[Determinants of human papillomavirus vaccine amongst boys in Reunion Island: Survey of parents and general practitioners]. / Les déterminants de la vaccination anti-papillomavirus humain des garçons à La Réunion : enquête auprès des parents et des médecins généralistes.

OBJECTIVES: To describe the knowledge, barriers and acceptability factors of parents and general practitioners about HPV vaccination amongst boys in Reunion Island, in order to adapt primary prevention locally. METHODS: This was a quantitative, descriptive, cross-sectional, observational study involving 88 parents of boys aged 11 to 19 and 81 general practitioners based in Reunion Island. Both populations volunteered to answer a questionnaire available online or on paper. RESULTS: Parents' knowledge about HPV was insufficient. In Reunion Island, social media and the precarious status of parents play a particularly negative role in the vaccine intention. The number of doctors who have started HPV vaccination on boys is low despite awareness of the recommendation, particularly older doctors who practice alone, in certain sectors of the island. CONCLUSIONS: The young and precarious population of Reunion Island is particularly at risk of pathologies related to HPV and requires adapted prevention to the territory's specificities. It seems necessary to continue to inform general practitioners, in order to promote vaccination and to fight against the misinformation of media about the HPV vaccine.

[Pregnancy after intrauterine insemination following hysterosalpingo-foam-sonography or hysterosalpingography]. / Grossesse par insémination intra-utérine après hystérosalpingo-foam-sonographie ou hystérosalpingographie.

OBJECTIVE: To compare clinical pregnancy rates following intrauterine insemination performed after hysterosalpingography (HSG) or hysterosalpingo-foam-sonography (HyFoSy). MATERIAL AND METHODS: This is a retrospective study including 242 intrauterine insemination (IUI) performed between 2015 and 2020 at the fertility center of the Reunion Island. Among these inseminations, 121 with previous HSG and 121 with previous HyFoSy were matched. The main outcome of interest was clinical pregnancy rate. Secondary outcomes were birth rate and time to pregnancy after tubal patency test. RESULTS: The pregnancy rate after insemination was 9.9% for the HSG group and 11.6% for the HyFoSy group, with no statistically significant difference between the groups (P=0.66). The live birth rate was similar in the two groups (7.4% for HSG and 10.7% for HyFoSy; P=0.37). Over half (57.1%) of the pregnancies occurred within 6 months after HyFoSy, whereas only 8.3% after HSG. CONCLUSION: IUI results are not influenced by HyFoSy compared to HSG with regard to the pregnancy rates. Use of HyFoSy in infertility assessment allows global evaluation and more rapid adapted management. This approach could optimize management of patients undergoing IUI.

[Prevalence of menorrhagia among women in Reunion Island]. / Prévalence des ménorragies chez les femmes à la Réunion.

OBJECTIVES: To estimate the prevalence of menorrhagia in women in Reunion Island using the Higham score, to evaluate self-reporting as an alternative diagnostic method, and to study women's level of knowledge about menorrhagia and its impact on their quality of life. METHODS: This was a descriptive, cross-sectional observational study involving 185 adult women with menstrual periods living in Reunion Island. Women volunteered to answer an online self-questionnaire proposed by healthcare professionals from January to May 2023 in Reunion Island. They completed a general information questionnaire, the Higham score, a menorrhagia knowledge questionnaire and a menstrual quality of life questionnaire. RESULTS: The prevalence of menorrhagia in the sample was 48.1% using the Higham score and 46.5% using self-report. Women's level of knowledge about menorrhagia is still insufficient, given the significant impact on quality of life during menstruation among those suffering from this symptom. CONCLUSION: The prevalence of menorrhagia in our sample of women on Reunion Island is high. Measures need to be taken to break the taboos surrounding menstruation, promote menstrual education and foster a better understanding by women of menstrual pathologies, particularly menorrhagia. Early detection of this symptom would enable faster treatment and avoid complications and adverse effects on quality of life.

[Determinants of papillomavirus vaccination in Mayotte: A qualitative study among general practitioners]. / Déterminants et leviers de la vaccination papillomavirus à Mayotte : une étude qualitative chez les médecins généralistes.

