de France HBV: hepatitis B virus HCC: hepatocellular carcinoma HCV: hepatitis C virus HDV: hepatitis Delta virus HIV: human immunodeficiency virus IFN: interferon MCO: medicine, surgery and obstetrics NABM: nomenclature of medical biology acts NIR: social security registration number NUC: nucleoside analogues treatments PACA: Provence Alpes Côte d’Azur PMSI: Program for the Medicalization of Information Systems RNA: ribonucleic acid RT: reflex testing SNDS: French national health data system WHO: world health organization Declarations Ethics The Limoges University Hospital has permanent access to the SNDS according to the decree of the Official Journal No. 0150 of June 30, 2021. Access and use of these data is performed in compliance with the SNDS security framework, and the personnel concerned have receiveed mandatory training and have been authorized to extract SNDS data. This project was evaluated and approved by the Limoges University Hospital and then registered in the Health Data Hub directory (No. F20231116101028). Consent for publication Not applicable. Availability of data and materials According to French law, sharing individual data from an SNDS data extraction is forbidden. However, any researcher from a European entity can submit a file to the Health Data Hub to have access to the same SNDS data extraction. Competing interests The authors declare that they have no competing interests. Funding Winning project of the international Gilead call for tender Delta Describe. Authors’ contributions VLR contributed to the design and supervision of the study. SF and CR performed the analyses. VLR, SF,CR and PC discussed the results and wrote the manuscript. Acknowledgments We would like to thank Mrs Magalie LEMAITRE (epidemiologist, HORIANA) for her invaluable advice. We thank Mrs Marie BOSSELUT and Mrs Sarah DEMAY for proofreading the manuscript. References Global HIV, Hepatitis and STIs Programmes (HHS),, Health Product Policy and Standards (HPS). Global hepatitis report 2024: action for access in low- and middle-income countries [Internet]. World Health Organization. 2024. Available from: https://www.who.int/publications/i/item/9789240091672 Stockdale AJ, Kreuels B, Henrion MYR, Giorgi E, Kyomuhangi I, de Martel C, et al. The global prevalence of hepatitis D virus infection: Systematic review and meta-analysis. J Hepatol 2020;73:523‑32. Gordien E. // THE HEPATITIS DELTA VIRUS INFECTION: RECENT DATA IN FRANCE. Bulletin Epidemiologique Hebdomadaire 2015;19‑20:347‑52. Brouard C, Schwager M, Expert A, Drewniak N, Laporal S, De Lagasnerie G, et al. Impact of Public Policy and COVID-19 Pandemic on Hepatitis C Testing and Treatment in France, 2014–2021. Viruses 2024;16:792. Brouard C, Laporal S, Cazein F, Saboni L, Bruyand M, Lot F. DÉPISTAGE DES HÉPATITES B ET C EN 2021 EN FRANCE, ENQUÊTE LABOHEP / HEPATITIS B AND C TESTING IN 2021 IN FRANCE, LABOHEP SURVEY. Bulletin Epidemiologique Hebdomadaire 2023;15‑16:276‑86. Tamandjou C. Dépistage et diagnostic des hépatites B et C en CeGIDD en 2022, surveillance SurCeGIDD / Screening and diagnosis of hepatitis B and C in French STI clinics (CeGIDD) in 2022, SurCeGIDD surveillance. Yan H, Zhong G, Xu G, He W, Jing Z, Gao Z, et al. Sodium taurocholate cotransporting polypeptide is a functional receptor for human hepatitis B and D virus. Elife 2012;1:e00049. Roulot D, Brichler S, Layese R, BenAbdesselam Z, Zoulim F, Thibault V, et al. Origin, HDV genotype and persistent viremia determine outcome and treatment response in patients with chronic hepatitis delta. J Hepatol 2020;73:1046‑62. Servant-Delmas A, Le Gal F, Gallian P, Gordien E, Laperche S. Increasing prevalence of HDV/HBV infection over 15 years in France. J Clin Virol 2014;59:126‑8. Chevaliez S, Roudot-Thoraval F, Brouard C, Gordien E, Zoulim F, Brichler S, et al. Clinical and virological features of chronic hepatitis B in the French national surveillance program, 2008-2012: A cross-sectional study. JHEP Rep 2022;4:100593. EASL Clinical Practice Guidelines on hepatitis delta virus. J Hepatol 2023;79:433‑60. HAS. Haute Autorité de santé. Prise en charge des personnes infectées par les virus de l’hépatite B, C ou D. [Internet]. 2024;Available from: https://www.has-sante.fr/jcms/p_3324682/fr/prise-en-charge-des-personnes-infectees-par-les-virus-de-l-hepatite-b-c-ou-d#toc_1_4_1 Wedemeyer H, Aleman S, Brunetto MR, Blank A, Andreone P, Bogomolov P, et al. A Phase 3, Randomized Trial of Bulevirtide in Chronic Hepatitis D. N Engl J Med 2023;389:22‑32. Tuppin P, Rudant J, Constantinou P, Gastaldi-Ménager C, Rachas A, de Roquefeuil L, et al. Value of a national administrative database to guide public decisions: From the système national d’information interrégimes de l’Assurance Maladie (SNIIRAM) to the système national des données de santé (SNDS) in France. Rev Epidemiol Sante Publique 2017;65 Suppl 4:S149‑67. Pioche C, Léon L, Larsen C, Lot F, Pillonel J, Brouard C. // HEPATITIS B AND C SCREENING IN FRANCE IN 2013, LABOHEP STUDY. :7. Enquête nationale périnatale Rapport 2016 [Internet]. 2017;Available from: https://enp.inserm.fr/wp-content/uploads/2020/05/ENP2016_Rapport.pdf Ramos-Rincon JM, Pinargote H, Ramos-Belinchón C, de Mendoza C, Aguilera A, Soriano V. Hepatitis delta in patients hospitalized in Spain (1997-2018). AIDS 2021;35:2311‑8. Degasperi E, Anolli MP, Jachs M, Reiberger T, De Ledinghen V, Metivier S, et al. Real-world effectiveness and safety of bulevirtide monotherapy for up to 96 weeks in patients with HDV-related cirrhosis. J Hepatol 2025;S0168-8278(25)00001-7. Tamandjou C, Laporal S, Lot F, Brouard C. DONNÉES ÉPIDÉMIOLOGIQUES RÉCENTES SUR LES HÉPATITES C, B ET DELTA / UPDATED EPIDEMIOLOGICAL DATA ON HEPATITIS C, B AND DELTA. Bulletin Epidemiologique Hebdomadaire 2023;15‑16:311‑7. Debette-Gratien M, François S, Chevalier C, Alain S, Carrier P, Rigaud C, et al. Towards hepatitis C elimination in France: Scanvir, an effective model to test and treat drug users on dedicated days. J Viral Hepat 2023;30:355‑61. Razavi HA, Buti M, Terrault NA, Zeuzem S, Yurdaydin C, Tanaka J, et al. Hepatitis D double reflex testing of all hepatitis B carriers in low-HBV- and high-HBV/HDV-prevalence countries. J Hepatol 2023;79:576‑80. Cossiga V, Brusa S, Montalti R, De Conte A, Jannuzzi G, Ranieri L, et al. Anti-HDV reflex testing in HBsAg-positive subjects: An efficacious strategy to identify HDV infection. Liver Int 2024;44:148‑54. Hilleret MN, Flacher E, Germi R, Lupo J, Larrat S. Reflex testing automatization for HBsAg carriers: A novel era for hepatitis delta management. JHEP Rep 2024;6:100813. Palom A, Rando-Segura A, Vico J, Pacín B, Vargas E, Barreira-Díaz A, et al. Implementation of anti-HDV reflex testing among HBsAg-positive individuals increases testing for hepatitis D. JHEP Rep 2022;4:100547. Buti M, Domínguez-Hernández R, Palom A, Esteban R, Casado MÁ. Impact of hepatitis D reflex testing on the future disease burden: A modelling analysis. Liver Int 2023;43:2611‑4. Abbas Z, Abbas M. Is there a need for universal double reflex testing of HBsAg-positive individuals for hepatitis D infection? World J Hepatol 2024;16:300‑3. Martínez-Campreciós J, Rando-Segura A, Buti M, Rodrigo-Velásquez F, Riveiro-Barciela M, Barreira-Díaz A, et al. Reflex viral load testing in dried blood spots generated by plasma separation card allows the screening and diagnosis of chronic viral hepatitis. J Virol Methods 2021;289:114039. Delagarde V, Gerber A, Dziri S, Roulot D, Gordien E, Le Gal F, et al. IMPROVING ACCESS TO HDV TESTING USING DRY BLOOD SPOTS. 1230C [Internet]. 2023;Available from: https://www.aasld.org/sites/default/files/2023-10/the_liver_meeting_boston_massachusetts_nov1_0.pdf Pioche C, Léon L, Vaux S, Brouard C, Lot F. DÉPISTAGE DES HÉPATITES B ET C EN FRANCE EN 2016, NOUVELLE ÉDITION DE L’ENQUÊTE LABOHEP / HEPATITIS B AND C SCREENING IN FRANCE IN 2016. THE NEW EDITION OF THE LABOHEP STUDY. 2018;188‑95. Journal Officiel. Décret n° 2023-700 du 31 juillet 2023 relatif à la transmission obligatoire de données individuelles à l’autorité sanitaire et à la création du traitement de données à caractère personnel « LABOé-SI » [Internet]. 