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Summary Background The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis is unclear, particularly in low-income and middle-income countries in Africa. South Africa has a national HIV prevalence of 19% among people aged 15–49 years and a tuberculosis prevalence of 0·7% in people of all ages. Using a nationally representative hospital surveillance system in South Africa, we aimed to investigate the factors associated with in-hospital mortality among patients with COVID-19. Methods In this cohort study, we used data submitted to DATCOV, a national active hospital surveillance system for COVID-19 hospital admissions, for patients admitted to hospital with laboratory-confirmed SARS-CoV-2 infection between March 5, 2020, and March 27, 2021. Age, sex, race or ethnicity, and comorbidities (hypertension, diabetes, chronic cardiac disease, chronic pulmonary disease and asthma, chronic renal disease, malignancy in the past 5 years, HIV, and past and current tuberculosis) were considered as risk factors for COVID-19-related in-hospital mortality. COVID-19 in-hospital mortality, the main outcome, was defined as a death related to COVID-19 that occurred during the hospital stay and excluded deaths that occurred because of other causes or after discharge from hospital; therefore, only patients with a known in-hospital outcome (died or discharged alive) were included. Chained equation multiple imputation was used to account for missing data and random-effects multivariable logistic regression models were used to assess the role of HIV status and underlying comorbidities on COVID-19 in-hospital mortality. Findings Among the 219 265 individuals admitted to hospital with laboratory-confirmed SARS-CoV-2 infection and known in-hospital outcome data, 51 037 (23·3%) died. Most commonly observed comorbidities among individuals with available data were hypertension in 61 098 (37·4%) of 163 350, diabetes in 43 885 (27·4%) of 159 932, and HIV in 13 793 (9·1%) of 151 779. Tuberculosis was reported in 5282 (3·6%) of 146 381 individuals. Increasing age was the strongest predictor of COVID-19 in-hospital mortality. Other factors associated were HIV infection (adjusted odds ratio 1·34, 95% CI 1·27–1·43), past tuberculosis (1·26, 1·15–1·38), current tuberculosis (1·42, 1·22–1·64), and both past and current tuberculosis (1·48, 1·32–1·67) compared with never tuberculosis, as well as other described risk factors for COVID-19, such as male sex; non-White race; underlying hypertension, diabetes, chronic cardiac disease, chronic renal disease, and malignancy in the past 5 years; and treatment in the public health sector. After adjusting for other factors, people with HIV not on antiretroviral therapy (ART; adjusted odds ratio 1·45, 95% CI 1·22–1·72) were more likely to die in hospital than were people with HIV on ART. Among people with HIV, the prevalence of other comorbidities was 29·2% compared with 30·8% among HIV-uninfected individuals. Increasing number of comorbidities was associated with increased COVID-19 in-hospital mortality risk in both people with HIV and HIV-uninfected individuals. Interpretation Individuals identified as being at high risk of COVID-19 in-hospital mortality (older individuals and those with chronic comorbidities and people with HIV, particularly those not on ART) would benefit from COVID-19 prevention programmes such as vaccine prioritisation as well as early referral and treatment. Funding South African National Government.

