Pediatric private practice in the Nord-Pas-de-Calais region: Demographics, organization, and challenges.

While the needs for pediatric care are increasing and becoming more diverse, pediatric private practice in France is encountering difficulties linked to a growing medical demographic deficit. The objective of this study was to give an overview of pediatric private practice in the Nord-Pas-de-Calais region and to describe the main challenges encountered. METHODS: For this descriptive observational survey, private practice pediatricians in the Nord-Pas-de-Calais region filled out an online questionnaire between April 2019 and October 2020. RESULTS: The response rate was 64%. Most respondents practiced in an urban area (87%) and shared the practice with other physicians (59%). A majority (85%) had previously worked in hospital; 65% reported training in a subspecialty. Overall, 48% had other professional activities; 28% worked night shifts and 96% accepted urgent requests for consultations. A total of 33% reported having difficulties contacting specialists for consults, and 46% had difficulties in obtaining written reports of their patients' hospitalizations. All respondents participated in a form of ongoing medical education. The main difficulties were: lack of information about how to found a private practice (68%), lack of personal time (61%), balance between medical and administrative work (59%), and an excess of patients to care for (57%). The main satisfactions were: trusting relationships with patients (98%), freedom in their choice of practice (85%), and the diversity of problems and situations encountered (68%). CONCLUSION: Our study underlines that private practice pediatricians are involved in healthcare provision, in particular regarding ongoing medical training, subspecialties, and continuity of care. It also highlights the problems encountered and the possible improvements: developing better communication between private practice and hospitals, reinforcing training during residency, and highlighting the importance and complementarity of private practice in children's healthcare.

Changes in pediatric emergency department visits during a COVID-19 lockdown period: An exhaustive single-center analysis.

BACKGROUND: In many countries, the restrictions related to the first period of lockdown during the coronavirus disease 2019 (COVID-19) pandemic led to widespread changes in health service usage in general and in emergency departments in particular. However, no comprehensive evaluation of changes has been published to date. The objective of the present study was to determine the precise impact of the 2020 lockdown on admissions to a pediatric emergency department (PED) compared to the same periods in 2018 and 2019. METHODS: This retrospective, observational study included all patients under the age of 183 months (15.25 years) admitted to our French university hospital's PED during the period from March 17 to May 11 in the years 2018, 2019, and 2020. The primary outcome was the change in PED admissions in 2020 compared to 2018 and 2019. The secondary outcomes were notably changes in the primary discharge diagnoses, the discharge destination, and unwarranted visits. RESULTS: A total of 10,479 PED visits were identified, of which 10,295 were analyzed. In 2020, the number of PED visits fell by 61% and 63% vs. 2018 and 2019, respectively. Although the number of discharges to other hospital departments decreased by 52% and 49%, the proportion of these discharges increased: 18% of 1579 in 2020 vs. 13% of 4232 in 2018 and of 4484 in 2019 (p<0.01). Discharge from the PED to the intensive care unit was significantly more frequent in 2020 (p<0.05). Unwarranted visits were significantly lower in 2020 (19%) as compared to 2018 (22%) and 2019 (24%). Surgical and injury-related discharge diagnoses increased by 6% in 2020 (p<0.001), with a significant rise in trauma and foreign-body injuries (p<0.05). With regard to disease-related discharge diagnoses, we observed a significant rise in mental, behavioral, and social issues (p<0.01). Conversely, there was a significant (p<0.01) drop in diagnoses of acute infectious diseases in 2020 compared with 2018 and 2019. CONCLUSION: Lockdown was associated with a massive reduction in the number of PED visits, a significant change in primary discharge diagnoses, and a decrease in the proportion of unwarranted PED visits compared to the previous 2 years. This should encourage public health researchers to examine how to alleviate the burden of unnecessary PED visits.

[Should French pregnant women be vaccinated against pertussis during pregnancy?] / Faut-il vacciner les femmes enceintes françaises contre la coqueluche ?

