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The latest ESC recommendations propose several interesting new concepts for the practitioner. The recommendations distinguish between the «apparently healthy» patient and the patient at specific cardiovascular risk (diabetes, renal failure, and familial hypercholesterolemia). New risk calculation tools are proposed (SCORE2 and SCORE2-OP). The proposed LDL-C targets are specific to each group, as a general rule,1.8 mmol/l for individuals at high risk and1.4 mmol/l for individuals at very high risk. Presence of risk modifiers, comorbidities and patient preferences modulates therapeutic approach which is usually based on optimizing lifestyle and statin medication when necessary.Les dernières recommandations de l’European Society of Cardiology (ESC) introduisent plusieurs nouveaux concepts intéressants pour le praticien. Le patient «en bonne santé apparente» est différencié de celui à risque spécifique (diabète, insuffisance rénale et hypercholestérolémie familiale). De nouveaux outils de calcul du risque cardiovasculaire sont proposés (SCORE2 et SCORE2-OP). Les cibles de LDL-C proposées sont spécifiques à chaque groupe avec, en règle générale, une valeur1,8 mmol/l pour les patients à haut risque et1,4 mmol/l pour ceux à très haut risque. La présence de modificateurs de risque, les comorbidités et les préférences du patient modulent l’approche thérapeutique, qui repose habituellement sur le respect des règles hygiénodiététiques et, au besoin, l’administration d’une statine.

A promising new delivery technology, the microarray patch (MAPs) consists of an array of small solid-coated or dissolvable needles, up to one mm in length, that administers a dry formulation of a vaccine or pharmaceutical. This study is not a real-life evaluation study but determines the anticipated acceptability of the Nanopatch™, a solid microarray patch device, in Benin, Nepal and Vietnam for vaccine delivery, and identifies factors that could improve the acceptability of the technology to increase measles immunization coverage. This study combined several evaluation methods, including simulation of vaccine administration on children and in-depth interviews with key stakeholders, healthcare workers, community health volunteers, caretakers, and community representatives. A total of 314 people participated in the study. The overall rate of total acceptability of the patch for child immunization was 92.7%. General opinions were very positive, providing clinical studies confirm that MAP administration is demonstrated to be painless, safe and effective for infectious disease prevention. The study participants were asked to consider the best strategy to introduce such vaccine delivery innovation. Firstly, delivery by skilled healthcare workers at the healthcare facilities will be preferred to establish the technology. Following this, administration by selected volunteers and outreach delivery may be possible, though under the supervision of skilled healthcare workers. This study's protocol received approval from the World Health Organization (WHO) Ethical Research Committee (ERC0002813) and the national IRB in Benin, Nepal and Vietnam.

People with severe mental illness (PSMI) have a shorter life expectancy and are more likely to have cardiovascular disease than the general population. Patients, carers, psychiatric professionals and primary care providers can all play a role in increasing PSMI physical health. The present qualitative exploratory study aimed to explore the views of these four populations as part of the multi-phase COPsyCAT project, whose objective is to build and test a cardiovascular risk prevention programme for PSMI. Overall, 107 people participated in the study’s 16 focus groups, which were transcribed and analysed in a thematic analysis. With a view to building the health promotion programme, major themes identified in the corpus were translated into a list of needs as follows: communication, information, training and support. Results show that it is essential to improve communication between all the different stakeholders in mental health. The greatest challenge facing this programme will be to adapt it to the needs and expectations of PSMI while facilitating work between the various mental health stakeholders. Simple and inexpensive actions could be taken to improve the cardiovascular health of PSMI and will be experimented with during the programme’s feasibility study which will start in September 2022.

