Co-construction d'une étude sur la santé des Gens du voyage : retours d'expériences.

INTRODUCTION: Travelers have poorer health than the general population due to more precarious living conditions. In France, there are no epidemiological studies on Travelers, accentuating their invisibility in public health policy and planning. Discrimination against them, their distrust of the state and institutions, and their non-prioritization of health were the reasons for a participatory research project on Travelers’ health status. This research was carried out collaboratively by researchers, decision-makers, associations, and volunteer Travelers in Nouvelle-Aquitaine. PURPOSE OF RESEARCH: In this article we aim to share the challenges and benefits of the co-construction of this research. RESULTS: The approach allowed the specific and sometimes divergent expectations of the stakeholders to be expressed and taken into consideration. It required a period of mutual acculturation, which resulted in a high level of participation in the study (74 percent), the acquisition of knowledge and skills, and the identification of points of contention. This participatory approach led to a better appropriation of the study and a greater awareness of health issues among the respondents, particularly thanks to the co-construction of the questionnaire and the communication tools. CONCLUSIONS: This approach highlights the need to involve stakeholders in the governance of the research project from the very beginning. The approach was all the more crucial as it involved socially excluded people, and aims to avoid the possibility of excluding them further in the production of knowledge that concerns them.

Health status, healthcare use and child MMR vaccination coverage in Travellers according to their environmental and living conditions in Nouvelle-Aquitaine, France, 2019-2022.

BACKGROUND: The poor health status of underserved populations is compounded by low vaccination uptake, leading to a greater risk of epidemics. On October 2017, a measles outbreak started in the southwest of France among under-vaccinated social groups, including Travellers. We aimed to describe the health status, healthcare use and child measles-mumps-rubella (MMR) vaccination coverage in Travellers according to their environmental and living conditions. METHODS: A cross-sectional study with a three-stage random sample design was conducted between October 2019 and March 2022 in the Nouvelle-Aquitaine region in France. Trained social workers administered face-to-face questionnaires to collect data on adults and children. Anthropometric measurements, vaccination records and data using an environmental exposure questionnaire were also collected. RESULTS: The participation rate was high (73.6%), with 1030 adults and 337 children included. Concerning the adults, 36.6% had obesity, 14.4% reported diabetes, 24.7% hypertension and 14.4% major depression. The prevalence of major depression was significantly higher in adults living in precarious and unauthorized housing than in those with adequate housing (19.8 vs. 14.7%, P = 0.03). With regard to children, 45.3% had full (i.e. 2-dose) MMR vaccination coverage at 24 months and 17.9% had obesity. Finally, 74.5% of the households experienced housing insecurity, and 22.2% did not have a supply of drinking water. CONCLUSION: Traveller children and adults faced deleterious environmental and living conditions potentially affecting their health, healthcare use and vaccination coverage. These results demonstrate the need for urgent interventions for underserved populations which take into account their specific needs.

Early clindamycin for bacterial vaginosis in pregnancy (PREMEVA): a multicentre, double-blind, randomised controlled trial.

BACKGROUND: Preterm delivery during pregnancy (<37 weeks' gestation) is a leading cause of perinatal mortality and morbidity. Treating bacterial vaginosis during pregnancy can reduce poor outcomes, such as preterm birth. We aimed to investigate whether treatment of bacterial vaginosis decreases late miscarriages or spontaneous very preterm birth. METHODS: PREMEVA was a double-blind randomised controlled trial done in 40 French centres. Women aged 18 years or older with bacterial vaginosis and low-risk pregnancy were eligible for inclusion and were randomly assigned (2:1) to three parallel groups: single-course or triple-course 300 mg clindamycin twice-daily for 4 days, or placebo. Women with high-risk pregnancy outcomes were eligible for inclusion in a high-risk subtrial and were randomly assigned (1:1) to either single-course or triple-course clindamycin. The primary outcome was a composite of late miscarriage (16-21 weeks) or spontaneous very preterm birth (22-32 weeks), which we assessed in all patients with delivery data (modified intention to treat). Adverse events were systematically reported. This study is registered with ClinicalTrials.gov, number NCT00642980. FINDINGS: Between April 1, 2006, and June 30, 2011, we screened 84 530 pregnant women before 14 weeks' gestation. 5630 had bacterial vaginosis, of whom 3105 were randomly assigned to groups in the low-risk trial (n=943 to receive single-course clindamycin, n=968 to receive triple-course clindamycin, and n=958 to receive placebo) or high-risk subtrial (n=122 to receive single-course clindamycin and n=114 to receive triple-course clindamycin). In 2869 low-risk pregnancies, the primary outcome occurred in 22 (1·2%) of 1904 participants receiving clindamycin and 10 (1·0%) of 956 participants receiving placebo (relative risk [RR] 1·10, 95% CI 0·53-2·32; p=0·82). In 236 high-risk pregnancies, the primary outcome occurred in 5 (4·4%) participants in the triple-course clindamycin group and 8 (6·0%) participants in the single-course clindamycin group (RR 0·67, 95% CI 0·23-2·00; p=0·47). In the low-risk trial, adverse events were more common in the clindamycin groups than in the placebo group (58 [3·0%] of 1904 vs 12 [1·3%] of 956; p=0·0035). The most commonly reported adverse event was diarrhoea (30 [1·6%] in the clindamycin groups vs 4 [0·4%] in the placebo group; p=0·0071); abdominal pain was also observed in the clindamycin groups (9 [0·6%] participants) versus none in the placebo group (p=0·034). No severe adverse event was reported in any group. Adverse fetal and neonatal outcomes did not differ significantly between groups in the high-risk subtrial. INTERPRETATION: Systematic screening and subsequent treatment for bacterial vaginosis in women with low-risk pregnancies shows no evidence of risk reduction of late miscarriage or spontaneous very preterm birth. Use of antibiotics to prevent preterm delivery in this patient population should be reconsidered. FUNDING: French Ministry of Health.