OBJECTIVES: In Mayotte, cervical cancer represents the second cause of cancer mortality in women. Vaccination coverage against papillomavirus and screening rates are difficult to quantify but among the lowest in France. Added to this is an under-calibrated health system, which does not allow optimal treatment of cancers on site. The objective of the study was to study the elements that would increase papillomavirus vaccination among general practitioners. METHODS: We carried out a qualitative study of phenomenological inspiration using semi-directed open interviews. The target population was private general practitioners based in Mayotte. The analysis was done by coding verbatim statements, from which emerged general themes, to build a model. RESULTS: Twenty-two interviews were conducted. Vaccination was part of a context and was organized around the trio doctor-patient-institutions. The main pillar to vaccination was information, which could concern doctors or patients. The information delivered to patients through the media, campaigns in schools, and vaccination obligation were the main elements. The study revealed positive emotional dynamics of on-site HPV vaccination. CONCLUSION: This study made it possible to better understand the ecosystem in which papillomavirus vaccination takes place in Mayotte, and to identify elements of vaccination promotion. Vaccination school campaigns should keep going on to increase vaccination uptake.

Preeclampsia in 2023: Time for preventing early onset- and term preeclampsia: The paramount role of gestational weight gain.

The 2023 goal is to halve the incidence of preeclampsia worldwide to reach 3 million cases per year vs the current approximately 7 million cases. Preventive treatment by low dose aspirin only halves the incidence of early-onset preeclampsia (EOP < 34 weeks gestation) in high-risk women. However, 90% of PE cases are the late onset form (LOP, 34 weeks onward) proportionally associated with increasing maternal pre-pregnancy BMI. In 2018, we published a new method to calculate individualized optimal gestational weight gain based on normal Gaussian distribution of neonatal birthweights (SGA 10%, LGA 10%) and demonstrated that this optimal gestational weight gain (GWG) follows a linear equation suitable for all maternal PRE-pregnancy BMIs (from lean to obesities classes 1-2-3). A similar linear equation has been published recently based on a 2022 US database of 200,000 multiple pregnancies. Subsequently, we demonstrated in a prospective population study that in overweight and obese women who are able to achieve an optimal GWG, the rate of term preeclampsia (> 37 week's gestation) halves. Providing individual app-based calculations of optimal individual GWG, all patients will be aware of their personal weight gain target over the pregnancy. CONCLUSION: Halving the incidence of early-onset- and term preeclampsia worldwide by prevention is now theoretically achievable. Appropriate and timely start of low-dose Aspirin and providing women clear advice on their optimal GWG are they ingredients to achieve this goal.

[Oncogenetics in the French overseas departments and regions: Situation in Reunion Island]. / Oncogénétique dans les départements et régions d'Outre-mer français : situation à La Réunion.

In view of the use of oncogenetics as a lever for proposing new-targeted therapies whose indications are expanding, this article provides an overview of this discipline in the French overseas departments and regions (DROM). Contrary to the metropolitan departments, where the number of consultations exceeds 100 consultations per 100,000 inhabitants for most centres in 2019, the number of consultations in the DROMs remains insufficient to meet the national average of 117 per 100,000 inhabitants. The financial and structural support offered by the INCa and the DGOS since 2003 has contributed favourably to the deployment of this activity in metropolitan France. This activity, which seems to be suffering in the DROMs, probably requires particular attention in order to understand the difficulties encountered and thus to meet the INCa's objective as well as possible: to identify and support patients with mutations by providing them with appropriate care.

Understanding barriers and motivations to papillomavirus vaccination in a middle school in Reunion Island.