2023. Available from: https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000047911698 Additional Declarations No competing interests reported. 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06:05:43","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14215,"visible":true,"origin":"","legend":"","description":"","filename":"TablesBMCAdditionalData1.docx","url":"https://assets-eu.researchsquare.com/files/rs-5662958/v1/7e33e233e3c2864960ee7e99.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eScreening for hepatitis B, C and D in metropolitan France from 2016 to 2022: A map based on the National Health Data System with a focus on HDV screening\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe World Health Organization (WHO) has set a goal of eliminating chronic hepatitis virus infections by 2030, with a 10% reduction in mortality, access to diagnosis for 90% of infected subjects and access to treatment for 80% of infected individuals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Targeted strategies have been implemented, especially in high-income countries, but this objective has not been achieved for all countries. The number of deaths related to viral hepatitis is increasing: there were 1.3\u0026nbsp;million deaths related to viral hepatitis in 2022 (83% caused by hepatitis B virus (HBV) and 17% by hepatitis C virus (HCV)) versus 1.1\u0026nbsp;million in 2019, according to the latest WHO report [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Delta virus (HDV) affects approximately 5% of people with chronic HBV infection globally and is largely underdiagnosed, but it is still responsible for one million deaths annually [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn France, the number of HCV patients tested increased by 9% per year between 2014 and 2021 (except during the COVID-19 pandemic). However, a 69% decrease in direct-acting antiviral initiation has been observed since mid-2017. Even if the pool of patients to be treated probably decreases, it is still necessary to increase awareness among undiagnosed infected people [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo studies recently reported the HBV positivity rate in France. (i) The 2021 LaboHEP survey [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] revealed a 25% increase in the number of HBs Ag performed compared with 2016, with a lower positivity rate in 2021 (0.69%) than in 2016. (ii) The CeGIDD 2022 survey [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] examined 529,453 consultations in French STI clinics (which provide free information, screening and diagnosis for human immunodeficiency virus (HIV), viral hepatitis and sexually transmitted infections) and revealed an HBV screening rate of 34.7% and an overall positivity rate of 1.1%, which is higher than that in the general population but concerns specific patients (more often males and people born abroad) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHDV is a small, defective RNA virus that depends on the expression of the HBs antigen (HBs Ag) of HBV for its structure and assembly. It uses the same entry mechanism as HBV to infect hepatocytes by binding to the sodium taurocholate cotransporter polypeptide [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Consequently, HDV screening requires adequate HBV screening.\u003c/p\u003e \u003cp\u003eChronic delta infection is the most serious form of hepatitis; at 10 years, the risk of cirrhosis is 57%, and the risk of hepatocellular carcinoma (HCC) is 15%, i.e., 3 to 5 times higher than the risks associated with HBV monoinfection [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In Europe, the estimated prevalence of anti-HDV antibodies (Ab) in the general population with positive HBs Ag is 3% (95% CI: 2.09\u0026ndash;4.21), and 64% of these cases are positive for HDV RNA [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In France, few studies have examined the prevalence and profile of HDV patients specific populations [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEuropean learned societies and the French High Authority for Health (HAS) recommend systematic screening for anti-HDV Ab for any new positive HBs Ag cases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNew therapeutic options, particularly the use of bulevirtide to treat HDV, are changing the management of these patients [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and limiting the incidence of complications such as cirrhosis and HCC.\u003c/p\u003e \u003cp\u003eThe objective of this study was to provide a map of viral hepatitis and HIV screening in France between 2016 and 2022 based on the French National Health Data System (SNDS), with a focus on delta hepatitis, as the prognosis of delta hepatitis has recently changed with the availability of new treatments.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData sources\u003c/h2\u003e \u003cp\u003eThe SNDS combines data from the Program for the Medicalization of Information Systems (PMSI), the National Inter-Regime Information System of the Health Insurance (SNIIRAM) and data related to causes of death [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The screening data from 2016 to 2022 for HBV (HBs Ag), HCV (Ab), HIV (Ab) and HDV (anti-HDV Ab and HDV RNA) in metropolitan France come from the inter-regime consumption database (DCIR), which contains data on biology procedures performed in city laboratories as well as in private establishments, and from the database of hospitalizations in Medicine, Surgery and Obstetrics (PMSI-MCO), which contains data on procedures and outpatient consultations in public establishments. Additional processing was applied to remove outpatient consultations of public establishments submitted to the DCIR (filter DPN_QLF\u0026thinsp;\u0026ne;\u0026thinsp;71).\u003c/p\u003e \u003cp\u003eOnly test reimbursement data were available in the dataset; test results were not available.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eScreening tests\u003c/h3\u003e\n\u003cp\u003eThe codes of the Nomenclature of Medical Biology Acts (NABM) used for the HBV, HCV, HIV and HDV tests are described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of NABM codes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTitle of the act\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNABM Code\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eHBs Ag\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHEPATITIS B VIRUS (HBV) : SD : HBS Ag by immune-enzymologic assay IEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0322*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSEROLOGICAL STATUS SCREENING AND/OR DIAGNOSIS OF HEPATITIS B. - HBS Ag - ANTI-HBS Ab \u0026ndash; ANTI-HBC Ab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHEPATITIS B (HBV) RECENT INFECTION:AG HBS\u0026thinsp;+\u0026thinsp;AC ANTI-HBC IGM BY IEA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4710*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSEROLOGICAL STATUS MONITORING OF CHRONIC HEPATITIS B - HBS Ag - HBE Ag - Ab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4711\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSEROLOGICAL STATUS PREGNANCY MONITORING HBS Ag\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4715\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHCV Ab\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSEROLOGICAL STATUS ANTI-VHC Ab.