Many countries with a high perinatal level have started a policy of vaccination of pregnant women against pertussis. To date, France has not chosen this policy. The objective was to review knowledge on pertussis mortality in infants. Compare the strategies available to protect the infant before his first vaccination, scheduled for two months of age. We proceeded to a litterature analysis, from January 1998 to 2021. Search by the following keywords used ; "Whooping cough, vaccination, pregnancy, strategy, cocooning", on the scientific basis of "Pubmed", as well as French and foreign vaccination recommendations. Currently 90% of whooping cough deaths are concerning infants under six months of age and this mortality represents 2% of mortality in the first year of life. Vaccination at birth is not effective. The cocooning strategy, which consists of vaccinating those around the child, is expensive and difficult to implement. A systematic vaccination policy for pregnant women is effective and reasonably expensive when compared to the cocooning strategy. In England, it was recently accompanied by a 78% reduction in confirmed cases of pertussis in infants under six months of age. In conclusion, compared to cocooning strategy, pertussis vaccination of pregnant women appears more effective and cost-effective, and this with each pregnancy.

Child abuse and neglect in a pediatric emergency department: epidemiology and outcome.

INTRODUCTION: Managing child abuse and neglect in pediatric emergency departments (PEDs) is difficult because of the complexity of screening and the prolonged care process. This study's main objective was to measure the child protection activity in a PED. METHODS: A retrospective, single-center study was conducted in the PED of the Lille University Hospital from 16 September∫2017 to 11 February 2019. All patients who required a social evaluation by the PED staff were included. Children admitted at first to the PED but for whom social management was exclusively performed by other units were not included. The whole population was analyzed first and then by type of abuse. The primary endpoint was the rate of patients who needed social management in the PED. The length of stay in the PED, the number of reports for investigation by child protective services, and reports to a judge were secondary assessment criteria. RESULTS: The study involved 245 patients (median age, 5 years; interquartile range [IQR], 2-13; boys, 49%), accounting for 0.6% of the PED visits. The main reasons for visiting the PED were somatic complaints (31%), sexual assault (23%), and behavioral disorders (20%). The median length of care in the PED was 5 h (IQR, 3-13). Thirty-three percent of the patients were monitored in the short-stay unit of the PED; 78% returned home. The main social measures taken were reports to child protective services (34%) and reports to a judge (24%); 51% of the patients required further actions by the PED physician after discharge. CONCLUSION: Management of child abuse in the PED is important and time-consuming. A hospital team specialized in child protection is essential for the initial care and monitoring of child victims.

Evolution between 2008 and 2018 of mothers' perception regarding vaccination and infant vaccine coverage in France.

OBJECTIVE: Monitoring of vaccination coverage rates (VCRs) is essential to assess the implementation of a country's vaccine policy and its effectiveness. Through the French Vaccinoscopy study, we measured the evolution of VCRs as well as mothers' opinion towards vaccination between 2008 and 2018, before and after implementation of infant mandatory vaccination extension. METHODS: This is a study based on an internet-standardised questionnaire. In 2018, a representative sample of 3000 mothers of infants 0 to 35 months of age answered on their opinion on vaccination and reported all vaccinations recorded in their child's health record. RESULTS: On the period considered, infant VCRs were stable and high for diphtheria, tetanus, poliomyelitis, pertussis and pneumococcus components and progressed for measles, mumps rubella, 2 doses at 24 months of age from 45.3% in 2008 to 81.0% in 2018, hepatitis B (HepB) complete primovaccination at 6 months of age from 45.9% in 2008 to 86.3% in 2017 and 95.5% in 2018, and meningococcus C (MenC) 1 dose at 6 months of age from 43.0% in 2017 to 74.2% in 2018. In 2018, 69.0% of mothers were in favour of vaccination while this rate dropped from 80.2% in 2012 to 64.0% in 2017, and 80.8 to 89.6% perceived HepB, MenC measles and pertussis vaccinations as useful/essential, percentages in progress versus 2017. CONCLUSION: Following the implementation of infant mandatory vaccination in 2018, proportion of mothers in favour of vaccination increased significantly. HepB and MenC VCRs significantly progressed between 2017 and 2018.

Simulation-based pediatric training: A French national survey.