BACKGROUND: In Reunion Island, papillomavirus (HPV) vaccination coverage is low. A study encouraging vaccination in middle school showed low rate of participation. The main objective of the study was to understand barriers and motivations to HPV vaccination in populations yet sensitized to its benefits. METHODS: The study focused on population around the intervention school where a health promotion program was conducted during school year 2020-2021. Semi-structured face-to-face interviews among children, children's parents, school staff, general practitioners (GP) and association members were conducted. A qualitative study was adopted using a grounded theory approach to obtain an in-depth understanding of issues pertaining to HPV vaccination. FINDINGS: A total of 19 school staff members, 20 parents of middle school children, 39 children, 5 GPs and 3 association members were interviewed in May 2021. Anti-vaccination attitudes included: fear of serious adverse effects (such as fertility) due to poor knowledge, fear of encouraging sexuality among teenagers, mistrust towards scientists and the pharmaceutical industry and the negative impact from social networks. However, we found that the influence of the school, GP's and 'story-telling' study testimonials were crucial to invert the balance and motivate children's vaccination. INTERPRETATION: Reproductive adverse events related to the HPV vaccine may be strongly perceived amongst our population, either regarding fertility or negative fetal effects; though Reunion island has 5% of pregnancies among teenagers. It is crucial to lift this taboo related to sexuality and encourage dialogue between children and their close social network. This better understanding of barriers and motivations will help us increase the impact of school-based HPV vaccination, which will be introduced in September 2023 in whole France.

Associated risk factors of severe dengue in Reunion Island: A prospective cohort study.

BACKGROUND: Since 2018, a dengue epidemic has been raging annually in Reunion Island, which poses the major problem of its morbidity and mortality. However, there is no consensus in the literature on factors associated with severity of illness. The objective of this study was to identify the factors associated with the occurrence of severe dengue (SD) according to the criteria adopted in 2009 by the World Health Organization (WHO), during the 2019 epidemic. METHODOLOGY/PRINCIPAL FINDINGS: A total of 163 patients with RT-PCR-confirmed dengue were included in a multicenter prospective cohort study in Reunion Island between January and June 2019. Of these, 37 (23%) were classified as SD, which involves presentation dominated by at least one organ failure, and 126 (77%) classified as non-SD (of which 90 (71%) had warning signs). Confusion, dehydration, and relative hypovolemia were significantly associated with SD in bivariate analysis (p < 0.05). The factors associated with SD in multivariate analysis were a time from first symptom to hospital consultation over 2 days (OR: 2.46, CI: 1.42-4.27), a history of cardiovascular disease (OR: 2.75, 95%CI: 1.57-4.80) and being of Western European origin (OR: 17.60, CI: 4.15-74). CONCLUSIONS/SIGNIFICANCE: This study confirms that SD is a frequent cause of hospitalization during dengue epidemics in Reunion Island. It suggests that cardiovascular disease, Western European origin, and delay in diagnosis and management are risk factors associated with SD fever, and that restoration of blood volume and correction of dehydration must be performed early to be effective. TRIAL REGISTRATION: NCT01099852; clinicaltrials.gov.

Robotic surgery implementation in an isolated overseas territory - The case of Reunion Island.

INTRODUCTION: In February 2020, robotic surgery was introduced in University Hospital of St Pierre in Reunion Island. The aim of this study was to evaluate the implementation of robotic assisted surgery in the hospital and its impact on operating times and patient outcomes. METHODS: Data was prospectively collected on patients undergoing laparoscopic robotic assisted surgery between February 2020 and February 2022. Information included patient demographics, type of surgery, operating times and length of stay. RESULTS: Over the two-year study period, 137 patients underwent laparoscopic robotic assisted surgery performed by 6 different surgeons. 89 of the surgeries were in gynecology, including 58 hysterectomies, 37 were in digestive surgery, and 11 in urology. The installation and docking times decreased across all specialties and were found to be significantly reduced when comparing the first and last 15 hysterectomies: mean installation time decreased from 18.7 to 14.5 minutes (p=0.048), mean docking time decreased from 11.3 to 7.1 minutes (p = 0.009). CONCLUSIONS: The implementation of robotic assisted surgery in an isolated territory such as Reunion Island was slow due to a lack of trained surgeons, supply difficulties and Covid crisis. Despite these challenges, the use of robotic surgery allowed for technically more challenging surgeries and demonstrated similar learning curves to other centers.

PROM SSCOL-Impact of a Papillomavirus Vaccination Promotion Program in Middle Schools to Raise the Vaccinal Coverage on Reunion Island.