Activities at risk of lead exposure and lead poisoning in children of travellers' families in charente, France.

Background: -A study to assess lead exposure of traveller children aged from 9 months to 18 years old was conducted in Charente-France between 2017 and 2019. Methods: A face-to-face questionnaire was administered to each participating family (N = 78). Blood samples were collected, and in case of lead poisoning, an environmental survey of soil, dust and water samples was also performed. Results: -Among the 100 children, they were 39 girls and 61 boys. Among them, 40 suffered from lead poisoning (Blood Lead Level ≥50 µg/L). Being a boy aged between 11 and 14 years old, and participating in lead exposure at-risk activities were significantly associated with higher mean blood lead level. Conclusion: -The high levels of lead detected advocate the reinforcement of lead poisoning screening for all children in the traveller population.

Lifestyle Patterns of Children Experiencing Homelessness: Family Socio-Ecological Correlates and Links with Physical and Mental Health.

Diet, screen time, physical activity, and sleep combine into lifestyle patterns with synergistic effects on health. This study aimed to identify lifestyle patterns in children without housing and assess their associations with physical and mental health and family socio-ecological factors. In the 2013 ENFAMS cross-sectional survey (children aged 6-12 experiencing homelessness, Greater Paris area, n = 235), parents reported socio-ecological factors, children's behaviours, and mental health (the latter was also child-reported). Nurses measured children's haemoglobin concentrations and body mass index. Principal component analysis was used to derive sex-specific lifestyle patterns. Hierarchical linear regressions and "outcome-wide" analyses assessed, respectively, these patterns' relations to health and family socio-ecological factors. A rather healthy lifestyle pattern-similarly characterized by diverse diet and high sleep time-was identified, with slight differences by sex. Scores for this pattern were higher for children in food-secure or higher-income households, whose parents were proficient in French, who slept longer, or who received more social support compared to their counterparts, with some nuances by sex. Higher scores for this pattern were associated with higher prosocial behaviour scores (girls) and lower anxiety and hyperactivity-inattention symptoms scores (boys), but not with physical health. For this underserved and understudied population, the results highlight the importance of family socio-ecological factors in shaping the lifestyles and mental health of children.

Classification and Regression Trees for Bacterial Vaginosis Diagnosis in Pregnant Women Based on High-Throughput Quantitative PCR.

Bacterial vaginosis (BV) diagnosis in pregnancy is based on the Nugent score, which consists of semiquantitation of bacterial morphotypes. Limited data exist concerning molecular-based diagnosis in asymptomatic pregnant women. Using high-throughput quantitative PCR, 34 microorganisms were screened in asymptomatic pregnant women and compared with the Nugent score. Three-hundred and four vaginal samples had a Nugent score <7 (69.9%) and 131, a Nugent score ≥7 (30.1%), consistent with BV. More pregnant women with BV share Atopobiumvaginae, bacterial vaginosis associated bacteria-2, Gardnerella spp., Mobiluncus curtisii, Mo. mulieris, Mycoplasma hominis, Ureaplasma urealyticum, Prevotella bivia, Megasphaera 1, and Megasphaera 2 in their vaginal sample. Fewer pregnant women with BV share Lactobacillus crispatus, L. gasseri, L. jensenii, and Enterococcus faecalis in their vaginal sample (P < 0.001). Classification and regression tree analysis was performed to determine which combinations of detected bacteria optimally diagnose BV in this population. A set of only four bacteria of 34 microorganisms (A. vaginae, Gardnerella spp., L. crispatus, and P. bivia) was the best combination to identify BV in a cohort of asymptomatic pregnant women, with a sensitivity of 77.1%, and specificity of 97.0% compared with the Nugent score. The quantitative PCR in the present study responds to the limits of the Nugent score by implementing an easily reproducible quantitative assay to assess the absence of BV in pregnancy.

