Statut vaccinal des médecins généralistes dans le département de la Loire,France

Objectives

We surveyed the vaccination status of family physicians (FP) in the Loire district (France) in 2010.

Subjects and methods

A self-administered questionnaire was proposed to a panel of 460 FP; 288 (64%) answered.

Results

The vaccination coverage for Diphtheria-Tetanus-Polio in the previous 10 years, BCG, pertussis, seasonal influenza, A/H1N1 2009 influenza, and hepatitis B was 81, 74, 59, 73, 65, and 87% respectively. Sixty-four percent of FP reported they were vaccinated against measles and 49% against chicken pox; 76% were aware of vaccination recommendations for healthcare professionals but 41% wanted more information on the subject. The younger physicians were better vaccinated for Diphtheria-Tetanus-Polio, measles, hepatitis B, and influenza according to a multivariate analysis.

Conclusions

The vaccinations of FP (knowledge, practice) must be improved, especially by yearly updates, continuous medical education, and medical follow-up of healthcare professionals.     

A critical analysis of physical activity recommendations in Spain

Objective

To identify official documents with recommendations on physical activity published by the autonomous regions of Spain with the goal of evaluating their compliance with the physical activity recommendations of the World Health Organization (WHO).

Methods

We conducted a content analysis of 55 documents of the ministries of health of several regional governments containing recommendations on physical activity.

Results

Eighty-four percent of the autonomous regions in Spain made recommendations on aerobic physical activity and 37% made recommendations on strength training. However, the number of documents consistent with the WHO criteria was as follows: aerobic activity (n = 11, 58%), adults (n = 10, 53%), the elderly (n = 5, 26%), children/adolescents (n = 1, 5%); strength training, adults (n = 6, 32%), the elderly (n = 3, 16%), children/adolescents (n = 1, 5%); balance (n = 5, 26%); at least 10 minutes continuous physical activity (n = 6, 32%); recommendation of up to 300 minutes per week (n = 10, 53%); intensity of physical activity (n = 2, 11%).

Conclusions

The recommendations of the autonomous regions tend to focus on aerobic physical activity and to under-represent strength training. Moreover, only one autonomous region conforms to the WHO recommendations for physical activity. The regions with higher rates of population aging and a higher percentage of children and adolescents fail to make recommendations on physical activity consistent with the WHO guidelines.     

Integrating family planning and prevention of mother to child HIV transmission in Zimbabwe

Objective

The objective was to integrate enhanced family planning (FP) and prevention of mother-to-child HIV transmission services in order to help HIV-positive Zimbabwean women achieve their desired family size and spacing as well as to maximize maternal and child health.

Study Design

HIV-positive pregnant women were enrolled into a standard-of-care (SOC, n= 33) or intervention (n= 65) cohort, based on study entry date, and followed for 3 months postpartum. The intervention cohort received education sessions aimed at increasing FP use and negotiation power. Both groups received care from nurses with enhanced FP training. Outcomes included FP use, FP knowledge and HIV disclosure, and were assessed with Fisher’s Exact Tests, binomial tests and t tests.

Results

The intervention cohort reported increased control over condom use (p=.002), increased knowledge about IUDs (p=.002), increased relationship power (p=.01) and increased likelihood of disclosing their HIV status to a partner (p=.04) and having that partner disclose to them (p=.04) when compared to the SOC cohort. Long-acting reversible contraception (LARC) use in both groups increased from ~ 2% at baseline to > 80% at 3 months postpartum (p<.001).

Conclusions

FP and sexual negotiation skills and knowledge, as well as HIV disclosure, increased significantly in the intervention cohort. LARC uptake increased significantly in both the intervention and SOC cohorts, likely because both groups received care from nurses with enhanced FP training. Successful service integration models are needed to maximize health outcomes in resource-constrained environments; this intervention is such a model that should be replicable in other settings in sub-Saharan Africa and beyond.

Implications

This study provides a rigorously evaluated intervention to integrate FP education into ante- and postnatal care for HIV-positive women and also to train providers on FP. Results suggest that this intervention had significant effects on contraception use and communication with sexual partners. This intervention should be adaptable to other areas.     

Does obstetrician knowledge regarding influenza increase HINI vaccine acceptance among their pregnant patients?