Introduction: On Reunion Island, cervical cancer is the third most common cause of cancer in women. Primary prevention is based on the HPV vaccination, yet coverage rate is low (8.1%). The objective of the study was to evaluate the impact of a health promotion program on the proportion of middle school girls who have completed the HPV vaccination schedule. Material and methods: In this prospective, controlled intervention study of superiority, 12 classes were randomly selected in an intervention school where the promotion program took place, and in a control school where no specific intervention was planned. The program combined: information to students during school classes, information to parents by letter and phone calls, information to general practitioners by letter and video conference call, and the free school-based vaccination (in a "health bus" parked in the schoolyard) with the nonavalent HPV vaccine. Results: In the intervention group, the completion was achieved for 26 girls, which was significantly higher than in the control group (three girls, p < 10−3). The initiated vaccination was also higher in the intervention group (31 girls vs. 6 girls in the control group, p < 10−3). The same results were obtained for the boys as for the full or partial scheme (seven boys vs. 0, p = 0.01; 16 boys vs. 1, p < 10−3, respectively). Conclusions: Implementing a health promotion program and offering the free, school-based vaccination raised the vaccination coverage. These results are promising and may be a stepping stone to expanding this program to the whole Reunion Island and hopefully someday decrease the burden of cervical cancer.

Impact of a Papillomavirus Vaccination Promotion Program in Middle School: Study Protocol for a Cluster Controlled Trial.

BACKGROUND: On Reunion Island, incidence and mortality for uterine cervical cancer is high, yet coverage rate for human papillomavirus (HPV) vaccination is low. OBJECTIVE: The main objective of the study is to evaluate the impact of a health promotion program promoting HPV vaccination on the proportion of middle school girls who complete the full HPV vaccination schedule (2 or 3 doses) by the end of school year. METHODS: This study is a cluster controlled intervention study using a superiority design. A combined health promotion program will be offered containing information to students and parents, training of general practitioners, and free school-based vaccination (in a "health bus"). Children who attend this program will constitute the intervention group and will be compared to children from another middle school who will not attend the program constituting the control group. RESULTS: Recruitment began in October 2020. In the intervention school, of 780 students, 245 were randomly selected in the 12 classes. In the control school, 259 students out of 834 were randomly selected. CONCLUSIONS: In this study, we explore the impact of a health promotion program combining information toward students, parents, and general practitioners with free school-based vaccination. We expect a significantly higher HPV vaccination coverage in the intervention school as compared to the control school, whether it be among girls or boys. The final implication would be an extension of this program in all middle schools on the Island and thus an increase in HPV vaccination coverage. TRIAL REGISTRATION: ClinicalTrials.gov NCT04459221; https://clinicaltrials.gov/ct2/show/NCT04459221. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35695.

Factors associated with non-visualisation of tubal patency during Hysterosalpingo-Foam-Sonography.

OBJECTIVE: Investigate potential factors associated with non-visualisation of tubal patency during Hysterosalpingo-Foam-Sonography (HyFoSy). STUDY DESIGN: This retrospective study was carried out at the medically assisted procreation centre of the University Hospital Centre in Reunion Island and focuses on HyFoSy performed between 01/01/2018 and 31/12/2020. We aimed to compare HyFoSy with bilateral tubal patency and those with a passage defect. Factors associated with non-visualisation of the contrast medium were investigated using comparison tests and logistic regression. Explanatory variables were patient history and ultrasound characteristics. RESULTS: 137 eligible HyFoSy were included, of which 70.8% could be established for bilateral tubal patency. The assessment of tubal patency decreased in cases of overweight/obesity (62.5% versus 47.4%), previous pelvic surgery (17.5% versus 10.3%) and deep endometriosis (12.5% versus 5.2%), without significant difference. In the logistic regression model, a trend towards significance was observed for body mass index ≥ 25 kg/m² (OR 2.01 [95% CI 0.93-4.35], p= 0.07). CONCLUSION: HyFoSy as a first-line infertility test should be discussed in certain circumstances, due to risk of non-visualisation of tubal patency. In case of poor echogenicity, it should be performed by a trained ultrasonographer or a hysterosalpingography should be preferred. For tubo-pelvic pathologies, a laparoscopy should be discussed for diagnostic and therapeutic purposes. DISCIPLINE: gynaecology, infertility.