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3784\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHIV Ab\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSEROLOGICAL STATUS HIV 1 and HIV 2 INFECTION\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e388\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHDV Ab\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSEROLOGICAL STATUS ANTI-DELTA IgG OR TOTAL ANTI-DELTA Ab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1740\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHDV RNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDETECTION-QUANTIFICATION OF HDV RNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003e*removed on 01/02/2019\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eThe profile of the patients tested was described using the SNDS variables (see Additional data 1). Public health publications usually use the term \u0026ldquo;precarious profile\u0026rdquo; to indicate vulnerable people living in social insecurity. In the SNDS, individuals are identified by special health insurance dedicated to people in difficulty. The precarious population included patients benefiting from either complementary universal medical coverage (CMUc), complementary health assistance (ACS) or supplementary health insurance (C2S). The analyses were carried out on people under 60 years of age because other allowances can be allocated to elderly people with low resources. The populations benefiting from state medical aid (AME) or a provisional social security registration number (NIR) are people who recently arrived in metropolitan France (immigrant population) and who are newly affiliated with the French health system. In two populations of interest, pregnant women (NAMB code 4715) and patients followed for chronic hepatitis B (NABM code 4711), we identified HBs via Ag tests associated with anti-HDV Ab (NABM code 1740) screening tests (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients who received at least one treatment delivery during the period 2016\u0026ndash;2022 were considered under treatment. Long-term illness (Affection Longue Dur\u0026eacute;e\u0026thinsp;=\u0026thinsp;ALD) is a financial scheme set up by the French health insurance system, allowing 100% coverage of health care costs related to the treatment of an illness whose severity and/or chronic nature require prolonged care and costly treatment. These patients can be identified using CIM10 codes for a given pathology (see Additional data 1).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical-legal aspects\u003c/h3\u003e\n\u003cp\u003eThe Limoges University Hospital has permanent access to the SNDS according to the decree of the Official Journal No. 0150 of June 30, 2021. Access and use of these data were performed in compliance with the SNDS security framework, and the personnel concerned received mandatory training and were authorized to extract SNDS data. This project was evaluated and approved by the Limoges University Hospital and then registered in the Health Data Hub directory (No. F20231116101028).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eAnalyses\u003c/h2\u003e \u003cp\u003eThe data are expressed as numbers, percentages or rates. Duplicates (patients who had several tests in a year) were removed using the unique anonymized beneficiary identifier of each patient. For each screening test, we described the distribution by age and sex.\u003c/p\u003e \u003cp\u003eThe data were extracted and analyzed with SAS guide v8.0.\u003c/p\u003e \u003cp\u003eThe number of expected anti-HDV Ab tests was calculated from the HBs Ag positivity rates of the Labohep 2013 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and Labohep 2021 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] surveys (0.8% and 0.7%, respectively) and the number of HBs Ag tests extracted from the SNDS. For women undergoing pregnancy monitoring, the number of expected HDV Ab tests was calculated using the prevalence of chronic HBV carriage estimated at 0.8% in the 2016 National Perinatal Survey [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo describe the geographical distribution of screening tests, the number was reported to the population living in each administrative region in metropolitan France (source INSEE).\u003c/p\u003e \u003cp\u003eComparisons were performed via the χ\u003csup\u003e2\u003c/sup\u003e test and the Mann‒Whitney test for categorical and continuous variables, respectively. Statistical analysis was performed with R V4.4.3 (R foundation for statistical computing). Values of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eNumber of tests performed and number of tests expected\u003c/h2\u003e \u003cp\u003eFrom 2016\u0026ndash;2022, 28,898,177 HBs Ag tests, 28,314,766 HCV Ab tests, 29,463,042 HIV Ab tests, 162,055 HDV Ab tests and 21,963 HDV RNA tests were performed in metropolitan France. More specifically, 16,355,991 patients benefited from HBs Ag tests (1.7 tests per patient), 24,361,337 patients benefited from HCV Ab tests (1.2 tests per patient), 17,482,079 patients benefited from HIV Ab tests (1.7 tests per patient), 150,165 patients benefited from HDV Ab tests (1.08 tests per patient), and 14,529 patients benefited from HDV RNA tests (1.5 tests per patient). Between 2016 and 2022, the number of tests performed increased by 45% for HBs Ag tests, 39% for HCV Ab tests, 30% for HIV Ab tests, 130% for anti-HDV Ab tests, and 206% for HDV RNA tests. However, in 2020, there were decreases in HBs Ag, anti-HCV Ab, anti-HIV Ab and anti-HDV Ab screening because of the COVID-19 pandemic (changes of -5.9%, -5.9%, -9% and \u0026minus;\u0026thinsp;4.9%, respectively, compared with the previous year), whereas the gradual increase in HDV RNA tests remained constant. The same variations were observed for the number of patients tested for HDV Ab and HDV RNA (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the evolution of the number of HDV Ab tests expected versus the number of HDV Ab tests performed per year. Fifty-five percent of the expected anti-HDV Ab tests were carried out in 2016 (14,280 vs. 25,887 expected), 69% of the expected anti-HDV Ab tests were carried out in 2020 and 94.7% of the expected anti-HDV Ab tests were carried out in 2022 (32,871 vs. 34,714 expected). The gaps from 2021\u0026ndash;2022 were significantly lower than those from 2016‒2020 (p\u0026thinsp;=\u0026thinsp;0.0476). The observed differences between the expected and performed values for the years 2016 and 2022 were highly significant (p\u0026thinsp;=\u0026thinsp;0,025). The ratio of HBs Ag tests to the number of inhabitants in each French region was greater in \u003cem\u003eIle de France\u003c/em\u003e (IDF) than in \u003cem\u003eProvence-Alpes-C\u0026ocirc;te d'Azur\u003c/em\u003e (PACA) and then in \u003cem\u003eOccitanie\u003c/em\u003e, without any change in trend since 2016. The same regional distribution was observed for the anti-HCV Ab and anti-HIV Ab tests (Supplementary Data S2).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWith respect to the anti-HDV Ab tests, the regional distributions were somewhat different: IDF, PACA and \u003cem\u003eAuvergne-Rh\u0026ocirc;ne-Alpes\u003c/em\u003e were the most important prescribers (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). However, when the regional HBs Ag positivity rates estimated from the 2021 LaboHep survey[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] were used to calculate the number of expected HDV Ab tests, almost no regions (except \u003cem\u003eBretagne\u003c/em\u003e, \u003cem\u003eCorse\u003c/em\u003e and \u003cem\u003eHauts de France\u003c/em\u003e) reached the target of 100% of the tests expected in 2016 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In 2021, the majority of regions improved, but some, such as \u003cem\u003eCentre Val de Loire\u003c/em\u003e, IDF, and \u003cem\u003eGrand Est\u003c/em\u003e, had not yet achieved these objectives. Finally, \u003cem\u003eHauts de France\u003c/em\u003e, which had achieved these objectives in 2016, no longer met them in 2021.