Objectives

Although numerous studies have demonstrated the safety and benefits of influenza vaccination in pregnancy, vaccination rates of pregnant women have remained low. The objective of this study is to evaluate whether physicians’ level of knowledge regarding H1N1 influenza in pregnancy is associated with vaccination frequency among their patients.

Methods

Between October 2009 and May 2010, all obstetricians (attending and resident physicians) at an urban tertiary care hospital were asked to complete a test that assessed knowledge of influenza. During this same time period, the vaccination status of all inpatient parturients was recorded. Associations between physician characteristics, physician test scores, and patient vaccination rates were assessed.

Results

110 providers (85% of those eligible) belonging to 16 practices completed the knowledge assessment. The mean (±SD) test score was 72% (±11%). Provider test scores were not associated with whether the provider was a trainee, the number of years since completion of training, or provider age. Test scores were not correlated with the number of providers or number of deliveries per month in a given practice. Mean scores were significantly higher (75% vs 68%, p = 004) among those who attended a hospital-sponsored educational forum on H1N1, and were positively and significantly associated with the percentage of patients cared for by that group who were vaccinated against H1N1 influenza (r = .50, p = .045).

Conclusion

Increased physician knowledge regarding H1N1 influenza, represented as higher test scores on a knowledge assessment test, was significantly associated with the frequency of H1N1 vaccination among their patients.     

Barriers to D&E practice among family planning subspecialists

Objective

Over 95% of all second-trimester abortions are managed by dilation and evacuation procedures (D&E) and account for nearly 9% of all abortions in the United States annually. The Fellowship in Family Planning (FFP) offers subspecialty training in abortion and contraception to obstetrician–gynecologists and family medicine physicians. Twenty years after the FFP founding, we report on the abortion practice characteristics and specific barriers these subspecialists face.

Study Design

We surveyed obstetrician–gynecologist family planning (FP) subspecialists by email regarding second-trimester abortion training and practice barriers with a focus on D&E.

Results

Our response rate was 62% (105/169) of all fellowship-affiliated physicians. Respondents were composed primarily of young women working in academic settings in the West and Northeast regions. Nearly all FP subspecialists have been trained to 24 weeks’ gestation and currently provide D&Es, with an average of nearly 200 per year. D&E practice barriers vary by geographical location and degree of “regional restrictiveness.” FP subspecialists practicing in more abortion-restrictive regions were four times more likely to report a personal main barrier (such as concern for safety) than other types of main barriers (p=.05). Providing D&Es in a hospital operating room was associated with 2.8 times higher odds of reporting an institutional or coworker main barrier (p=.02). High-volume D&E practice was associated with three times lower odds of reporting an institutional/coworker main barrier (p=.02).

Conclusions

By identifying the barriers to D&E practice experienced by FP subspecialists, we can begin to develop a coordinated approach to eradicating modifiable barriers and, ultimately, improve access for women seeking D&E services.     

Impact of early chest radiography and empirical antibiotherapy on delay in the diagnosis of pulmonary tuberculosis

Objective

The treatment of community-acquired pneumonia relies on empirical antibacterial treatment, guided by chest X-ray. We evaluated the impact of this practice on delay in the diagnosis of pulmonary tuberculosis.

Patients and methods

We performed a retrospective monocentric study on 64 documented cases of pulmonary tuberculosis.

Results

Empirical antibacterial treatment was prescribed between the first symptoms and pulmonary tuberculosis diagnosis in 42.2% of cases. The median delay between first contact with a healthcare provider and pulmonary tuberculosis treatment initiation (medical delay) was 13.5 days. The factors associated with medical delay above 30 days were alcohol abuse (OR 7.62; P = 0.02), and late chest X-ray (OR 9.33; P = 0.01). Empirical antibacterial treatment was more frequent in case of late chest X-ray (P = 0.02) and increased the risk of medical delay above 7 days (OR 6.3; P = 0.05).

Conclusion

When lower respiratory tract infection is suspected, early chest X-ray reduces the empirical use of antibacterial agents and decreases delay in the diagnosis of pulmonary tuberculosis.     

Hand hygiene in medical students: performance, education and knowledge

Background

Despite several guidelines on hand hygiene (HH), compliance especially in physicians is reported to be low which has huge implications for healthcare-associated infections. To evaluate performance of HH, influence of teaching and influence of monitoring the results in medical students, we conducted an observational study.