BACKGROUND: The occurrence of congestive heart failure (CHF) hospitalization among patients with atrial fibrillation (AF) is a poor prognostic marker. OBJECTIVE: The purpose of this study was to assess whether insulin-like growth factor-binding protein 7 (IGFBP-7), a marker of myocardial damage, identifies AF patients at high risk for this complication. METHODS: We analyzed 2 prospective multicenter observational cohort studies that included 3691 AF patients. Levels of IGFBP-7 and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured from frozen plasma samples at baseline. The primary endpoint was hospitalization for CHF. Multivariable adjusted Cox regression analyses were constructed. RESULTS: Mean patient age was 69 ± 12 years, 1028 (28%) were female, and 879 (24%) had a history of CHF. The incidence per 1000 patient-years across increasing IGFBP-7 quartiles was 7, 10, 32, and 85. The corresponding multivariable adjusted hazard ratios (aHRs) (95% confidence interval [CI]) were 1.0, 1.05 (0.63-1.77), 2.38 (1.50-3.79), and 4.37 (2.72-7.04) (P for trend

Objective At the end of 2013, a pilot experiment was carried out in Come health zone (HZ) in an attempt to optimize the vaccine supply chain. Four commune vaccine storage facilities were replaced by one central HZ facility. This study evaluated the incremental financial needs for the establishment of the new system; compared the economic cost of the supply chain in the Come HZ before and after the system redesign; and analyzed the changes induced by the pilot project in immunization logistics management. Method The purposive sampling method was used to draw a sample from 37 health facilities in the zone for costing evaluation. Data on inputs and prices were collected retrospectively for 2013 and 2014. The analysis used an ingredient-based approach. In addition, 44 semi-structured interviews with health workers for anthropological analysis were completed in 2014. Results The incremental financial costs amounted to US$55,148, including US$50,605 for upfront capital investment and US$4543 for ongoing recurrent costs. Annual economic cost per dose administered (including all vaccines distributed through the Expanded Program on Immunization (EPI)) in the Come HZ increased from US$0.09 before system redesign to US$0.15 after implementation, mainly due to a high initial investment and the operational cost of HZ mobile warehouse. Interviews with health workers suggested that the redesigned system was associated with improvements in motivation and professional awareness due to training, supportive supervision, and improved work conditions. Conclusions The system redesign involved a considerable investment at HZ level. Benefits were found in the reduction of transportation costs to health posts (HP) and commune health center (CHC) levels, and the strengthening of health workers professional skills at all levels in Come. The redesigned system contributed to a decrease in funding needs at HP and CHC levels. The benefits of the investment need to be examined after the introduction of new vaccines and after a longer period.

La problématique de l’accès aux soins de santé est particulièrement complexe et multidimensionnelle. Au Maroc, le recours à un prestataire biomédical est majoritairement privilégié. L’analyse des décisions de recourir à une structure de soins, première étape du parcours, permet de mettre en évidence l’importance des liens intergénérationnels, du genre, mais aussi des difficultés à atteindre une structure de soins. Les résultats de notre étude, menée dans trois sites (deux zones rurales et une zone urbaine), amènent à mettre en évidence les contraintes qui entourent la prise de décision au sein des ménages. The difficulties of having access to healthcare are particularly complex and multidimensional. In Morocco, the use of a biomedical service provider is keenly desirable. The analysis of the decisions to use caring facilities, the primary step in the process, makes it possible to demonstrate the importance of intergenerational links, of gender, but also of the exertions in reaching caring facilities. The results of our survey, conducted in three sites (two rural areas and one urban), contributed to determine the constraints which influence the decision-making character within the households. يُعد الحصول على العلاجات الصحية أمرا معقدا بشكل خاص ومتعدد الأبعاد. والاستعانة في المغرب بخدمة مخابر التحليل البيولوجية والطبية محبذة في الغالب. ويسمح تحليل قرارات الاستعانة بهيكل صحي، والتي تعتبر الخطوة الأولى من المسار، بعرض أهمية العلاقات بين الأجيال، وعلاقات النوع، ولكن أيضا صعوبات الوصول إلى هيكل صحي.تكشف نتائج الدراسة التي أجريناها في ثلاثة مواقع (منطقتان ريفيتان ومنطقة حضرية) إلى عن الصعوبات التي تحيط باتخاذ القرار داخل الأسر.