Objective The primary objective of this document is to clarify the indications for pelvic examination. Intended Users Physicians, including gynaecologists, obstetricians, family physicians, and emergency physicians; nurses, including registered nurses and nurse practitioners; midwives, including midwives in clinical practice and midwifery trainees; medical trainees, including medical students, residents, and fellows; and all other health care providers who care for women. Target Population This publication provides evidence and expert-based recommendations for pelvic examination in adult women (18 years and older) both with and without gynaecologic symptoms. Outcomes This publication clarifies indications for pelvic examination in the context of recently published national task force statements on the utility of pelvic examination. We aim to ensure that women who have clinical indications for examination receive proper clinical investigation with minimal delays to diagnosis of treatable disease. Evidence For this committee opinion, relevant studies were identified in PubMed and Medline using the following terms, either alone or in combination, with the search limited to English-language materials and human subjects and no publication date cut-off: pelvic examination, bimanual examination, speculum examination, rectovaginal examination, ovarian cancer screening, asymptomatic women, periodic health examination. The search was performed in May and June 2018. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines and national task force statements, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional articles were identified by cross-referencing the identified publications. A formal systematic review was not conducted for all topics discussed due to the paucity of evidence and number of different subtopics discussed. The total number of publications included in this review was 66. Validation Methods The content and recommendations were drafted and agreed upon by the principal authors. The Boards of the Society of Gynecologic Oncology of Canada (GOC), the College of Family Physicians of Canada (CFPC), and the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication after review by their respective representative committees. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2). The Summary of Findings is available upon request. Benefits, Harms, and Costs This committee opinion should benefit all women with and without gynaecologic symptoms who present to gynaecologists and primary care practitioners. It will help guide practitioners in identifying indications for pelvic examination to reduce unnecessary examination with related potential harm while also increasing indicated examination to reduce delays in diagnosis of treatable gynaecologic conditions. Guideline Update This SOGC Committee Opinion will be automatically reviewed 5 years after publication to determine if all or part of the committee opinion should be updated. However, this review may be performed earlier if new high-impact research is published in the interim. SUMMARY STATEMENTS 1National and international statements and guidelines on pelvic examination should not be interpreted to suggest that the pelvic examination is irrelevant or noncontributory to physical assessment or that the pelvic examination in symptomatic women should be omitted. 2Pelvic examination may include visual inspection, speculum examination, bimanual examination, single digit examination, and/or rectovaginal examination depending on the indication for examination. 3No study published to date has adequately evaluated any component of the pelvic examination as a screening method for any type of malignant gynaecologic disease, except for the speculum examination for cervical cancer cytology screening. As such, any universal recommendations for or against pelvic examinations for other indications can only be made based on expert opinion and low-quality evidence. 4In asymptomatic women at average risk for cervical cancer, cervical cytology screening reduces both the incidence of, and mortality from, cervical cancer by detecting pre-invasive, treatable lesions. 5In asymptomatic women at average risk of malignancy, a visual and bimanual examination at the time of obtaining cervical cytology samples may add value to this screening manoeuvre: Women might not raise certain gynaecologic concerns until the time of pelvic examination; the examination provides an opportunity for patient education and practitioner skill maintenance; and, although inadequately studied to date, there may be positive effects on ovarian and vulvar malignancy that require further investigation. These potential benefits should be weighed against potential harms like patient discomfort and false positives/negatives that may result in inappropriate reassurance or unnecessary investigations/interventions. RECOMMENDATIONS Symptomatic Women 1Any woman with gynaecologic complaints including, but not limited to, vulvar complaints, vaginal discharge, abnormal premenopausal bleeding, postmenopausal bleeding, infertility, pelvic organ prolapse symptoms, urinary incontinence, new and unexplained gastrointestinal symptoms (abdominal pain, increased abdominal size/bloating, and difficulty eating/early satiety), pelvic pain, or dyspareunia should undergo appropriate components of the pelvic examination to identify benign or malignant disease (strong, low). 2Health care providers may consider discussing the risks and benefits of performing a baseline pelvic examination including visual and bimanual examination prior to prescribing hormonal replacement therapy/menopausal hormonal treatment (weak, very low). Asymptomatic Women 3Health care practitioners should perform cervical cytology cancer screening in accordance with provincial/territorial guidelines (strong, strong). 4There is insufficient evidence to guide recommendations on screening pelvic examination for noncervical gynaecologic malignancy or any benign gynaecologic disease in healthy, asymptomatic women with average risk of malignancy. However, health care practitioners may consider performing a screening pelvic examination including visual, speculum, and bimanual examinations in concert with cervical cytology sampling intervals as recommended by provincial/territorial guidelines. This practice may identify clinically important benign or malignant disease not recognized or reported by the patient (weak, very low). 5In women over age 70 who no longer require screening with cervical cytology, health care practitioners should consider continuing periodic screening of asymptomatic women for vulvar disease with inspection of the vulva, perineum, and anus to identify benign or malignant disease unrecognized by this population. There is insufficient evidence to guide recommendations on frequency of this examination (weak, low). 6Women with a personal history of gynaecologic malignancy, a genetic diagnosis that increases gynaecologic malignancy risk, or a history of in utero diethylstilbestrol exposure may benefit from more frequent screening pelvic examinations to identify early primary, recurrent, or metastatic malignancy in the absence of symptoms. Because there is inadequate evidence to define these screening intervals, they should be in accordance with provincial/territorial guidelines and expert opinion (weak, very low). 7Non-invasive and self-collection screening options for chlamydia and gonorrhea are acceptable in asymptomatic women, but pelvic examination, including visual inspection, speculum examination, and bimanual examination, is required in the presence of symptoms to rule out pelvic inflammatory disease or tubo-ovarian abscess (strong, low). 8No pelvic examination is required prior to prescription of hormonal contraception in a healthy woman with no gynaecologic symptoms (strong, low).