Methods

Performance of hand disinfection was evaluated in first (N = 28), third (N = 193) and fifth (N = 45) year medical students using fluorescent hand disinfectant. The influence of teaching and information about result control was assessed. The students perception of the impact of HH was also evaluated by a questionnaire.

Results

Presence of disinfectant gaps was observed significantly more often in first year medical students compared to third year ones (82% vs, 60%; p = 0.02). In additional, > 3 gaps were seen significantly more often in first year medical students compared to fifth year students (36% vs. 9%; p = 0.007). Both information about teaching and monitoring the results improved outcome significantly. For example, gaps were present in 92% without information and without teaching, in 70% (RR: 1.3 (1.0–1.6); p = 0.003) with information about result control only, and in only 18% (5.1 (3.0–8.5); p = 0.0001) after teaching. Notably, the medical students ascribed HH to be of a great importance regardless of their level of education.

Conclusions

Performance of HH could be improved by practical training as evidenced by best HH performance being documented immediately after teaching and a training effect during the course of medical studies was also observed. Thus, we suggest implementing regular education and practical training on HH from early on in the medical studies curricula to improve overall quality of patient care. regular education and practical training on HH from early on in the medical studies curricula to improve overall quality of patient care.     

Postplacental intrauterine device insertion at a teaching hospital

Objective

To determine whether postplacental intrauterine device (IUD) insertion can be safely and effectively performed within a teaching program.

Study Design

This was a prospective cohort of 177 subjects planning vaginal delivery enrolled antenatally who desired postplacental IUD insertion of either the copper T380A IUD or levonorgestrel IUS. Insertions were performed primarily by resident physicians following a training session. Follow-up included a 4- to 8-week visit and telephone calls at 3 and 6 months.

Results

Ninety-nine subjects underwent successful postplacental IUD insertion of 100 attempts. Seventeen expulsions (17%) were noted: 10 complete and 7 partial. The study identified no differences in outcome by training level; however, the study lacked statistical power to evaluate anything other than large differences.

Conclusion

Postplacental IUD insertions can be safely and effectively performed within a training program.

Implications

A training protocol may safely and feasibly be initiated among physicians, advanced practice clinicians or trainees with no prior experience with postplacental IUD insertion. By initiating this practice, access to highly effective contraception may increase for patients who have difficulty returning for a visit or otherwise receiving effective methods.     

Human papillomavirus vaccination and sexual behaviour: cross-sectional and longitudinal surveys conducted in England

Objective

To examine whether HPV vaccination influences sexual behaviour in adolescent girls, either by giving them a ‘green light’ to have sex, or because perceived protection afforded by the vaccine permits compensatory risky sexual behaviour.

Design

Cross-sectional and longitudinal surveys.

Setting

Seven English schools.

Main outcome measures

Self-reported sexual behaviour.

Participants

The cross-sectional survey included 1053 girls (mean age 17.1 years) who had (n = 433 recruited in March 2010) or had not (n = 620 recruited in March 2009) been offered the HPV vaccine. The longitudinal survey included 407 girls (mean age 17.5 years) who had been offered HPV vaccination and had either received at least one dose (n = 148) or had not received any doses (n = 259).

Results

In the cross-sectional survey, the group of girls who had been offered the HPV vaccine were no more likely to be sexually active than the group of girls who had not been offered the HPV vaccine. In the longitudinal survey, the vaccinated group were no more likely to have changed their condom use or increased their total number of sexual partners than the unvaccinated group.

Conclusions

Neither being offered the HPV vaccine nor receiving it affected sexual behaviour.     

Hepatitis B vaccination coverage and uptake in prisons across England and Wales 2003-2010: a retrospective ecological study

Objective

To describe the custodial hepatitis B vaccination programme performance and examine these data by geographical region and prison category.

Design

Retrospective ecological study.

Data source

Health Protection Agency (HPA) published data.

Setting

Custodial primary healthcare providers located in prisons across England and Wales.

Participants

147 prisons which reported vaccination data between July 2003 and April 2010 to the HPA Prison Infection Prevention team.