Prevention of spontaneous preterm birth: Guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF).

In France, 60,000 neonates are born preterm every year (7.4%), half of them after the spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated with decreased prematurity (level of evidence [LE]1). It is therefore recommended (Grade A). Routine screening and treatment of vaginal bacteriosis is not recommended in the general population (Grade A). The only population for which vaginal progesterone is recommended is that comprising asymptomatic women with singleton pregnancies, no history of preterm delivery, and a short cervix at 16-24 weeks of gestation (Grade B). A history-indicated cerclage is not recommended for women with only a history of conization (Grade C), uterine malformation (professional consensus), isolated history of preterm delivery (Grade B), or twin pregnancies for primary (Grade B) or secondary (Grade C) prevention of preterm birth. A history-indicated cerclage is recommended for a singleton pregnancy with a history of at least 3 late miscarriages or preterm deliveries (Grade A). Ultrasound cervical length screening is recommended between 16 and 22 weeks for women with a singleton previously delivered before 34 weeks gestation, so that cerclage can be offered if cervical length <25mm before 24 weeks (Grade C). A cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with twin pregnancies (Grade A) or in populations of asymptomatic women with a short cervix (professional consensus). Although the implementation of universal screening by transvaginal ultrasound for cervical length at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In cases of preterm labor, (i) it is not possible to recommend any one of the several methods (ultrasound of the cervical length, vaginal examination, or fetal fibronectin assay) over any other to predict preterm birth (Grade B); (ii) routine antibiotic therapy is not recommended (Grade A); (iii) prolonged hospitalization (Grade B) and bed rest (Grade C) are not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (Grade B), unlike beta-agonists (Grade C), can be used for tocolysis in spontaneous preterm labor without preterm premature rupture of membranes. Maintenance tocolysis is not recommended (Grade B). Antenatal corticosteroid administration is recommended for all women at risk of preterm delivery before 34 weeks of gestation (Grade A). After 34 weeks, the evidence is insufficiently consistent to justify recommending systematic antenatal corticosteroid treatment (Grade B), but a course of this treatment might be indicated in clinical situations associated with high risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (Grade C). Repeated courses of antenatal corticosteroids are not recommended (Grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended for women at high risk of imminent preterm birth before 32 weeks (Grade A). Cesareans are not recommended for fetuses in vertex presentation (professional consensus). Both planned vaginal and elective cesarean delivery are possible for breech presentations (professional consensus). Delayed cord clamping may be considered if the neonatal or maternal state allows (professional consensus).

Vaginal Mucosal Homeostatic Response May Determine Pregnancy Outcome in Women With Bacterial Vaginosis: A Pilot Study.

Bacterial vaginosis (BV) is considered as a trigger for an inflammatory response that could promote adverse pregnancy outcome (APO). We hypothesized that BV-related inflammation could be counterbalanced by anti-inflammatory and mucosal homeostatic responses that could participate in pregnancy outcomes.A total of 402 vaginal self-samples from pregnant women in their first trimester were screened by Nugent score. In this population, we enrolled 23 pregnant women with BV but without APO, 5 pregnant women with BV and developing APO, 21 pregnant women with intermediate flora, and 28 random control samples from pregnant women without BV or APO.BV without APO in pregnant women was associated with 28-fold interleukin-8, 5-fold interleukin-10, and 40-fold interleukin-22 increases in expression compared to controls. BV associated with APO in pregnant women shared 4-fold increase in tumor necrosis factor, 100-fold decrease in interleukin-10, and no variation in interleukin-22 expressions compared to controls. Next-generation sequencing of vaginal microbiota revealed a shift from obligate anaerobic bacteria dominance in BV without APO pregnant women to Lactobacillus dominance microbiota in BV with APO.Our results show that the anti-inflammatory and mucosal homeostatic responses to BV may determine outcome of pregnancy in the setting of BV possibly through effects on the vaginal microbiota.