OBJECTIF L'objectif principal du present document est de clarifier les indications de l'examen pelvien. UTILISATEURS CONCERNeS: Medecins, y compris les gynecologues, obstetriciens, medecins de famille, urgentologues; infirmieres, y compris les infirmieres autorisees et les infirmieres praticiennes; sages-femmes, y compris les sages-femmes en pratique clinique et les apprenties sages-femmes et les apprentis en medecine, y compris les etudiants de medecine, residents, stagiaires (fellows); et tous les autres fournisseurs de soins de sante qui prodiguent des soins aux femmes. POPULATION CIBLE La presente publication fournit des donnees probantes et des recommandations fondees sur des avis d'experts sur l'examen pelvien chez les femmes adultes (18 ans et plus) avec et sans symptomes gynecologiques. ISSUES La presente publication clarifie les indications de l'examen pelvien dans le contexte des declarations de groupes d'etude nationaux recemment publiees sur l'utilite de l'examen pelvien. L'objectif est de veiller a ce que les femmes qui presentent des indications cliniques d'examen fassent rapidement l'objet d'une evaluation clinique adequate pour diagnostiquer les maladies traitables. DONNeES PROBANTES Pour la presente opinion de comite, les etudes pertinentes ont ete reperees dans PubMed et Medline a l'aide des termes suivants, seuls ou combines, et les recherches ont ete limitees aux publications en anglais portant sur des humains sans date limite de publication : pelvic examination, bimanual examination, speculum examination, rectovaginal examination, ovarian cancer screening, asymptomatic women, periodic health examination. La recherche a ete effectuee en mai et en juin 2018. Les donnees probantes pertinentes ont ete retenues dans l'ordre suivant : meta-analyses, revues systematiques, lignes directrices et declarations des groupes d'etude nationaux, essais cliniques randomises, etudes de cohorte prospective, etudes observationnelles, revues non systematiques, etudes de serie de cas et rapports. Des articles supplementaires ont ete reperes en consultant les notices bibliographiques des publications selectionnees. Une revue systematique officielle n'a pas ete menee pour tous les sujets discutes en raison du manque de donnees probantes et du nombre de differents sous-themes abordes. Le nombre total de publications examinees dans le cadre de cette revue etait de 66. MeTHODES DE VALIDATION Les auteurs principaux ont redige le contenu et les recommandations et ils se sont entendus sur ces derniers. Les conseils d'administration de la Society of Gynecologic Oncology of Canada (GOC), de College des medecins de famille du Canada (CMFC) et de la Societe des obstetriciens et gynecologues du Canada (SOGC) ont approuve la version definitive aux fins de publication apres que leurs comites representatifs respectifs l'aient passee en revue. La qualite des donnees probantes utilisees dans le present document a ete evaluee au moyen des criteres du cadre methodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). (Tableaux 1 et 2) Le resume des conclusions est disponible sur demande. AVANTAGES, PReJUDICE ET COuTS La presente opinion de comite devrait aider toutes les femmes qui souffrent ou non de symptomes gynecologiques qui se presentent chez le gynecologue et un fournisseur de soins primaires. Elle aidera les praticiens a determiner les indications d'examen pelvien afin de reduire le nombre d'examens inutiles et susceptibles de porter prejudice tout en augmentant le nombre d'examens indiques afin de reduire les retards de diagnostic des affections gynecologiques traitables. MISE a JOUR DE LA DIRECTIVE CLINIQUE La presente opinion de comite de la SOGC sera automatiquement passee en revue cinq ans apres sa publication pour determiner si une partie ou l'ensemble de l'opinion de comite devrait etre mis a jour. Cependant, cette revue peut etre effectuee plus tot si de nouvelles recherches revolutionnaires sont publiees entre-temps. DECLARATIONS SOMMAIRES 1) Les declarations et les directives nationales et internationales sur l'examen pelvien ne devraient pas etre interpretees comme si l'examen pelvien est superflu, qu'il ne contribue pas a l’evaluation physique ou que l'examen pelvien chez les femmes symptomatiques devrait etre omis. 2) L'examen pelvien peut comprendre les examens visuels, au speculum, bimanuel, a un doigt ou rectovaginal selon l'indication d'examen. 