International audience; Background: The Zambian Ministry of Health implemented a reactive one-dose Oral Cholera Vaccine (OCV) campaign in April 2016 in three Lusaka compounds, followed by a pre-emptive second-round in December. Understanding uptake of this first-ever two-dose OCV campaign is critical to design effective OCV campaigns and for delivery of oral vaccines in the country and the region.Methods: We conducted 12 Focus Group Discussions (FGDs) with men and women who self-reported taking no OCV doses and six with those self-reporting taking both doses. Simple descriptive analysis was conducted on socio-demographic and cholera-related data collected using a short questionnaire. We analyzed transcribed FGDs using the framework of dose, gender and geographic location.Results: No differences were found by gender and location. All participants thought cholera to be severe and the reactive OCV campaign as relevant if efficacious. Most reported not receiving information on OCV side-effects and duration of protection. Those who took both doses listed more risk factors (including ‘wind’) and felt personally susceptible to cholera and protected by OCV. Some described OCV side-effects, mostly diarrhoea, vomiting and dizziness, as the expulsion of causative agents. Those who did not take OCV felt protected by their good personal hygiene practices or, thought of themselves and OCV as powerless against the multiple causes of cholera including poor living conditions, water, wind, and curse. Most of those who did not take OCV feared side-effects reported by others. Some interpreted side-effects as ‘western’ malevolence. Though > 80% discussants reported not knowing duration of protection, some who did not vaccinate, suggested that rather than rely on OCV which could lose potency, collective action should be taken to change the physical and economic environment to prevent cholera.Conclusions: Due to incomplete information, individual decision-making was complex, rooted in theories of disease causation, perceived susceptibility, circulating narratives, colonial past, and observable outcomes of vaccination. To increase coverage, future OCV campaigns may benefit from better communication on eligibility and susceptibility, expected side effects, mechanism of action, and duration of protection. Governmental improvements in the physical and economic environment may increase confidence in OCV and other public health interventions among residents in Lusaka compounds.

BACKGROUND Patients with atrial fibrillation (AF) have an increased risk of cognitive decline, potentially resulting from clinically unrecognized vascular brain lesions. OBJECTIVES This study sought to assess the relationships between cognitive function and vascular brain lesions in patients with AF. METHODS Patients with known AF were enrolled in a multicenter study in Switzerland. Brain magnetic resonance imaging (MRI) and cognitive testing using the Montreal Cognitive Assessment (MoCA) were performed in all participants. Large noncortical or cortical infarcts (LNCCIs), small noncortical infarcts (SNCIs), microbleeds, and white matter lesions were quantified by a central core laboratory. Clinically silent infarcts were defined as infarcts on brain MRI in patients without a clinical history of stroke or transient ischemic attack. RESULTS The study included 1,737 patients with a mean age of 73 ± 8 years (28% women, 90% taking oral anticoagulant agents). On MRI, LNCCIs were found in 387 patients (22%), SNCIs in 368 (21%), microbleeds in 372 (22%), and white matter lesions in 1715 (99%). Clinically silent infarcts among the 1,390 patients without a history of stroke or transient ischemic attack were found in 201 patients with LNCCIs (15%) and 245 patients with SNCIs (18%). The MoCA score was 24.7 ± 3.3 in patients with and 25.8 ± 2.9 in those without LNCCIs on brain MRI (p < 0.001). The difference in MoCA score remained similar when only clinically silent LNCCIs were considered (24.9 ± 3.1 vs. 25.8 ± 2.9; p < 0.001). In a multivariable regression model including all vascular brain lesion parameters, LNCCI volume was the strongest predictor of a reduced MoCA (β = -0.26; 95% confidence interval: -0.40 to -0.13; p < 0.001). CONCLUSIONS Patients with AF have a high burden of LNCCIs and other brain lesions on systematic brain MRI screening, and most of these lesions are clinically silent. LNCCIs were associated with worse cognitive function, even among patients with clinically silent infarcts. Our findings raise the question of MRI screening in patients with AF.

