[Relationship between precariousness, social coverage, and vaccine coverage: survey among children consulting in pediatric emergency departments in France]. / Précarité, couverture sociale et couverture vaccinale : enquête chez les enfants consultant aux urgences pédiatriques.

UNLABELLED: Poor children are more susceptible to infectious diseases. Routine medical follow-up is infrequent in these patients, sometimes resulting in immunization delays. The aim of this study was to correlate a number of socioeconomic factors related to poverty with vaccination coverage in children visiting a pediatric emergency ward. PATIENTS AND METHODS: Previous routine vaccinations and various socioeconomic features were prospectively recorded for children aged 9 months to 7 years visiting two public pediatric emergency departments in Marseilles (southern France) from 2009 to 2010. RESULTS: Three hundred and seventy-five children were included. Vaccination coverage was 87% for diphtheria, tetanus, poliomyelitis, Haemophilus influenzae type b infections and pertussis, 69% for tuberculosis (Bacillus Calmette-Guérin), 77% for measles, mumps and rubella, 74% for pneumococcal infections (conjugate vaccine), and 55% for hepatitis B. Socioeconomic factors related to poverty were significantly associated with delays in immunizations. Children not attending school (OR=2.5), having parents who were not fluent in French (OR=5.7), living in caravans or squatting (OR=11.5), or being recipients of the national medical assistance for foreigners (OR=12.8) had significant delays with diphtheria, tetanus, and poliomyelitis vaccines. The measles-mumps-rubella vaccine was also delayed in homeless children (OR=3.4). Children who were recipients of the national medical assistance for citizens were better vaccinated against tuberculosis and hepatitis B. CONCLUSION: Poor children living in southern France had significant delays in their routine immunizations, resulting in gaps in their protection. Every medical visit, even those conducted in an emergency ward, should identify children with immunization delays and offer a catch-up schedule if necessary.

[Values of clinical signs and rapid diagnostic test in the diagnosis of influenza A (H1N1) new variant in pediatric emergency department]. / Valeurs des signes cliniques et d'un test de diagnostic rapide dans le diagnostic de la grippe A (H1N1) nouveau variant aux urgences pédiatriques.

AIM OF THE STUDY: To evaluate the values of clinical signs and the rapid diagnostic test (RDT) in the diagnosis of influenza H1N1 new variant in the pediatric emergency room. METHOD: From 18 August to 1st December 2009, children admitted to the pediatric emergency department of CHU Nord (Marseille, France) and suspected of flu according to French guidelines, were tested for influenza using both an influenza RDT and a polymerase chain reaction (PCR) assay specific for H1N1. From 3 November to 3 December, clinical signs were also noted (fever, headaches, myalgia-arthralgia, shivers, diarrhea). RESULTS: A total of 1122 children were tested: 367 children (32.1%) had a positive specific PCR. The RDT value was: sensitivity 65.2% [55.8-73.6], specificity 99.5% [98.1-100], positive predictive value (PPV) 97.5% [91.8-100], negative predictive value (NPV) 91.2% [90.3-91.5], positive likelihood ratio (LRP) 153.7 [53.5-452.9] and negative likelihood ratio (LRN) 0.393 [0.387-0.411]. Clinical data were available for 504 children (328 over 2 years of age). In children more than 2 years of age and in multivariate analysis, headaches were the only sign significantly associated with a positive PCR (aOR=2.53 [1.25-5.12]). Overall, headaches and/or myalgia-arthralgia were valuable indicators for clinical diagnosis of flu, with a 75.8% NPV. Among children with a positive PCR, diarrhea was more frequent in children under 2 years of age (OR=2.76 [1.19-6.40]). The sensitivity of the RDT improved (90.9% [85.2-94.6]) when flu signs were also present. CONCLUSION: Associating clinical signs and RDT for the diagnosis of influenza A (H1N1) new variant in a pediatric emergency room improves selection of children requiring appropriate antiviral treatment.

[Bacillus Calmette-Guérin (BCG) vaccine coverage in newborns and infants at risk before and after a change in BCG policy]. / Couverture vaccinale par le BCG ciblé en maternité avant et après la suspension de l'obligation vaccinale.

AIM OF THE STUDY: To evaluate vaccine coverage in at-risk newborns during the maternity hospital stay and at the age of 3 months, before and after the change in the French national Calmette-Guérin Bacillus (BCG) vaccine policy. METHODS: A vaccine program targeting newborns at risk for tuberculosis was implemented in a university maternity hospital in Marseille, France, in 2007. At-risk newborns were mainly defined as those with 1 parent born in an endemic country for tuberculosis, those planning to travel in such a country for at least 1 month in their 1st year of life, or those with previous tuberculosis cases within the family. From February to November 2007, the French BCG policy changed (BCG was no longer mandatory, but only recommended for at-risk children). Parental acceptance of a targeted vaccine delivered during the hospital stay and BCG vaccination during the infant's first 3 months were evaluated before and after the change. RESULTS: A total of 289 newborns at risk of tuberculosis were included. BCG vaccine coverage in the maternity hospital was 72%, significantly higher when BCG was not mandatory (81% versus 66%; p<0.05). At 3 months of age, 90% of the children were BCG vaccinated. Among the infants whose parents refused an early vaccine, the BCG coverage rate at 3 months of age decreased from 78 to 41% (p<0.005) when only a targeted vaccine was recommended. CONCLUSION: Targeted vaccination of newborns at risk for tuberculosis in a maternity hospital is acceptable. When BCG was not mandatory, parental acceptance of an early-targeted vaccine increased, whereas the policy change decreased later vaccination rates within the first 3 months in children whose parents had previously refused. Early BCG vaccination of at-risk newborns in the maternity hospital may prevent a low BCG coverage rate at 3 months and subsequent tuberculosis cases in this population.