Application of new fetal growth standards in a multiethnic population.

OBJECTIVES: Ultrasound assessment of fetal growth is essential to reduce adverse pregnancy outcomes. Intergrowth-21st developed international standards. Currently, we use in France chart based on Hadlock's formula. This study aims to evaluate, the impact of switching from national curves to IG-21 curves or a combination of IG-21 with Hadlock. METHODS: The study population consisted of 3 697 singleton pregnancies with fetal biometry measured between 22 and 38 weeks of gestation. Z-scores were calculated for each biometry according to CFEF and IG-21. The estimated fetal weight and its Z-score were calculated using the Hadlock formula and IG-21 formula. RESULTS: We observed 21% of head circumference, 9% of abdominal circumference and 7% of femoral length below the 10th centile with Intergrowth-21. Concerning estimated fetal weight, IG-21 classified 13.8% fetuses as SGA, IG-21/Hadlock 10.8% and CFEF 16.1%. Between 36 and 38 weeks of gestation, IG-21 classified more fetuses as SGA than IG-21/Hadlock and CFEF, respectively 18%, 14.1% and 13.3%. CONCLUSION: The use of IG-21 or IG-21/Hadlock in the general population would lower the number of fetuses classified as SGA except for fetuses between 36 and 38 weeks. During this period, many decisions of induced early delivery or specific management are established to prevent adverse perinatal outcome. Those results must be supplemented by a comparison to newborns' weight.

Admission into intensive care unit in preeclampsia: a four-year population-based study in Reunion Island.

INTRODUCTION: Preeclampsia is one of the leading causes of maternal and fetal morbidity and mortality. The objective of our study was to study risk factors and complications associated with severe preeclampsia requiring intensive care unit (ICU) admission. METHODS: Retrospective comparative study over a period from 1st of January 2015 to 1st of January 2019 in the University's maternity unit of South Reunion (Indian Ocean). Our sampling included all preeclamptic patients who delivered in the Southern part of the island. Patients admitted to intensive care unit (ICU) and those who remained in the maternity unit (controls) were reviewed. RESULTS: Out of 482 preeclampsia cases, 94 women (19.5%) needed a transfer in ICU, of which only 21 (4.3%) needed invasive intensive care. Mean length of stay was 2.4 ± 2.1 days. ICU admission was associated with HELLP syndrome (OR 8.5 [4.9-14.9], p<.001), severe post-partum hemorrhage (OR 5.86 [1.29-26.70], p=.01) and early onset of preeclampsia (<34 weeks gestation), 2.97 [1.9-4.7], p<.001), leading to higher rate of C-section (OR 2.83 [1.67-4.78], p<.001). There were three patients with a history of eclampsia and no case of maternal death was reported. Fetal prognosis was much poorer in maternal ICU admissions than in controls, with outcomes including lower birth weight (1776 vs. 2304 g, p<.001) and higher perinatal morbidity (infant respiratory distress syndrome 3.70 [1.94-7.05], p<.001) and mortality (<.001). CONCLUSIONS: Women needing invasive ICU represented 4.3% of preeclampsia cases. This experience is of interest for lower resource settings such as in countries like Madagascar where very intensive ICU means are very poor, but simpler ICU surveillance is possible. Fetal prognosis was poor though no maternal death was reported. Thus, a multidisciplinary approach of patients with preeclampsia should be encouraged; admission into ICU should be facilitated, as soon as any sign of severity and complications appears.

The blurring boundaries between placental and maternal preeclampsia: a critical appraisal of 1800 consecutive preeclamptic cases.