Heterogeneous coverage threatens to compromise the effectiveness of immunization programs in Zambia. Demand-creation initiatives are needed to address this; however, there is incomplete understanding of why vaccine coverage is suboptimal. We investigated overarching perceptions on vaccine acceptability, hesitancy, and accessibility at three informal settlements in Lusaka, Zambia.Nested within a cholera vaccination uptake study, we sought to understand overarching perceptions on vaccines' hesitancy in three informal settlements in Lusaka, Zambia. We conducted 48 focus group discussions with a convenience sample of laypersons, lay healthcare workers, neighbourhood health committee members and vaccinators.Both laypersons and community-based health actors reported high vaccine acceptance though several sources of hesitancy were reported. Traditional remedies, alcohol use and religious beliefs emerged as drivers of vaccine hesitancy, likely reinforced by a background of distrust towards western medicine. Also mentioned were previous adverse events, fear of injections and low perceived need for immunization. Limited understanding of how vaccines work and overlapping local terms for vaccine and other medical concepts created confusion and inaccurate views and expectations. Some reported refusing injections to avoid pain and perceived risk of infection. Discussants emphasised the importance of education and preferred mobile immunization campaigns, with weekend to reach those with poor access and delivered by a combination of professional and volunteer workers.Vaccine hesitancy in Zambia is underpinned by many factors including personal experiences with vaccinations, alternative belief models, limited knowledge, deep misunderstanding about how vaccines work, and barriers to access. To overcome these, community-driven models that incorporate factual communication by professionals and operate outside of traditional hours, may help. Better research to understand community preferences for vaccine uptake could inform interventions to improve immunization coverage in Zambia.

Background Missed opportunities for immunization (MOIs) may contribute to low coverage in diverse settings, including developing countries. Methods We conducted a systematic literature review on MOIs among children and women of childbearing age from 1991 to the present in low- and middle-income countries. We searched multiple databases and the references of retrieved articles. Meta-analysis provided a pooled prevalence estimate and both univariate and multivariate meta-regression analysis was done to explore heterogeneity of results across studies. Results We found 61 data points from 45 studies involving 41,310 participants. Of the 45 studies, 41 involved children and 10 involved women. The pooled MOI prevalence was 32.2% (95% CI: 26.8–37.7) among children – with no change during the study period – and 46.9% (95% CI: 29.7–64.0%) among women of child-bearing age. The prevalence varied by region and study methodology but these two variables together accounted for only 12% of study heterogeneity. Among 352 identified reasons for MOIs, the most common categories were health care practices, false contraindications, logistic issues related to vaccines, and organizational limitations, which did not vary by time or geographic region. Conclusions MOI prevalence was high in low- and middle-income settings but the large number of identified reasons precludes standardized solutions.

Highlights • Political resistance impacts potential OCV acceptability. • Perceived vulnerability to cholera overrides rationale for OCV hesitancy. • Case-by-case preemptive studies maximize public health intervention acceptability., Introduction While planning an immunization campaign in settings where public health interventions are subject to politically motivated resistance, designing context-based social mobilization strategies is critical to ensure community acceptability. In preparation for an Oral Cholera Vaccine campaign implemented in Nampula, Mozambique, in November 2016, we assessed potential barriers and levers for vaccine acceptability. Methods Questionnaires, in-depth interviews, and focus group discussions, as well as observations, were conducted before the campaign. The participants included central and district level government informants (national immunization program, logistics officers, public health directors, and others), community leaders and representatives, and community members. Results During previous well chlorination interventions, some government representatives and health agents were attacked, because they were believed to be responsible for spreading cholera instead of purifying the wells. Politically motivated resistance to cholera interventions resurfaced when an OCV campaign was considered. Respondents also reported vaccine hesitancy related to experiences of problems during school-based vaccine introduction, rumors related to vaccine safety, and negative experiences following routine childhood immunization. Despite major suspicions associated with the OCV campaign, respondents’ perceived vulnerability to cholera and its perceived severity seem to override potential anticipated OCV vaccine hesitancy. Discussion Potential hesitancy towards the OCV campaign is grounded in global insecurity, social disequilibrium, and perceived institutional negligence, which reinforces a representation of estrangement from the central government, triggering suspicions on its intentions in implementing the OCV campaign. Recommendations include a strong involvement of community leaders, which is important for successful social mobilization; representatives of different political parties should be equally involved in social mobilization efforts, before and during campaigns; and public health officials should promote other planned interventions to mitigate the lack of trust associated with perceived institutional negligence. Successful past initiatives include public intake of purified water or newly introduced medication by social mobilizers, teachers or credible leaders.