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCalculations of HDV Ab tests expected in 2016 and 2021 by region\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNb of HBs Ag\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePositivity rate (%) HBs Ag + *\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNb of HDV Ab expected\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNb of HDV Ab carried out\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePercent of tests performed relative to expected tests (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNb of HBS Ag\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePositivity rate (%) HBs\u003c/p\u003e \u003cp\u003eAg + *\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNb of HDV Ab expected\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNb of HDV Ab carried out\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003ePercent of tests performed relative to expected tests (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAuvergne-Rh\u0026ocirc;ne Alpes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e340,880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,909\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1,351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e71\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e528,339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2,325\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e3,451\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e148\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBourgogne Franche Comt\u0026eacute;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104,441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e648\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e149,373\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e612\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e709\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e116\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBretagne\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e124,169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e546\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e690\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e126\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e197,541\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1,013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e125\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCentre-Val de Loire\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e92,346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e683\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e413\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e152,371\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1,402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e790\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e56\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCorse\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17,341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e413\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e23,777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e208\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGrand Est\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e276,636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e892\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e70\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e375,956\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1,880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1,514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e81\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHauts de France\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e264,045\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e819\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e109\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e393,704\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2,008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1,564\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e78\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIle de France\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e791,636\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11,400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4,339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1,104,013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e14,573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e8,908\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e61\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNormandie\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140,161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e659\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e399\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e61\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e209,928\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e630\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e833\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e132\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNouvelle Aquitaine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e269,624\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e885\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e70\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e407,074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1,832\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1,927\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e105\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOccitanie\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e301,231\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,717\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1,531\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e89\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e463,632\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2,272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2,113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e93\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePays de Loire\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146,953\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e545\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e69\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e239,128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1,124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1,543\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e137\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProvence-Alpes-C\u0026ocirc;te d'Azur\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e364,074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,748\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1,444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e83\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e444,597\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2,534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2,711\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e107\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003e*positivity rates are from the LaboHep 2021 study[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDescription of the people screened\u003c/h2\u003e \u003cp\u003eBetween 2016 and 2022, the individuals who were screened for HBV were mainly women between 21 and 40 years old (sex ratio\u0026thinsp;=\u0026thinsp;0.54), with a median age of 34 years. The sex ratios were 0.62 and 0.60 for the HCV Ab and HIV Ab screening tests, respectively, with median ages of 34 and 33 years (see distribution of age/sex in Additional Data S1). For the anti-HDV Ab test, the sex ratios were 1.4 and 1.6 for HDV RNA, with median ages of 40 and 41 years, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Among the patients tested for anti-HDV Ab, 41.7% had a precarious profile, 14.5% had received a provisional NIR, and 8.3% benefited from AME. A total of 51.8% of patients tested for HDV RNA had a precarious profile, 18.7% had provisional NIR, and 12.9% benefited from AME. The percentages of prisoners (almost exclusively men) screened for anti-HDV Ab and HDV RNA were 2.2% and 2.8%, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatients tested for HDV RNA used opioid substitution therapy 4 times more frequently than patients screened for anti-HDV Ab (2.9% vs. 0.7%), with a majority of men (sex ratio\u0026thinsp;=\u0026thinsp;11) being 2 times more likely to use antidepressants (28.5% vs. 11.5%). Similarly, patients tested for HDV RNA were more likely to be HIV-infected (7.7% vs. 4.1%), with a sex ratio of 1.9, and to be on HBV and/or HDV treatments (9.8% vs. 0.3% for interferon and 39.1% vs. 15.8% for nucleoside analogue treatments (NUCs)). Among patients tested for HDV RNA (N\u0026thinsp;=\u0026thinsp;6619) from 2019\u0026ndash;2022, 9.7% were treated with bulevirtide.