Cost-effectiveness of vaccination against cytomegalovirus (CMV) in adolescent girls to prevent infections in pregnant women living in France.

BACKGROUND: CMV infections are the most frequent congenital infections worldwide. AIM: Assess the cost-effectiveness of vaccination strategies of adolescent girls vs. current practice (hygiene counseling) to prevent CMV seroconversions during pregnancy in France. METHOD: A Markov decision-tree model simulated overtime the trajectory of a single fictive cohort of 390,000 adolescent women aged 14 years old, living in France. Impact of vaccination was explored until the end of their reproductive live 40 years later. STRATEGIES COMPARED: "S1: No vaccination" (current practice); "S2: Routine vaccination"; "S3: Screening and vaccination of the seronegative". MODEL PARAMETERS: Seroconversion rate without vaccination (0.035%/pregnant woman-week); fetal transmission risk (41%). Vaccine vs. no vaccination: a 50% decrease in maternal seroconversions. OUTCOMES: Quality-Adjusted Life-Years (QALYs) of the cohort-born babies; discounted costs; Incremental Cost-Effectiveness Ratio (ICER). RESULTS: S2 was the most effective strategy (with 35,000 QALYs gained) and the most expensive (€211,533,000); S1 was the least effective and least costly (€75,423,000). ICERs of strategy S3 vs. S1, and S2 vs. S3 were 6,000€/QALY gained (95% uncertainty range [2700-13,300]) and 16,000€/QALY [negative ICER (S3 dominated by S2) - 94,000] gained, respectively; highly cost-effective because ICER < 1∗France's GPD/capita = €30,000. SENSITIVITY ANALYSIS: If the seroprevalence was >62% (vs. 20% in the base case), S3 would become the most efficient strategy. CONCLUSION: In France, systematic vaccination of adolescent girls was the most efficient strategy to prevent maternal seroconversions. If the population was less than 62% immune, systematic screening and vaccination of susceptibles would become the most cost-effective approach.

[Observational study of a social device for women in precarious situations during pregnancy and post-partum]. / Étude observationnelle d'un dispositif d'aide aux femmes en situation de précarité pendant la grossesse et le post-partum.

OBJECTIVES: To assess the impact of the Regional experimental accompanying nutrition and breast-feeding for pregnant women (PRENAP) 75 social device on the duration of postpartum hospitalization and breast-feeding for pregnant women in precarious situation. METHODS: A retrospective observational study took place between November 2013 and May 2015 in a type III Parisian maternity. Comparison of sociodemographic, perinatal and postpartum characteristics of women in precarious situations (no stable housing and no social care or universal medical coverage or state medical aid) was done according to whether they were included in the system PRENAP or not. RESULTS: Over the study period, 344 (4.6%) women in precarious situations gave birth in this maternity. Among these women, the women included in the PRENAP system were more frequently in a very unfavorable social situation than those who were not included. The inclusion in the PRENAP device did not reduce the hospitalization in post-partum. Breast-feeding was chosen more frequently by the women included in the PRENAP device. CONCLUSION: The PRENAP device seems to favor the use of breast-feeding, but is not associated with a diminution of the hospitalization time in post-partum. This social device, which seems to be beneficial in terms of social and medical support for women in precarious situations, deserves to be evaluated prospectively.

[Social inequalities in maternal health]. / Inégalités sociales de santé maternelle.

Although medical literature on social inequalities in perinatal health is qualitatively heterogeneous, it is quantitatively important and reveals the existence of a social gradient in terms of perinatal risk. However, published data regarding maternal health, if also qualitatively heterogeneous, are relatively less numerous. Nevertheless, it appears that social inequalities also exist concerning severe maternal morbidity as well as maternal mortality. Analyses are still insufficient to understand the mechanisms involved and explain how the various dimensions of the women social condition interact with maternal health indicators. Inadequate prenatal care and suboptimal obstetric care may be intermediary factors, as they are related to both social status and maternal outcomes, in terms of maternal morbidity, its worsening or progression, and maternal mortality.

[Social inequalities in perinatal health]. / Inégalités sociales en santé périnatale.

Social insecurity is a known perinatal risk factor but beyond that, a social gradient in perinatal health is observable. This social gradient is particularly visible for the risk of neonatal mortality from congenital anomalies, premature delivery, and low birth weight. Analysis of mechanisms that would explain how the different dimensions of the social status of women interact with perinatal health indicators are not to this day fully understood. However, numbers of intermediate factors related to both the social status and perinatal risk have been identified. Among them, smoking, drug use, exposure to psychological and physical stress, genital infections, access to care, or drudgery. Finally, it was observed that the interaction of social conditions with the level of maternal education, geographic or ethnic origin, and the environment in which women live are complex and make the generalization of data obtained in a particular context sensitive.

[How to decide with precision, justice, and equity? Reflections on decision-making in the context of extreme prematurity. Part two: moving toward making the best possible decision: defining conditions for putting decisions into practice]. / Comment décider avec justesse, justice et équité? Réflexion sur la décision en situation d'extrême prématurité. Deuxième partie: comment tendre vers une décision optimale? Définition des conditions d'exercice de la décision.

Extreme premature child's long-term prognostic is getting better and better known, and if a resuscitation procedure is possible at birth, it won't guarantee survival or a survival free of disability. Incertitude toward individual prognosis and outcome for those children remains considerable. In this field, we are at the frontier of medical knowledge and the answer to the question, "how to decide the ante and postnatal care" is crucial. This work is focused on this problematic of decision-making in the context of extreme prematurity. It attempts to deconstruct this concept and to explicit its stakes. Thus, with the support of the medical sources and of philosophical debates, we tried to build a decision-making procedure that complies with the ethical requirements of medical care, accuracy, justice and equity. This decision-making procedure is primarily concerned with the singularity of each decision situation and it intends to link it closely to the notions of rationality and responsibility.

[How to decide with precision, justice, and equity? Reflections on decision-making in the context of extreme prematurity. Part one: the problematics of decision-making in the context of extreme prematurity]. / Comment décider avec justesse, justice et équité? Réflexion sur la décision en situation d'extrême prématurité. Première partie: problématique de la décision dans le contexte de la prématurité extrême.

Extreme premature child's long-term prognostic is getting better and better known, and if a resuscitation procedure is possible at birth, it won't guarantee survival or a survival free of disability. Incertitude toward individual prognosis and outcome for those childs remains considerable. In this field, we are at the frontier of medical knowledge and the answer to the question, "how to decide the ante and postnatal care?" is crucial. This work is focused on this problematic of decision making in the context of extreme prematurity. It attempts to deconstruct this concept and to explicit its stakes. Thus, with the support of the medical sources and of philosophical debates, we tried to build a decision-making procedure that complies with the ethical requirements of medical care, accuracy, justice and equity. This decision-making procedure is primarily concerned with the singularity of each decision situation and it intends to link it closely to the notions of rationality and responsibility.