3) Aucune etude publiee a ce jour n'a evalue adequatement quelque composante que ce soit de l'examen pelvien comme methode de depistage pour quelconque type de maladie gynecologique maligne, a l'exception de l'examen au speculum pour le depistage cytologique du cancer du col de l'uterus. Ainsi, toute recommandation universelle, pour ou contre les examens pelviens pour d'autres indications ne peut qu’etre faite selon l'opinion des specialistes et des donnees probantes de faible qualite. 4) Chez les femmes asymptomatiques dont le risque de cancer du col de l'uterus est moyen, le depistage cytologique du cancer du col de l'uterus reduit a la fois son incidence et son taux de mortalite en detectant les lesions preinvasives traitables. 5) Chez les femmes asymptomatiques dont le risque de tumeur ou affection maligne est moyen, un examen visuel et bimanuel au moment d'obtenir des echantillons cytologiques cervicaux peut apporter une valeur ajoutee a cette methode de depistage. Les femmes peuvent ne pas soulever certaines inquietudes sur le plan gynecologique jusqu'au moment de l'examen pelvien; l'examen offre une occasion de sensibiliser les patientes et de maintenir les competences du praticien; de plus, meme si le sujet n'a pas encore ete etudie adequatement, il pourrait comporter des effets positifs sur les tumeurs ou affections malignes ovariennes et vulvaires qui necessiteraient des analyses plus poussees. Ces avantages potentiels devraient etre soupeses par rapport aux prejudices potentiels comme l'inconfort de la patiente et les faux positifs ou negatifs qui pourraient la rassurer a tort ou entrainer des analyses et des interventions non justifiees. RECOMMANDATIONS Femmes symptomatiques 1) Toute femme qui exprime des plaintes de nature gynecologique, y compris, mais sans s'y limiter, des plaintes concernant la vulve, des pertes vaginales, des saignements premenopausiques anormaux, des saignements postmenopausiques, l'infertilite, des symptomes de prolapsus des organes pelviens, l'incontinence urinaire, de nouveaux symptomes gastro-intestinaux inexpliques (douleur abdominale, distension abdominale ou ballonnement et difficulte a manger ou satiete precoce), la douleur pelvienne ou la dyspareunie, devrait subir des composantes pertinentes de l'examen pelvien afin de detecter les maladies benignes ou malignes (forte, basse). 2) Les fournisseurs de soins de sante peuvent envisager de discuter des risques et avantages de l'execution d'un examen pelvien de base qui comprend un examen visuel et un examen bimanuel avant de prescrire une hormonotherapie substitutive ou un traitement hormonal de la menopause (faible, tres basse). Femmes asymptomatiques 3) Les professionnels de la sante devraient faire le depistage cytologique du cancer du col de l'uterus conformement aux lignes directrices provinciales ou territoriales (forte, forte). 4) Les donnees sont insuffisantes pour orienter les recommandations sur l'examen pelvien aux fins de depistage de tumeurs ou affections malignes de nature gynecologique non cervicales ou de toute maladie gynecologique benigne chez les femmes asymptomatiques en sante dont le risque de tumeur ou affection maligne est moyen. Cependant, les professionnels de la sante peuvent envisager d'effectuer un examen pelvien aux fins de depistage comprenant les examens visuel, bimanuel et au speculum conjointement avec le prelevement d’echantillons cytologiques cervicaux selon les intervalles recommandes dans les lignes directrices provinciales ou territoriales. Cette pratique pourrait permettre de detecter d'importantes maladies benignes ou malignes non reconnues ou signalees par la patiente (faible, tres basse). 