\u003c/p\u003e \u003cp\u003eFinally, long-term disease status was twice as common for people who had an HDV RNA test than for those screened for anti-HDV Ab (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEvolution of HDV screening in two populations of interest\u003c/h2\u003e \u003cp\u003eAccording to the coding for pregnancy monitoring, in 2016, 0.05% of HBV screenings were followed by an HDV test, versus 0.26% in 2022. When calculating the number of expected HDV Ab tests based on the prevalence of chronic HBV, estimated at 0.8% from the 2016 National Perinatal Survey[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], only 7.1% of the expected HDV Ab tests were performed. In 2022, however, there was a clear increase of 37.4% compared with 2016. Among patients monitored for chronic hepatitis B in 2022, 26% benefitted from an HDV Ab test, compared with 17.2% in 2016.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eProfile of prescribers\u003c/h2\u003e \u003cp\u003eWhile the coding available in the SNDS makes it possible to differentiate employees of public establishments from private practitioners, the specialties can be correctly extracted for private practitioners only, with the specialties of public employees being coded incorrectly (by default, two-thirds are coded in general medicine).\u003c/p\u003e \u003cp\u003eThe majority of the prescribers of HBs Ag tests were private practitioners (63%), followed by practitioners employed by public institutions (25%) and practitioners employed by private institutions (only 4%). In 8% of the cases, the prescribers were not specified. Private practitioners were composed of 56.6% of general practitioners (37% of total prescribers), followed by gynecologists (20.3% of private practitioners, 13.4% of the total), hepato-gastroenterologists (2.3% of private practitioners, 1.4% of the total), nephrologists (2.1% of private practitioners, 1.3% of the total) and various specialties (up to 11.6%). In 10% of the cases, the specialties were not specified.\u003c/p\u003e \u003cp\u003eThe profiles of prescribers of the HCV Ab and HIV Ab tests were very similar, with more than 60% of the tests being prescribed by private doctors, followed by practitioners in public institutions. General practitioners and gynecologists were the most involved (see details in Additional data S3).\u003c/p\u003e \u003cp\u003eThe trend was reversed for anti-HDV Ab, with 57.8% of practitioners working in public institutions and 33.5% being private practitioners. Employees of private institutions represented only 3.1% of the anti-HDV Ab prescribed, and 5.6% of the prescribers were not specified. Sixty-nine percent of private practitioners were general practitioners (23.1% of all prescribers), followed by hepato-gastroenterologists (24%, 8% of all prescribers). Gynecologists represented only 1.5% of private practitioners (0.51% of the total), and other specialties represented 5.5%.\u003c/p\u003e \u003cp\u003eEmployees of public institutions generated 80.5% of HDV RNA prescriptions, and private practitioners generated 13.3%. Employees of private institutions represented only 2.5% of the total HDV RNA prescribed, and in 3.7% of the cases, the prescribers were not specified. Private practitioners were composed of hepato-gastroenterologists, 52% (i.e., 7% of total prescribers), followed by 40% of general practitioners (5% of the total). Gynecologists accounted for only 2% of private practitioners (0.3% of the total). Six percent of private practitioners belonged to other specialties (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe WHO and European and American societies have issued recommendations on screening for hepatitis delta in at least every patient identified as HBsAg\u0026thinsp;+\u0026thinsp;to be repeated in case of risk factors. This is a crucial strategy for preventing a high incidence of cirrhosis and HCC in this population.\u003c/p\u003e \u003cp\u003eA recent Spanish study of patients hospitalized for HDV between 1997 and 2018 revealed that while this number has remained stable over time, liver-related events and CHC linked to HDV are increasing in this population, whereas severe acute hepatitis is decreasing [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, the underdiagnosis of HDV is concerning as new antiviral drugs are approved, including bulevirtide [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which has been shown real-life efficacy for preventing liver-related events [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eIs hepatitis Delta screening sufficient?\u003c/h2\u003e \u003cp\u003eThere was a clear increase in HBV and HDV screening in 2022 compared with 2016, despite a decline in HBV screening in 2020 due to the COVID-19 pandemic. The availability of Bulevirtide in France for HDV infection, first under nominative Temporary Authorization for Use (early 2019) then cohort (September 2019) and then under Marketing Authorization (July 2020), has clearly encouraged health care professionals to screen for HDV 1.8 times more often in 2022 than in 2016. However, specific populations, such as pregnant women and patients monitored for chronic hepatitis B, remain largely underscreened (0.8% and 26%, respectively). Considering the chronic hepatitis B population, the High Authority of Health of France [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] recommends not only screening for delta Ab upon the first detection of an HBsAg\u0026thinsp;+\u0026thinsp;result but also offering annual HDV screening in cases of repeated or persistent exposure to a risk of superinfection (e.g., regular travel to endemic areas, drug users, and populations at sexual risk). Migrant HBV patients may travel frequently within their country of origin. On average, we can estimate that delta Ab should be repeated every 2 to 3 years, and in the global population of HbsAg\u0026thinsp;+\u0026thinsp;patients, the number of tests carried out should exceed 100% of the tests expected.\u003c/p\u003e \u003cp\u003eWhen examining the association between the number of tests carried out and the number of inhabitants by region, we found that the IDF, \u003cem\u003eAuvergne-Rh\u0026ocirc;ne-Alpes\u003c/em\u003e and PACA regions were the most efficient in terms of the absolute number of HBV, HDV Ab and HDV RNA prescriptions. The population density in these regions, the high proportion of migrants and drug users, can explain the reinforcement of screening earlier than in other regions of France (e.g., the development of numerous reception centers for migrants or drug users and offsite screening). However, the same IDF region, as well as \u003cem\u003eCentre Val de Loire\u003c/em\u003e, \u003cem\u003eGrand Est\u003c/em\u003e and \u003cem\u003eHauts de France\u003c/em\u003e, still demonstrates insufficient screening compared with the \u0026ldquo;expected HDV tests\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe people screened for HBV were mostly women between 21 and 40 years old, as already described by Tamandjou et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. On the other hand, patients screened for HDV were mostly men, with a peak between 31 and 40 years of age. The majority of these patients were precarious or recently affiliated with the Primary Health Insurance Fund by a provisional NIR or benefited from AME and were more likely to be infected with HIV.