Main outcome measures

Hepatitis B vaccination coverage (July 2003 to April 2010) and uptake (December 2007 to April 2010).

Results

Median hepatitis B vaccination coverage was 22% (interquartile range [IQR] 5–49%) and uptake was 36% (IQR 16–59%). Vaccination coverage varied significantly between July 2003 and November 2007 compared to December 2007 and April 2010 (median 12% [IQR 2–31%] versus median 48% [IQR 26–67%], Mann–Whitney W = 14,689,158.0, p < 0.001). There was significant variation between vaccination coverage (Kruskal–Wallis H = 613.44, DF = 9, p < 0.001) and uptake (Kruskal–Wallis H = 247.99, DF = 9, p < 0.001) across the HPA regions. Compared to England and Wales, estimated population median vaccination coverage was significantly (p ≤ 0.05) lower in three regions and one prison category and higher in four regions and seven prison categories; estimated population median vaccination uptake was significantly lower in three regions and three prison categories and higher in two regions and four prison categories.

Conclusion

Prisoners are a vulnerable group with a high prevalence of hepatitis B infection and the custodial setting plays an important role in the delivery of hepatitis B vaccination to this hard to reach group. This study suggests that variation in hepatitis B vaccination coverage and uptake may exist by geographical region and prison category. Further research is required to confirm and identify possible explanations for our findings.     

Efficacy of ceftriaxone and doxycycline in the treatment of early syphilis

Introduction

An increase of syphilis cases has been recorded in the past few decades, especially among HIV-infected patients. These patients often present with concomitant primary and secondary lesions or extensive presentations of syphilis.

Objective

Our goal was to compare alternative regimens to the recommended penicillin treatment.

Method

We retrospectively studied 116 patient files (80% HIV1-infected) treated for a first episode of early syphilis.

Results

Patients mainly presented with symptoms of secondary syphilis. In 15.5% of the cases patients were asymptomatic and 17.2% of patients with secondary syphilis presented with neurologic or ophthalmic symptoms. Some less usual clinical presentations included diffuse polyadenopathy or isolated fever. The time to serological response was similar among those treated with benzathine-penicillin (n = 52), ceftriaxone (n = 49), or doxycycline (n = 15).

Conclusion

Ceftriaxone and doxycycline could be suitable alternatives to penicillin in the treatment of early syphilis in HIV-infected patients. These two treatments have a concomitant effectiveness even for asymptomatic forms of neurosyphilis.     

Parents' Internet use for information about HPV vaccine

Purpose

The Internet is an increasingly common source of health-related information. We sought to examine associations between parents’ Internet information-seeking and their knowledge, attitudes and beliefs about human papillomavirus (HPV) vaccine.

Methods

We interviewed parents within a year after approval of HPV vaccine for females and males. Participants were North Carolina parents with daughters ages 10–18 surveyed by telephone in Fall 2007 (n = 773); and a national sample of parents with sons ages 11–17 surveyed online in Fall 2010 (n = 115). We used multivariate regression to examine associations of past and intended Internet seeking for HPV vaccine information with knowledge and health belief model-related constructs.

Results

Among parents of daughters, having heard of HPV vaccine through the Internet (8%) was associated with higher HPV knowledge, perceived likelihood of HPV, and vaccination willingness, and with receiving a doctor's recommendation. It was also associated with lower perceived vaccine harms, uncertainty, and anticipated regret. Parents of sons who heard of HPV vaccine through the Internet (10%) perceived greater barriers to vaccination than parents who learned about HPV vaccine for males through other sources. Intended future Internet information-seeking among parents of daughters (69%) was more likely if they perceived a lower likelihood that their daughters would get HPV if they were vaccinated (all p < .05).

Conclusions

Our findings suggest a positive influence of accessing information on the Internet about HPV vaccine. It was associated with higher knowledge and mostly positive parental attitudes and beliefs.     

Health-related quality of life in the Anthrax Vaccination Program for workers in the Laboratory Response Network

Background

In 2002 CDC initiated the Anthrax Vaccination Program (AVP) to provide voluntary pre-exposure vaccination with Anthrax Vaccine Adsorbed (AVA) for persons at high risk of exposure to Bacillus anthracis spores. There has been concern that AVA could be associated with long term impairment of physical and/or mental health.