At the end of 2013, the Government of Benin and Agence de Medecine Preventive (AMP) launched a demonstration project in Come Health Zone (HZ) to optimize the vaccine supply chain. A key part of the demonstration project was the creation of an "informed push model" of vaccine distribution supported by a new logistician position at the health zone (district) level. At the conclusion of the demonstration project in 2015, the authors conducted an anthropological study consisting of semi-structured interviews with 62 participants to assess how the new model changed the professional identities, roles, responsibilities, and practices of personnel involved in vaccine management during and just after the demonstration project end in Come HZ. The study found that health workers considered the logistician as a key player in enabling them to perform their public health mission, notably by improving knowledge and practices in vaccine management, providing supportive supervision, and improving the availability of vaccines and other supplies so that immunization sessions could occur more reliably and professionally within the communities they served. The demonstration project was widely accepted among study participants. The study was approved by the Cotonou Ethics Committee (CER-ISBA No. 56 dated 09/04/2015).

Background Prefilled syringes are the standard in developed countries but logistic and financial barriers prevent their widespread use in developing countries. The current study evaluated use of a compact, prefilled, autodisable device (CPAD) to deliver pentavalent vaccine by field actors in Senegal and Vietnam. Methods We conducted a logistic, programmatic, and anthropological study that included a) interviews of immunization staff at different health system levels and parents attending immunization sessions; b) observation of immunization sessions including CPAD use on oranges; and c) document review. Results Respondents perceived that the CPAD would improve safety by being non-reusable and preventing needle and vaccine exposure during preparation. Preparation was considered simple and may reduce immunization time for staff and caretakers. CPAD impact on cold storage requirements depended on the current pentavalent vaccine being used; in both countries, CPAD would reduce the weight and volume of materials and safety boxes thereby potentially improving outreach strategies and waste disposal. CPAD also would reduce stock outages by bundling vaccine and syringes and reduce wastage by using a non-breakable plastic presentation. Respondents also cited potential challenges including ability to distinguish between CPAD and other pharmaceuticals delivered via a similar mechanism (such as contraceptives), safety, and concerns related to design and ease of administration (such as activation, ease of delivery, and needle diameter and length). Conclusions Compared to current pentavalent vaccine presentations in Vietnam and Senegal, CPAD technology will address some of the main barriers to vaccination, such as supply chain issues and safety concerns among health workers and families. Most of the challenges we identified can be addressed with health worker training, minor design modifications, and health messaging targeting parents and communities. Potentially the largest remaining barrier is the marginal increase in pentavalent cost – if any – from CPAD use, which we did not assess in our study.

L’affaire de l’Arche de Zoe oblige a interroger une nouvelle fois les incomprehensions qui peuvent exister entre les acteurs locaux et des acteurs humanitaires exterieurs, animes par des projets a priori genereux fondes sur leur systeme de valeurs. Quels enseignements tirer de cet episode mediatique, politique et juridique exceptionnel ? Le 25 octobre 2007 les six membres de l’association L’Arche de Zoe sont arretes alors qu’ils s’appretent a quitter le Tchad avec 103 enfants. Il en est de me...