\u003c/p\u003e \u003cp\u003eIn France, very few studies are available on the prevalence and profile of HDV patients, and these studies are heterogeneous and not comparable. An old survey of blood donors from 1997\u0026ndash;2011 reported a prevalence of 1.98%, with 22.9% positive RNA [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Data from a survey conducted by \u003cem\u003eSant\u0026eacute; Publique France\u003c/em\u003e on people diagnosed with HBV between 2008 and 2012 revealed a 6% rate of HDV coinfection, of which 62.5% had a replicative profile and a quarter originated from a country with high endemicity for HDV [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Finally, a national study of a targeted population of 1,112 HDV-infected patients with advanced disease referred to university hospitals revealed a median age of 36.5 years, 68.6% male, with geographical origin as the main risk factor (74.2% of the cases), followed by a history of intravenous drug use (15.8%), iatrogenic or nosocomial contamination (5.5%) and sexual transmission (4.5%). Viral coinfections were frequent, with HIV coinfection found in 9% of the cases [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eWho prescribes screening tests today?\u003c/h2\u003e \u003cp\u003eThe majority of screening tests for hepatitis B and C and HIV are prescribed by general practitioners or obstetricians-gynecologists (60%). The screening rate for these three viruses is continuously increasing, indicating ongoing surveillance in our territory. Since 2024, in addition to screening for HIV, screening for hepatitis B has been available without a prescription for those under 26 years of age in all laboratories (decree 2024). Only screening for hepatitis C, which is curable, remains problematic, as HCV affects specific populations (e.g., drug users and individuals transfused in the 1980s) who are often distant from health care pathways. In this particular case, \"outreach\" screening initiatives are necessary [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGeneral practitioners are the primary actors in HBV screening but are also involved in anti-HDV Ab screening. However, a significant proportion of these practitioners work part-time in public institutions. Specialists working in a public institution are the main prescribers of HDV RNA tests. Owing to the complexity of the management of HDV, patients are referred primarily to hospital centers. Additionally, access to HDV treatments in France involves a multidisciplinary consultation meeting in reference centers. Finally, paramedical staff are needed for therapeutic education.\u003c/p\u003e \u003cp\u003eInterestingly, the management of HDV in public and mainly in university referral hospitals promotes the declaration of HDV and HBV as long-term diseases by general practitioners.\u003c/p\u003e \u003cp\u003eObstetricians-gynecologists have very little involvement in HDV screening, but HBV screening is recommended for pregnant women in the first trimester of pregnancy: 0.26% of prescribed HBs Ag tests are followed by an anti-HDV Ab test only (i.e., 7.1% of the expected tests carried out in 2022, with an increase of 37.4% compared with 2016). There is no pregnancy monitoring code for HDV in the SNDS. Thus, it can be assumed that pregnant women who tested positive for HBs Ag were either not systematically referred to a specialist or were referred, but the test prescribed by the specialist was not coded during pregnancy monitoring. A specific survey on the matter would be welcome.\u003c/p\u003e \u003cp\u003eFurthermore, only a quarter of the patients monitored for chronic HBV infection benefited from HDV screening. We can therefore assume that despite the recommendations of learned societies [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and the French High Authority for Health [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], an insufficient number of repeated HDV tests are performed in chronic HBV patients, who are at risk of Delta superinfection, especially when migrant patients repeatedly stay in endemic countries of origin.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSolutions to strengthen screening\u003c/h2\u003e \u003cp\u003eA first solution would be to strengthen HDV Reflex Testing (RT) in laboratories with the registration of this RT at the official nomenclature in the event of screening of a first positive HBs Ag test. This practice already exists in many university hospital centers, including the National Reference Center for hepatitis viruses, but is not currently applicable to the private sector. Several publications on RT have flourished in the literature [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] and show the effectiveness and profitability of screening in detecting HDV-positive patients [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A recent Spanish study demonstrated that RT performed at 100% reduced liver-related events and mortality by 35% in HDV patients and was cost-effective [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. However, in this model, with respect to the Spanish population, the number of HDV tests prescribed spontaneously to HBs Ag patients was very low (\u0026lt;\u0026thinsp;10%), which helped to demonstrate the cost-effectiveness of RT. Thus, cost-effectiveness studies in countries with a low prevalence and an already acceptable screening of HDV are still essential [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eDevelopment of new solutions for offsite screening\u003c/h2\u003e \u003cp\u003ePending HDV rapid diagnostic tests, detection of viral DNA or RNA could be carried out from a single blotting paper sample (dried blood spot test) in the event of positive HBs Ag, anti-HIV Ab, anti-HCV Ab or anti-HDV Ab tests. Dried blood spot tests are being developed [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and are currently validated by the National Reference Center for hepatitis viruses. These tests are particularly suitable for migrant patients [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, optimizing screening involves raising awareness about HDV screening among certain specialties, such as obstetricians-gynecologists, and repeating targeted screening in patients monitored for hepatitis B (treated or not treated with NUCs).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study\u003c/h2\u003e \u003cp\u003eThe use of individual data from the SNDS, which covers almost the entire population in metropolitan France over six years, was an important strength of this work. However, the main limitation also comes from the use of SNDS data, which do not allow us to calculate the positivity rate of the prescribed screening tests, particularly the HBV tests. We therefore had to estimate the number of positive HBV tests from the estimated HBV positivity rates in France [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] to calculate the number of HDV screening tests that should have been prescribed. Furthermore, certain data, such as those from CeGIDD, are not transferred to the SNDS (mandatory anonymization procedure for individuals undergoing screening). To our knowledge, in 2022, the number of HBs with Ag tests performed in CeGIDDs was 141,989 according to Tamandjou et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], but the rate of HDV screening remains unknown.\u003c/p\u003e \u003cp\u003eSimilarly, it is not possible to extract the biological tests carried out during hospital stays in public institutions from the SNDS. However, HDV Ab screening tests during hospitalization represent a minority of all HDV screening practices. Notably, SNDS data only allow us to identify recent migrant patients through the provisional NIR or the AME. Because this SNDS database is based solely on reimbursement rates for medical tests and procedures, patients' place of birth and origin are not accessible at all. However, some patients of foreign origin who have been in France for a long time may not be included in provisional NIRs or AME.\u003c/p\u003e \u003cp\u003eFinally, it would be useful to improve the coding of the specialties of prescribers, particularly in public institutions, to better map screening data from the SNDS and the future National Biology Data Warehouse, LABO\u0026eacute;-SI [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eBetween 2016 and 2022, we observed a clear increase in screening tests for HCV, HBV and HIV viruses. Overall, the prevalence of HBV screening, which is key for HDV screening, increased by 45%. Over the same period, the number of anti-HDV Ab prescribed increased 2.4 times. The availability of bulevirtide at the end of 2019 clearly increased HDV screening dynamics. However, significant work remains to be done, particularly in pregnant women and in chronic hepatitis B patients treated with NUCs. Raising awareness among prescribers about the proper targeting of populations at risk of HDV remains essential. Helpful solutions can also be proposed, such as HDV Reflex Testing by laboratories at the first diagnosis of HBs Ag\u0026thinsp;+\u0026thinsp;and the dissemination of blotting techniques (authorizing the performance of PCR on the same sample), particularly in migrant reception facilities.