Objectives

To ascertain whether physical and mental functional status, as measured by the SF-36v2 health survey (Medical Outcomes Trust, Boston, MA), of AVA recipients and controls changed differently over time.

Methods

We enrolled 437 exposed (received AVA) and 139 control subjects. The exposed group received AVA under then-current Advisory Committee on Immunization Practices (ACIP) recommendations. SF-36v2 surveys were completed at 0, 12, and 30 months. SF-36v2 physical and mental scores both range from 0 to 100 with an estimated national average of 50 points.

Results

For physical scores, the average change from baseline was −0.53 for exposed vs. −0.67 for controls at 12 months (p = 0.80) and −1.09 for exposed vs. −1.97 for controls at 30 months (p = 0.23). For mental scores, the average change from baseline was −1.50 for exposed vs. −1.64 for controls at 12 months (p = 0.86) and −2.11 for exposed vs. −0.24 for controls at 30 months (p = 0.06). In multivariable analysis, the difference in mental score change between exposed vs. controls at 30 months was less pronounced (p = 0.37) but other findings were similar to univariate analyses.

Conclusions

These results do not favor an association between receipt of AVA and an altered health related quality of life over a 30-month period.     

Measurement of unmet need for family planning: longitudinal analysis of the impact of fertility desires on subsequent childbearing behaviors among urban women from Uttar Pradesh,India

Background

The measure of unmet need relies on women's reported fertility desires; previous research has demonstrated that fertility desires may be fluid and not firm.

Study Design

Our study uses recently collected longitudinal data from four cities in Uttar Pradesh, India, to examine whether women's fertility desires and family planning (FP) use at baseline predict pregnancy/birth experience in the 2-year follow-up period.

Results

Multivariate models demonstrate that women who were using any method of FP and reported an intention to stop childbearing were the least likely to experience a pregnancy/birth in the 2-year follow-up period. The stated desire to delay childbearing, whether or not the woman was using FP, did not distinguish pregnancy/birth experience. Ninety-two percent of pregnancies/births over the follow-up period were considered “wanted then” suggesting post-hoc rationalization of the pregnancy/birth even among those women who reported a desire to stop childbearing 2 years earlier.

Conclusions

More nuanced assessments of fertility intentions may be needed to adequately gauge latent FP needs. Non-users of FP may be ambivalent about future childbearing and the timing of future births; these women may not have an unmet need for FP as typically defined.     

Effect of needle length for response to hepatitis B vaccine in macrosomic neonates: a prospective randomized study

Objectives

The objective of this study was to determine whether use of a longer (1 in.) rather than a standard (5/8 in.) needle used for macrosomic neonates (birthweight over 4000 g) may affect antibody titers after immunization against hepatitis B virus (HBV).

Methods

Fifty nine healthy infants were vaccinated at birth, 1, and 6 months of age with hepatitis B vaccine, with follow up to 7 months of age. Infants were randomized into two groups according to needle length of first vaccine at birth. First group vaccinated with standart needle length and other group received vaccine by longer needle length.

Results

Macrosomic infants who were immunized with a longer needle achieved significantly higher antibody titers to hepatitis B surface antigen than standart needle length (median, 3890.2 vs 1311.7 mIU/mL, respectively; p = 0.001).

Conclusions

Macrosomic neonates benefit from longer needle length with higher levels of antibody titers after HBV vaccination.     

The missing link: Family physician perspectives on barriers and enablers to prescribing a new Meningococcal B vaccine and other recommended,non-government funded vaccines

Objectives

To determine factors influencing Family Physician (FP) uptake of non government-funded vaccines, and to explore FP attitudes towards the introduction and use of a new vaccine to protect against serogroup B meningococcal disease to inform its future introduction into the Australian Immunisation Schedule.

Design setting and participants

Quantitative, self-administered state-wide questionnaire mailed to all FPs in South Australia (n = 1786). Results from 523 FP respondents in South Australia, collected between June and October 2013.

Main outcome measures

Self-reported immunisation counselling practices; and knowledge, attitudes and barriers to prescribing of Meningococcal B (Men B) vaccine and other recommended, non-funded immunisations.