5) Chez les femmes âgees de plus de 70 ans qui n'ont plus a subir de depistage cytologique cervical, les professionnels de la sante devraient envisager de continuer chez les femmes asymptomatiques le depistage periodique des maladies vulvaires en examinant la vulve, le perinee et l'anus afin de detecter les maladies benignes ou malignes meconnues de cette population. Les donnees sont insuffisantes pour determiner des recommandations sur la frequence de cet examen (faible, basse). 6) Des examens pelviens de depistage plus frequents pour deceler les signes precoces de tumeurs ou affections malignes primitives, recidivantes ou metastatiques en l'absence de symptomes pourraient s'averer benefiques pour les femmes qui ont des antecedents personnels de tumeurs malignes de nature gynecologique, un diagnostic genetique qui augmente le risque de tumeurs ou affections malignes gynecologiques ou des antecedents d'exposition in utero au diethylstilbestrol. Puisque les donnees pour determiner ces intervalles de depistage sont inadequates, on devrait les determiner en fonction des lignes directrices provinciales ou territoriales et de l'opinion des specialistes (faible, tres basse). 7) Les options non effractives et par auto-prelevement de depistage de la chlamydia et de la gonorrhee sont acceptables chez les femmes asymptomatiques, mais l'examen pelvien, qui comprend les examens visuel, bimanuel et au speculum, est requis en presence de symptomes pour ecarter la possibilite d'une maladie inflammatoire pelvienne ou d'un abces tubo-ovarien (forte, basse). 8) Aucun examen pelvien n'est requis avant la prescription de contraception hormonale chez une femme en sante qui ne presente aucun symptome gynecologique (forte, basse).

Background: The interaction between COVID-19, non-communicable diseases, and chronic infectious diseases such as HIV and tuberculosis (TB) are unclear, particularly in low- and middle-income countries (LMIC) in Africa. We investigated this interaction using a nationally representative hospital surveillance system in South Africa. Methods: A national surveillance system for laboratory-confirmed COVID-19 hospital admissions (DATCOV) was established. Using DATCOV data, we describe the demographic characteristics, clinical features, and in-hospital mortality among individuals admitted to public and private hospitals with COVID-19 during 5 March to 11 August 2020. Multivariable logistic regression models were used to compare individuals who were HIV-infected and HIV-uninfected and determine the factors associated with in-hospital mortality. Findings: Hospital admissions peaked at 1,560 admissions per day, in late July. Among the 41,877 individuals admitted with laboratory-confirmed COVID-19, 7,662 (18.3%) died. Comorbidities were documented in 27,555 (65.8%) individuals, most commonly observed were hypertension (36.8%), diabetes (29.6%), obesity (19.7%), and HIV (8.7%); TB was reported in 0.7% of individuals. Increased risk of in-hospital mortality was associated with HIV and TB, as well as other described risk factors for COVID-19, such as increasing age, male sex, non-White race (Black, mixed and Indian race), chronic underlying conditions particularly hypertension, diabetes and obesity. In addition, HIV-infected individuals with immunosuppression had increased risk of mortality (adjusted odds ratio 2.2; 95% confidence interval 1.6-3.1). Among HIV-infected individuals, the prevalence of other comorbidities associated with severe COVID-19 outcomes was 39.9%. The effect of multiple comorbidities on mortality was similar in HIV-infected and -uninfected individuals. Interpretation: These data provide a better understanding of the interaction of non-communicable diseases, chronic infectious diseases like HIV and TB and COVID-19. Increasing age and presence of chronic underlying comorbidities (particularly hypertension and diabetes) are important additional factors associated with COVID-19 mortality in a middle-income African setting and are common among HIV-infected individuals. HIV- and TB-infected individuals, particularly those with additional comorbidities, would benefit from COVID-19 prevention and treatment programmes.