[Standpoint and practice concerning the human Papillomavirus vaccine among French family physicians]. / Opinions et pratiques des médecins généralistes face à la vaccination anti-Papillomavirus.

AIMS: The purpose of this study was to assess the standpoint of family physicians in the Southern French region Provence-Alpes-Cote d'Azur concerning human Papillomavirus vaccination and to evaluate the factors associated with a favorable standpoint. METHODOLOGY: A questionnaire was sent to a random sample of 1,000 family physicians. The survey focused on their profile, their views on vaccination generally and on HPV vaccination, their knowledge of HPV, their standpoint concerning STD prevention and cervical cancer screening. Multivariable linear regression system was used to study the variations associated with a favorable response to HPV vaccination. OUTCOME: Response was 36.6%. The responses were analyzed taking into account gender of the family physicians, location and size of their practice. There was reasonable similarity amongst those questioned. Around 89.6% of family physicians answers were in favor of HPV. The ideal age for vaccination was between 11 and 13 years of age for 34.4% and between 14 and 15 for 53.9%. The family physicians most in favor of vaccination were those involved in screening for STDs, those who did not think that the vaccine would have a negative effect on the image of sexuality and on screening for cervical cancer, and those who were confident about the vaccine safety. CONCLUSION: The study identified the negative elements concerning HPV in order to optimize information strategies among family physicians.

[Congenital tuberculosis in preterm neonate: a case report]. / Tuberculose congénitale chez le nouveau-né prématuré : à propos d'un cas.

Congenital tuberculosis is a rare but severe disease. Diagnosis is often delayed, especially in preterm neonates. We report a premature infant born after 27 weeks of gestation and in vitro fertilization. Tuberculosis was suspected after 112 days of life in view of sepsis, respiratory distress, and the discovery of maternal tuberculosis. Mycobacterium tuberculosis was isolated in endotracheal aspirates, gastric aspirates, and stools. The infant initially received four antitubercular antibiotics over 3 months, then two antibiotics over 9 months. A wide screening for a possible nosocomial transmission from this index case was set up. At the chronological age of 2 years, the baby is healthy without after-effects and no secondary cases were diagnosed. This article recalls the difficulty diagnosing congenital tuberculosis, particularly in preterm neonates. It also underlines the need to raise and eliminate the diagnosis of tuberculosis in an infertile woman.

[Treatment of visceral leishmaniasis in children]. / Le traitement de la leishmaniose viscérale infantile.

Visceral Leishmania infantum leishmaniasis is endemic in the south of France. For many years the mainstay for treatment of infected children was pentavalent antimony: meglumine antimoniate (Glucantime) or sodium stibogluconate (Pentostam). However these drugs are poorly tolerated and resistance similar to that observed in the treatment of Indian visceral Leishmania donovani leishmaniasis has been reported. Currently liposomal amphotericin B is being used instead of antimony for treatment of visceral leishmaniasis in children in France. In addition to being well tolerated, liposomal amphotericin B is almost 100% effective. It can be administered in six intravenous injections of 3-4 mg/kg each (days 1 to 5 then day 10). A two-day protocol (10 mg/kg/d) that would reduce overall cost by shortening the duration of hospitalization is now being studied. Another oral drug, i.e., miltefosine, has been successfully used for treatment of visceral leishmaniasis in India. However it has not been evaluated for treatment of Mediterranean visceral leishmaniasis.

[New blood tests for diagnosis of infection with Mycobacterium tuberculosis]. / Les nouveaux tests diagnostiques de la tuberculose.

INTRODUCTION: A major challenge in tuberculosis (TB) control is the diagnosis and the treatment of latent tuberculosis infection. STATE OF THE ART: At the time, the diagnosis is based on tuberculin skin test (TST). TST is not specific, has poor sensitivity and is not easy to perform. PERSPECTIVES: Two interferon-based tests for the diagnosis of tuberculosis have just been licensed. These tests have some advantages on TST. They require only a blood sample and their results are not dependent on the examinator. Their specificity is higher than TST because they don't cross-react with BCG vaccination and with most of the environmental Mycobacterium species. Their sensitivity is higher for the diagnosis of active tuberculosis too. For latent tuberculosis, the interferon-gamma assays show a better correlation with the exposure to Mycobacterium tuberculosis than TST. The ability to detect TB of the two tests seem to be reduced in immunocompromised patients, specially in medically ones. CONCLUSIONS: Interferon-gamma assays seems to be useful tools in TB detection, but these good results have to be confirmed in larger studies with unselected patients.

[Management of cutaneous leishmaniasis in adults and children]. / Traitement des leishmanioses cutanées de l'adulte et de l'enfant.

Cutaneous leishmaniasis can present a variety of clinical features and courses. The causative Leishmania species is an important prognostic factor in immunocompetent patients. Local treatment modalities including topical paromomycin, cryotherapy, localized controlled heat, carbon dioxide laser therapy, or intralesional meglumine antimoniate can be effective against Leishmania major or Leishmania tropica. Oral fluconazole may be a second-line treatment. Parenteral antimonials are useful for persistent or recurrent Old World leishmaniasis. For New World leishmaniasis, parenteral antimonials represent the first-line treatment in all forms except those caused by Leishmania guyanensis in which pentamidine is preferable. Liposomal amphotericin B appears to be effective for treatment of cutaneous leishmaniasis but further study will be needed. Results using oral Miltefosine are promising against Indian kala-azar (Leishmania donovani) but disappointing against South American leishmaniasis.