OBJECTIVES: To present a comprehensive overview of different risk factors for early onset preeclampsia (<34 weeks gestation, EOP) vs. late onset (LOP). STUDY DESIGN: South-Reunion University's maternity (Reunion Island, Indian Ocean). 18.5 year-observational population-based cohort study (2001-2019). Epidemiological perinatal database with information on obstetrical and neonatal risk factors. All consecutive singleton pregnancies (>21 weeks) compared with all preeclamptic pregnancies delivered in the south of Reunion island. MAIN OUTCOME MEASURES: Comparing risk factors between EOP and LOP. RESULTS: Among 1814 singleton preeclamptic pregnancies (600 EOP and 1214 LOP), EOP women were older than LOP 29.5 vs. 28.6 years, p = .009, primigravidas (OR 0.78 [0.63-0.96], p = .02) were prone to LOP. History of preeclampsia (PE) (aOR 12.8 vs. 7.1), chronic hypertension (aOR 6.5 vs. 4.5) had much higher adjusted odds ratios for EOP than for LOP, p < .001. Specific to EOP: coagulopathies (aOR 2.95, p = .04), stimulated pregnancies (aOR 3.9, p = .02). Specific to LOP: renal diseases (aOR 2.0, p = .05) and protective effect for smoking (aOR 0.75, p = .008). EOP women were prone to have a lower BMI. CONCLUSION: "Placental preeclampsia" (defective placentation) being linked to early onset PE (<34 weeks gestation) while "maternal preeclampsia" (maternal cardiovascular predisposition) being typically manifesting as the late form of the disease LOP is not systematically verified. Future researches are needed to propose a more adapted paradigm.Highlights  Risk factors for different preeclampsia phenotypes (early/late); challenging proposed models.

Effect of air temperature on human births, preterm births and births associated with maternal hypertension.

OBJECTIVE: We studied potential effects of outdoor air temperatures or barometric pressure on births, preterm births and births associated with maternal hypertension. METHODS: 12,269 births were retrospectively reviewed in Brussel and 25,880 in South Reunion Island. National Belgium and French weather reference centers provided outdoor air temperatures and barometric pressures from the nearest weather stations on the corresponding birthdays. Poisson regression models were used to assess if outdoor air temperatures or barometric pressure could be correlated, immediately and several days later, with the number of daily births, preterm births and births associated with hypertension. RESULTS: Outdoor air temperature was significantly correlated to the number of daily births in Brussels. For each additional degree Celsius, overall births increased by 0.4% during the same day. Four days later, overall births increased by 1.8%, preterm births by 2.6% and births associated with hypertension by 5.7%. Similar observations on numbers of daily births were reported in South Reunion Island, without reaching statistical significance (p = .08). CONCLUSION: As previously demonstrated in recent studies, increased air temperature leads progressively to higher rates of births and preterm births. An even stronger delayed effect of air temperature was observed on births associated with hypertension. This would be worth further investigating.

Primipaternities and human birthweights.

OBJECTIVES: To investigate in singleton multiparous pregnancies the effect of having a new father for an index pregnancy on new-borns' birthweights and intrauterine growth restriction. DESIGN: 20 year-observational cohort study (2001-2020). SETTINGS: Centre Hospitalier Universitaire Hospitalier Sud Reunion's maternity (French overseas department, Indian Ocean). MAIN OUTCOMES AND MEASURES: Comparing the 811 multiparas (cases) who had a new partner with the 49,712 who did not (controls), there were no differences concerning maternal age, education, ovulation induction/IVF, previous miscarriages, exams during pregnancies, pre-pregnancy BMI, gestational diabetes, and chronic hypertension. Cases had more previous pregnancies than controls (gravidity 4.2 vs 2.8, p < 0.001), volunteer abortions (OR1.93, p < 0.001), in vitro fecundations (OR 4.34, p < 0.001), were more likely to be unmarried (OR 2.94, p < 0.001) smoker (OR 2.2, p < 0.0001) and consuming alcohol during pregnancy (OR 2.35, p = 0.001). Cases had a much higher risk of preeclampsia than controls (OR 3.94, p < 0.001), especially early-onset preeclampsia (< 34 weeks) with an OR 4.1 (p < 0.001). Controlling for confounding factors (preeclampsia, smoking, alcohol use, early prematurity < 33 weeks, maternal ethnicity), primipaternity was an independent factor for small for gestational age newborns (OR 1.48, p < 0.001). CONCLUSIONS: It has been known for decades that primiparas have lighter babies than multiparas. Primipaternity represents also a risk for lower birth weights. Human birthweight seems to be linked with a "couple habituation" (to paternal genes) which may be not fully established in the first pregnancy of the couple.