Results

The response rate was 30% (n = 523). While most (59%) respondents had worked in general practice for over 20 years, only 39% of all respondents had ever had personal or professional experience with a case of invasive meningococcal disease (IMD). Most FPs (63%) were aware that a meningococcal B vaccine was being developed, and 93% of respondents agreed that this vaccine should be government-funded. FPs ranked Men B vaccine as the highest priority to receive funding of eight currently non-funded immunisation strategies. High vaccine cost and low patient socioeconomic status were identified as definite barriers to prescribing non-funded vaccines by 59% of respondents. Past IMD experience significantly affected attitudes and prescribing practices.

Conclusions

IMD, while encountered rarely in clinical practice, is considered an important disease to vaccinate against by FPs. Cost and perceived low socioeconomic status of patients are substantial barriers to FPs prescribing Men B and other non-funded vaccines, and inclusion of such vaccines on the National Immunisation Program is likely to improve equity of access.     

Public health and economic impact of 13-valent pneumococcal conjugate vaccine in US adults aged ≥50 years

Background

A 13-valent pneumococcal conjugate vaccine (PCV13) was recently developed for use in older adults, and may be effective not only against invasive pneumococcal disease (IPD) but also nonbacteremic pneumococcal pneumonia. The potential public health and economic impact of PCV13 in this population is unknown.

Methods

A microsimulation model depicting risk and costs of IPD and all-cause nonbacteremic pneumonia (NBP) in US adults aged ≥50 years (n = 96.1 million), as well as expected impact of vaccination, was developed. Effectiveness of PPSV23 was based on published literature, and for all-cause NBP, was zero; effectiveness of PCV13 was based on PCV7 data in children, and for all-cause NBP, was varied across a reasonable range. Lifetime outcomes and costs were projected assuming: (1) use of PCV13 in all subjects at model entry, with and without periodic revaccination; and (2) use of PPSV23 per current ACIP recommendations.

Results

Use of PCV13 in all subjects at model entry without revaccination – in lieu of PPSV23 use per recommendations – reduced cases of IPD by 15,000 (95% CI 9000–21,000); cases of NBP by 1.2 million (0.9–1.5); total healthcare costs by $3.5 billion (1.9–5.2); and total societal costs by $7.4 billion (5.3–9.8). Use of PCV13 with revaccination every 5–10 years resulted in fewest cases of disease and lowest total costs. Findings were largely unchanged in sensitivity analyses.

Conclusions

Assuming that the effectiveness of PCV13 in adults is comparable to that observed for PCV7 in children and under reasonable assumptions regarding the underlying risks and costs of IPD and NBP, model projections suggest that routine use of PCV13 – in lieu of PPSV23 – would result in a greater reduction in the overall burden of pneumococcal disease in older US adults.     

Provider acceptability of Sayana® Press: results from community health workers and clinic-based providers in Uganda and Senegal

Background

Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uniject™, has potential to be a valuable innovation in family planning (FP) because it may overcome logistic and safety challenges in delivering intramuscular DMPA (DMPA IM). However, SP's acceptability is unknown. We measured acceptability of SP among clinic-based providers (Senegal only) and community health workers.

Study design

This open-label observational study was conducted in clinics in three districts in Senegal and community-based services in two districts in Uganda. Providers administered SP to clients seeking reinjection of DMPA IM. We conducted in-depth interviews with 86 providers (52 in Senegal, 34 in Uganda) to assess their experiences providing SP to clients.

Results

Almost all providers (84/86; 98%) preferred SP over DMPA IM. The main reason Uganda providers preferred SP was the prefilled/all-in-one design made preparation and administration easier and faster. Some providers thought the SP all-in-one feature may decrease stock outs (DMPA IM requires syringe and vial). Providers also felt clients preferred the shorter SP needle because it is less intimidating and less painful. Similarly, the main reasons Senegal providers preferred SP were its characteristics (prefilled/all-in-one) and client preference (especially less pain). They also saw a potential to increase access to FP, especially through community-based distribution. Providers from both countries reported SP introduction would be enhanced through client counseling and community engagement. Providers also said SP must be accessible, affordable and in stock.

Conclusion

Almost all providers preferred SP over DMPA IM. Provider recommendations should be considered during SP introduction planning.

Implications

We found that SP was acceptable to both clinic-based FP providers and community health workers. Providers' positive attitudes towards SP may facilitate introduction and uptake of this method.