Despite relatively high vaccination coverage rates in the European Region, vaccine hesitancy is undermining individual and community protection from vaccine preventable diseases. At the request of its European Technical Advisory Group of Experts on Immunization (ETAGE), the Vaccine-preventable Diseases and Immunization Programme of the WHO Regional Office for Europe (WHO/EURO) developed tools to help countries address hesitancy more effectively. The Guide to Tailoring Immunization Programmes (TIP), an evidence and theory based behavioral insight framework, issued in 2013, provides tools to (1) identify vaccine hesitant population subgroups, (2) diagnose their demand- and supply-side immunization barriers and enablers and (3) design evidence-informed responses to hesitancy appropriate to the subgroup setting, context and vaccine. The Strategic Advisory Group of Experts on Immunization (SAGE) through its Working Group on Vaccine Hesitancy has closely followed the development, implementation, use and evolution of TIP concluding that TIP, with local adaptation, could be a valuable tool for use in all WHO regions, to help address countries' vaccine hesitancy problems. The TIP principles are applicable to communicable, noncommunicable and emergency planning where behavioral decisions influence outcomes.

The SAGE Working Group on Vaccine Hesitancy concluded that vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines. It is influenced by factors such as complacency, convenience and confidence. The Working Group retained the term ‘vaccine’ rather than ‘vaccination’ hesitancy, although the latter more correctly implies the broader range of immunization concerns, as vaccine hesitancy is the more commonly used term. While high levels of hesitancy lead to low vaccine demand, low levels of hesitancy do not necessarily mean high vaccine demand. The Vaccine Hesitancy Determinants Matrix displays the factors influencing the behavioral decision to accept, delay or reject some or all vaccines under three categories: contextual, individual and group, and vaccine/vaccination-specific influences.

Despite a wide array of safe and effective vaccines in use globally, with major impacts on health worldwide, the WHO Strategic Advisory Group of Experts (SAGE) on Immunization has been repeatedly confronted with reports of hesitancy towards accepting specific vaccines or vaccination programmes. This paper summarizes the rationale for a SAGE review of the issue of vaccine hesitancy, its impact and ways to address it, and the convening of a Vaccine Hesitancy Working Group in March 2012 to prepare for the SAGE review. It describes the methods used and mode of operations, and advances in the relatively new field of research on vaccine hesitancy. It further elaborates and references the work conducted, including a series of products, conclusions and recommendations that emerged from the SAGE review in October 2014.

Resume Objectif Passer en revue l'utilisation du morcellement tissulaire dans le cadre de la chirurgie gynecologique a effraction minimale. Issues Dans le cadre d'une chirurgie gynecologique, le morcellement peut etre utilise en vue de permettre le retrait de prelevements uterins de grandes dimensions, ce qui permet l'offre d'une option chirurgicale a effraction minimale aux patientes visees. Les issues oncologiques indesirables du morcellement tissulaire devraient etre attenuees par l'intermediaire d'une meilleure selection des patientes, d'explorations preoperatoires et de techniques novatrices qui minimisent la dispersion tissulaire. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et Medline au printemps 2014 au moyen d'un vocabulaire controle (« leiomyomsarcoma », « uterine neoplasm », « uterine myomectomy », « hysterectomy ») et de mots cles (« leiomyoma », « endometrial cancer », « uterine sarcoma », « leiomyosarcoma », « morcellation » et « MRI ») appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction n'a ete imposee en matiere de date; toutefois, les resultats ont ete limites aux documents rediges en anglais ou en francais. Les recherches ont ete mises a jour de facon reguliere et ont ete integrees a la directive clinique jusqu'en aout 2014. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Avantages, desavantages et couts Les gynecologues peuvent offrir l'option de la chirurgie a effraction minimale a leurs patientes, ce qui pourrait mettre en jeu le morcellement tissulaire et l'utilisation d'un morcellateur motorise a des fins de retrait de prelevements. Les femmes devraient etre avisees que, dans les cas ou l'on en vient a constater un sarcome uterin ou un cancer de l'endometre dont la presence etait insoupconnee, l'utilisation d'un morcellateur est associee a un risque accru de dissemination tumorale. Une formation adequate et des pratiques sures devraient etre mises en œuvre avant que l'on puisse offrir le recours au morcellement tissulaire. Declarations sommaires 1.Les sarcomes uterins peuvent etre difficiles a diagnostiquer de facon preoperatoire. Dans le cadre d'une chirurgie visant un leiomyome uterin supposement benin, le risque de constater un sarcome uterin dont la presence etait insoupconnee est d'environ 1 sur 350; dans le cas des leiomyosarcomes, ce risque est de 1 sur 500. (II-2) Un tel risque augmente avec l'âge. (II-2) 2.Dans les cas ou l'on constate un sarcome uterin dont la presence n'etait pas soupconnee, la tenue d'une chirurgie primaire donnant lieu a une rupture tumorale (y compris le morcellement de la tumeur) pourrait mener a la propagation intra-abdominale de la tumeur et a l'aggravation du pronostic. (II-2) 3.Les techniques chirurgicales permettant de preserver l'uterus demeurent une option sure pour les patientes presentant des leiomyomes symptomatiques qui souhaitent demeurer fertiles. (II-1) Recommandations 1.De nombreuses techniques peuvent etre utilisees aux fins du morcellement d'un prelevement uterin; les medecins devraient envisager l'utilisation de techniques qui minimisent la rupture des prelevements et leur propagation intra-abdominale. (III-C) 2.Toutes les patientes qui presentent un leiomyome uterin devraient faire l'objet d'une evaluation cherchant a determiner la presence possible d'une tumeur maligne, en fonction de leurs facteurs de risque et des resultats de l'imagerie preoperatoire, et ce, bien que la valeur de ces parametres soit limitee. (III-C) 3.La tenue preoperatoire d'une biopsie endometriale et d'une evaluation du col uterin en vue de chercher a eviter le morcellement de tumeurs malignes et premalignes potentiellement detectables est recommandee. (II-2A) 4.Les syndromes cancereux hereditaires donnant lieu a une hausse du risque de constater la presence d'une tumeur uterine maligne devraient etre consideres comme etant une contre-indication a la tenue d'un morcellement uterin non confine. (III-C) 5.Le morcellement de l'uterus est contre-indique pour ce qui est des femmes chez qui la presence d'un cancer est etablie ou soupconnee. (II-2A) Face a un fort indice de suspicion quant a la presence d'un sarcome uterin avant la chirurgie, les patientes devraient etre avisees de choisir de subir une hysterectomie abdominale totale, une salpingectomie bilaterale et peut-etre meme une ovariectomie. (II-2C) Une consultation en gyneco-oncologie devrait etre mise en œuvre. 6.La mise en œuvre de techniques de morcellement tissulaire necessite une formation et une experience adequates. Des initiatives visant a assurer la surete de la technique et du materiel de morcellement utilises devraient etre mises en œuvre au niveau local. (II-3B) 7.Le morcellement constitue une option acceptable pour le retrait de prelevements uterins benins et pourrait faciliter la mise en œuvre d'une approche chirurgicale a effraction minimale (laquelle est associee a des risques perioperatoires moindres). Des services de counseling devraient etre offerts a toutes les patientes au sujet des risques potentiellement associes a l'utilisation du morcellement (y compris les risques associes a la presence sous-jacente d'une tumeur maligne). (III-C)

The long-term efficacy of hepatitis B vaccine, long-term effectiveness of hepatitis B immunisation programmes, immune memory induced by hepatitis B vaccine, current booster policies, and impact of hepatitis B virus mutants on immunisation programmes were reviewed at the Viral Hepatitis Prevention Board (VHPB) meeting in Sevilla, Spain, March 2004. The main focus was on universal vaccination programmes with data being presented from Italy, Saudi Arabia, Singapore, Spain, Taiwan, Thailand, The Gambia, and USA (Alaska).