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAb: antibody\u003c/p\u003e\n\u003cp\u003eACS:\u0026nbsp;complementary health assistance\u003c/p\u003e\n\u003cp\u003eAg: antigene\u003c/p\u003e\n\u003cp\u003eALD: affection longue dur\u0026eacute;e = long-term illness\u003c/p\u003e\n\u003cp\u003eAME: state medical aid\u003c/p\u003e\n\u003cp\u003eBLV: bulevirtide\u003c/p\u003e\n\u003cp\u003eC2S:\u0026nbsp;supplementary health insurance\u003c/p\u003e\n\u003cp\u003eCeGIDD: free information, screening and diagnosis centers for human immunodeficiency virus, viral hepatitis and sexually transmitted infections\u003c/p\u003e\n\u003cp\u003eCMUc:\u0026nbsp;complementary universal medical coverage\u003c/p\u003e\n\u003cp\u003eDCIR: inter-regime consumption database\u003c/p\u003e\n\u003cp\u003eIDF: Ile de France\u003c/p\u003e\n\u003cp\u003eHBV: hepatitis B virus\u003c/p\u003e\n\u003cp\u003eHCC:\u0026nbsp;hepatocellular carcinoma\u003c/p\u003e\n\u003cp\u003eHCV: hepatitis C virus\u003c/p\u003e\n\u003cp\u003eHDV: hepatitis Delta virus\u003c/p\u003e\n\u003cp\u003eHIV: human immunodeficiency virus\u003c/p\u003e\n\u003cp\u003eIFN: interferon\u003c/p\u003e\n\u003cp\u003eMCO: medicine, surgery and obstetrics\u003c/p\u003e\n\u003cp\u003eNABM: nomenclature of medical biology acts\u003c/p\u003e\n\u003cp\u003eNIR: social security registration number\u003c/p\u003e\n\u003cp\u003eNUC: nucleoside analogues treatments\u003c/p\u003e\n\u003cp\u003ePACA: Provence Alpes C\u0026ocirc;te d\u0026rsquo;Azur\u003c/p\u003e\n\u003cp\u003ePMSI: Program for the Medicalization of Information Systems\u003c/p\u003e\n\u003cp\u003eRNA: ribonucleic acid\u003c/p\u003e\n\u003cp\u003eRT: reflex testing\u003c/p\u003e\n\u003cp\u003eSNDS: French national health data system\u003c/p\u003e\n\u003cp\u003eWHO: world health organization\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Limoges University Hospital has permanent access to the SNDS according to the decree of the Official Journal No. 0150 of June 30, 2021. Access and use of these data is performed in compliance with the SNDS security framework, and the personnel concerned have receiveed mandatory training and have been authorized to extract SNDS data. This project was evaluated and approved by the Limoges University Hospital and then registered in the Health Data Hub directory (No. F20231116101028).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to French law, sharing individual data from an SNDS data extraction is forbidden. However, any researcher from a European entity can submit a file to the Health Data Hub to have access to the same SNDS data extraction.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWinning project of the international Gilead call for tender Delta Describe.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eVLR contributed to the design and supervision of the study. SF and CR performed the analyses. VLR, SF,CR and PC discussed the results and wrote the manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Mrs Magalie LEMAITRE (epidemiologist, HORIANA) for her invaluable advice. We thank Mrs Marie BOSSELUT and Mrs Sarah DEMAY for proofreading the manuscript.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal HIV, Hepatitis and STIs Programmes (HHS),, Health Product Policy and Standards (HPS). Global hepatitis report 2024: action for access in low- and middle-income countries [Internet]. World Health Organization. 2024. Available from: https://www.who.int/publications/i/item/9789240091672\u003c/li\u003e\n\u003cli\u003eStockdale AJ, Kreuels B, Henrion MYR, Giorgi E, Kyomuhangi I, de Martel C, et al. The global prevalence of hepatitis D virus infection: Systematic review and meta-analysis. J Hepatol 2020;73:523‑32.\u003c/li\u003e\n\u003cli\u003eGordien E. // THE HEPATITIS DELTA VIRUS INFECTION: RECENT DATA IN FRANCE. Bulletin Epidemiologique Hebdomadaire 2015;19‑20:347‑52.\u003c/li\u003e\n\u003cli\u003eBrouard C, Schwager M, Expert A, Drewniak N, Laporal S, De Lagasnerie G, et al. Impact of Public Policy and COVID-19 Pandemic on Hepatitis C Testing and Treatment in France, 2014\u0026ndash;2021. Viruses 2024;16:792.\u003c/li\u003e\n\u003cli\u003eBrouard C, Laporal S, Cazein F, Saboni L, Bruyand M, Lot F. D\u0026Eacute;PISTAGE DES H\u0026Eacute;PATITES B ET C EN 2021 EN FRANCE, ENQU\u0026Ecirc;TE LABOHEP / HEPATITIS B AND C TESTING IN 2021 IN FRANCE, LABOHEP SURVEY. Bulletin Epidemiologique Hebdomadaire 2023;15‑16:276‑86.\u003c/li\u003e\n\u003cli\u003eTamandjou C. D\u0026eacute;pistage et diagnostic des h\u0026eacute;patites B et C en CeGIDD en 2022, surveillance SurCeGIDD / Screening and diagnosis of hepatitis B and C in French STI clinics (CeGIDD) in 2022, SurCeGIDD surveillance.\u003c/li\u003e\n\u003cli\u003eYan H, Zhong G, Xu G, He W, Jing Z, Gao Z, et al. Sodium taurocholate cotransporting polypeptide is a functional receptor for human hepatitis B and D virus. Elife 2012;1:e00049.\u003c/li\u003e\n\u003cli\u003eRoulot D, Brichler S, Layese R, BenAbdesselam Z, Zoulim F, Thibault V, et al. Origin, HDV genotype and persistent viremia determine outcome and treatment response in patients with chronic hepatitis delta. J Hepatol 2020;73:1046‑62.\u003c/li\u003e\n\u003cli\u003eServant-Delmas A, Le Gal F, Gallian P, Gordien E, Laperche S. Increasing prevalence of HDV/HBV infection over 15 years in France. J Clin Virol 2014;59:126‑8.\u003c/li\u003e\n\u003cli\u003eChevaliez S, Roudot-Thoraval F, Brouard C, Gordien E, Zoulim F, Brichler S, et al. Clinical and virological features of chronic hepatitis B in the French national surveillance program, 2008-2012: A cross-sectional study. JHEP Rep 2022;4:100593.\u003c/li\u003e\n\u003cli\u003eEASL Clinical Practice Guidelines on hepatitis delta virus. J Hepatol 2023;79:433‑60.\u003c/li\u003e\n\u003cli\u003eHAS. Haute Autorit\u0026eacute; de sant\u0026eacute;. Prise en charge des personnes infect\u0026eacute;es par les virus de l\u0026rsquo;h\u0026eacute;patite B, C ou D. [Internet]. 2024;Available from: https://www.has-sante.fr/jcms/p_3324682/fr/prise-en-charge-des-personnes-infectees-par-les-virus-de-l-hepatite-b-c-ou-d#toc_1_4_1\u003c/li\u003e\n\u003cli\u003eWedemeyer H, Aleman S, Brunetto MR, Blank A, Andreone P, Bogomolov P, et al. A Phase 3, Randomized Trial of Bulevirtide in Chronic Hepatitis D. N Engl J Med 2023;389:22‑32.\u003c/li\u003e\n\u003cli\u003eTuppin P, Rudant J, Constantinou P, Gastaldi-M\u0026eacute;nager C, Rachas A, de Roquefeuil L, et al. Value of a national administrative database to guide public decisions: From the syst\u0026egrave;me national d\u0026rsquo;information interr\u0026eacute;gimes de l\u0026rsquo;Assurance Maladie (SNIIRAM) to the syst\u0026egrave;me national des donn\u0026eacute;es de sant\u0026eacute; (SNDS) in France. Rev Epidemiol Sante Publique 2017;65 Suppl 4:S149‑67.\u003c/li\u003e\n\u003cli\u003ePioche C, L\u0026eacute;on L, Larsen C, Lot F, Pillonel J, Brouard C. // HEPATITIS B AND C SCREENING IN FRANCE IN 2013, LABOHEP STUDY. :7.\u003c/li\u003e\n\u003cli\u003eEnqu\u0026ecirc;te nationale p\u0026eacute;rinatale Rapport 2016 [Internet]. 2017;Available from: https://enp.inserm.fr/wp-content/uploads/2020/05/ENP2016_Rapport.pdf\u003c/li\u003e\n\u003cli\u003eRamos-Rincon JM, Pinargote H, Ramos-Belinch\u0026oacute;n C, de Mendoza C, Aguilera A, Soriano V. Hepatitis delta in patients hospitalized in Spain (1997-2018). AIDS 2021;35:2311‑8.\u003c/li\u003e\n\u003cli\u003eDegasperi E, Anolli MP, Jachs M, Reiberger T, De Ledinghen V, Metivier S, et al. Real-world effectiveness and safety of bulevirtide monotherapy for up to 96 weeks in patients with HDV-related cirrhosis. J Hepatol 2025;S0168-8278(25)00001-7.\u003c/li\u003e\n\u003cli\u003eTamandjou C, Laporal S, Lot F, Brouard C. DONN\u0026Eacute;ES \u0026Eacute;PID\u0026Eacute;MIOLOGIQUES R\u0026Eacute;CENTES SUR LES H\u0026Eacute;PATITES C, B ET DELTA / UPDATED EPIDEMIOLOGICAL DATA ON HEPATITIS C, B AND DELTA. Bulletin Epidemiologique Hebdomadaire 2023;15‑16:311‑7.\u003c/li\u003e\n\u003cli\u003eDebette-Gratien M, Fran\u0026ccedil;ois S, Chevalier C, Alain S, Carrier P, Rigaud C, et al. Towards hepatitis C elimination in France: Scanvir, an effective model to test and treat drug users on dedicated days. J Viral Hepat 2023;30:355‑61.\u003c/li\u003e\n\u003cli\u003eRazavi HA, Buti M, Terrault NA, Zeuzem S, Yurdaydin C, Tanaka J, et al. Hepatitis D double reflex testing of all hepatitis B carriers in low-HBV- and high-HBV/HDV-prevalence countries. J Hepatol 2023;79:576‑80.\u003c/li\u003e\n\u003cli\u003eCossiga V, Brusa S, Montalti R, De Conte A, Jannuzzi G, Ranieri L, et al. Anti-HDV reflex testing in HBsAg-positive subjects: An efficacious strategy to identify HDV infection. Liver Int 2024;44:148‑54.\u003c/li\u003e\n\u003cli\u003eHilleret MN, Flacher E, Germi R, Lupo J, Larrat S. Reflex testing automatization for HBsAg carriers: A novel era for hepatitis delta management. JHEP Rep 2024;6:100813.\u003c/li\u003e\n\u003cli\u003ePalom A, Rando-Segura A, Vico J, Pac\u0026iacute;n B, Vargas E, Barreira-D\u0026iacute;az A, et al. Implementation of anti-HDV reflex testing among HBsAg-positive individuals increases testing for hepatitis D. JHEP Rep 2022;4:100547.\u003c/li\u003e\n\u003cli\u003eButi M, Dom\u0026iacute;nguez-Hern\u0026aacute;ndez R, Palom A, Esteban R, Casado M\u0026Aacute;. Impact of hepatitis D reflex testing on the future disease burden: A modelling analysis. Liver Int 2023;43:2611‑4.\u003c/li\u003e\n\u003cli\u003eAbbas Z, Abbas M. Is there a need for universal double reflex testing of HBsAg-positive individuals for hepatitis D infection? World J Hepatol 2024;16:300‑3.\u003c/li\u003e\n\u003cli\u003eMart\u0026iacute;nez-Campreci\u0026oacute;s J, Rando-Segura A, Buti M, Rodrigo-Vel\u0026aacute;squez F, Riveiro-Barciela M, Barreira-D\u0026iacute;az A, et al. Reflex viral load testing in dried blood spots generated by plasma separation card allows the screening and diagnosis of chronic viral hepatitis. J Virol Methods 2021;289:114039.\u003c/li\u003e\n\u003cli\u003eDelagarde V, Gerber A, Dziri S, Roulot D, Gordien E, Le Gal F, et al. IMPROVING ACCESS TO HDV TESTING USING DRY BLOOD SPOTS. 1230C [Internet]. 2023;Available from: https://www.aasld.org/sites/default/files/2023-10/the_liver_meeting_boston_massachusetts_nov1_0.pdf\u003c/li\u003e\n\u003cli\u003ePioche C, L\u0026eacute;on L, Vaux S, Brouard C, Lot F. D\u0026Eacute;PISTAGE DES H\u0026Eacute;PATITES B ET C EN FRANCE EN 2016, NOUVELLE \u0026Eacute;DITION DE L\u0026rsquo;ENQU\u0026Ecirc;TE LABOHEP / HEPATITIS B AND C SCREENING IN FRANCE IN 2016. THE NEW EDITION OF THE LABOHEP STUDY. 2018;188‑95.\u003c/li\u003e\n\u003cli\u003eJournal Officiel. D\u0026eacute;cret n\u0026deg; 2023-700 du 31 juillet 2023 relatif \u0026agrave; la transmission obligatoire de donn\u0026eacute;es individuelles \u0026agrave; l\u0026rsquo;autorit\u0026eacute; sanitaire et \u0026agrave; la cr\u0026eacute;ation du traitement de donn\u0026eacute;es \u0026agrave; caract\u0026egrave;re personnel \u0026laquo; LABO\u0026eacute;-SI \u0026raquo; [Internet]. 2023. Available from: https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000047911698\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Screening, Hepatitis B, Hepatitis C, Delta hepatitis, French National Health Data System","lastPublishedDoi":"10.21203/rs.3.rs-5662958/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5662958/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAccording to the latest World Health Organization report, the incidence and mortality rates of viral hepatitis, including hepatitis delta infection, have increased in recent years. The simultaneous screening of these viruses and HIV remains important for containing their spread or eliminating them. Many treatments are now available that can either cure or limit the complications of these infections. Delta infection, which affects 5% of hepatitis B (HBV)-positive patients, is largely underestimated, whereas the prevalence of delta cirrhosis and hepatocellular carcinoma (HCC) is 3 to 5 times greater than that of HBV monoinfection. The real-life prevalence of hepatitis delta virus (HDV) in metropolitan France has rarely been studied.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study aimed to determine the number of HCV, HIV, HBV and HDV screening tests performed from 2016\u0026ndash;2022 based on data from the French National Health Data System. We compared the results of HDV Ab tests with the number of expected HDV Ab tests, which was calculated based on the estimate of positive HBV screening in France (0.7%).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFrom 2016\u0026ndash;2022, 28,314,766 anti-HCV Ab tests, 29,463,042 anti-HIV Ab tests, 28,898,177 HBs Ag tests, 162,055 anti-HDV Ab tests and 21,963 HDV RNA tests were performed. We observed an increase of 39%, 30%, 45%, 130% and 206% respectively, during this period. Fifty-five percent of the expected anti-HDV Ab tests were carried out in 2016, 69% were carried out in 2020, and 94.7% were carried out in 2022. However, with respect to two specific populations in 2022, only 0.26% of pregnant women and 26% of patients monitored for chronic HBV infection underwent an anti-HDV Ab test. The patients screened for HBs Ag, anti-HCV Ab, anti-HIV Ab and anti-HDV Ab were mainly in the \u003cem\u003eIle de France\u003c/em\u003e and \u003cem\u003eProvence-Alpes-C\u0026ocirc;te d\u0026rsquo;Azur\u003c/em\u003e regions. A total of 41.7% of the patients tested for anti-HDV Ab and 51.8% of the patients tested for HDV RNA had a precarious profile. HDV screening test prescribers were hospital-based, and HBV, HCV and HIV test prescribers worked mainly in the private sector.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn total, HDV screening increased 2.3-fold from 2016 to 2022 but remained insufficient in some populations.\u003c/p\u003e","manuscriptTitle":"Screening for hepatitis B, C and D in metropolitan France from 2016 to 2022: A map based on the National Health Data System with a focus on HDV screening","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-28 05:40:45","doi":"10.21203/rs.3.rs-5662958/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-23T17:27:39+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"8469282432029983699714005458764684078","date":"2025-05-22T09:01:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294787419004083373686964201139085801503","date":"2025-05-22T07:10:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-21T18:32:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"3168675655437058350597536520254175874","date":"2025-05-09T09:01:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"278052102342678966691649155932828070351","date":"2025-05-09T08:13:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"225197143514147035904188633074905816555","date":"2025-04-28T06:24:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-21T22:42:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-21T22:33:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-04-18T12:24:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd8ecdeb-7165-4cd3-8116-f19f67f18872","owner":[],"postedDate":"April 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:05:07+00:00","versionOfRecord":{"articleIdentity":"rs-5662958","link":"https://doi.org/10.1186/s12889-025-24083-3","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-09-30 15:58:17","publishedOnDateReadable":"September 30th, 2025"},"versionCreatedAt":"2025-04-28 05:40:45","video":"","vorDoi":"10.1186/s12889-025-24083-3","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24083-3","workflowStages":[]},"version":"v1","identity":"rs-5662958","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5662958","identity":"rs-5662958","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}