INTRODUCTION: To have an overview of pediatric medical simulation within a country would be helpful to improve the offer and quality of teaching. The main objective of this study was to identify the scope for simulation-based teaching in pediatrics in France. METHODS: An assessment of professional practices was conducted by means of a national survey conducted among all university hospitals between 20 May and 6 August 2018. A standardized GoogleForm® was created and sent to heads of simulation centers or persons responsible for pediatric simulation. Descriptive analyses and comparisons of centers with and without university trainers as well as with and without research activity were performed. RESULTS: All 34 teaching hospitals or faculties of medicine responded to our survey. Of these, 31 had a simulation center. There was a median of nine trainers per center (interquartile range: 5-13). Most used simulation for communication and teamwork, as well as for technical and relational skills. These sessions were mainly dedicated to residents and health professionals. All centers reported working on high-fidelity newborn mannequins and 84% used low-fidelity newborn mannequins. Research activity was declared by 14 centers (45%), but only six of these had at least one publication. No difference was identified between centers with and without university trainers or with and without research activity. CONCLUSION: Compared with the 2012 report, 19 new centers have emerged within 6 years in France (+158%). Pursuing research to evaluate the impact of simulation programs on physician skills and patient management would appear to be important.

Infant mandatory vaccinations: Confirmation of a positive impact.

OBJECTIVE: Infant vaccines protecting against 11 diseases have changed from recommended to mandatory status in France for all children born from first of January 2018. Through Vaccinoscopie survey, we measured for the second consecutive year the impact of this new policy on vaccine coverage rates (VCRs) and mothers' perception regarding vaccination. METHODS: Web-based survey on a representative sample of 1500 mothers of 0 to 17-month-old infants. RESULTS: Non-optimal VCRs continued to increase in 2019 versus 2017 (according to age, +7 to 8 points VCR for Hepatitis B and +36 to 68 points for Meningococcus C). After a progressive decrease between 2012 and 2017, the rate of favorable mothers' opinion towards vaccination continued to progress in 2018 and 2019. CONCLUSION: These results confirmed the positive impact of this new law on infant VCRs and mothers' favorable opinion regarding vaccination.

Meningococcal C vaccine coverage in France in infants, children, and adolescents.

OBJECTIVES: Meningococcal C (MenC) vaccination was introduced in the French vaccination calendar in 2010 to reduce the incidence of invasive meningococcal C disease (IMDC), mainly through herd immunity. The Vaccinoscopie survey helps follow vaccination coverage rates (VCRs) of children. METHODS: This annual survey is based on a self-administered online questionnaire. In 2017, 4500 mothers of children completed the questionnaire and reported all vaccinations recorded in their child's health record. RESULTS: MenC vaccination was deemed indispensable or useful by 77% to 84% of mothers. The main barrier mentioned by mothers considering the vaccination useless/not very useful, was fear of adverse effects. VCR was estimated at 77% among 24-35-month-old infants, 79% among 6-year-old children, and 50% among 14-15-year-old adolescents. VCR strongly varied depending on the physician's advice for vaccination and on the type of follow-up. Six months after publication of the new French vaccine calendar in April 2017, with a MenC vaccine recommendation for all 5-month-old infants, 43% of infants had received a dose at 6 months of age. CONCLUSIONS: VCRs are insufficient to reach herd immunity. Between 2011 and 2017 more than 100 deaths could have been avoided in France if optimal VCRs had been achieved. Faced with this vaccine strategy failure, the new vaccine recommendation at 5 months of age seems well-accepted. This recommendation and the implementation of infant mandatory vaccination in 2018 should have a major impact on IMD C incidence in this age group.

Parental acceptance of an intranasal vaccine: Example of influenza vaccine.

BACKGROUND: Influenza vaccination coverage of children with chronic disease is insufficient in France, although a nasal live attenuated influenza vaccine (LAIV) has been approved. OBJECTIVE: We aimed to evaluate the acceptance of nasally administered vaccines by parents of children with chronic illness, by comparing LAIV vs. injectable inactivated influenza vaccine (IIV) acceptance. METHODS: We performed a retrospective, observational study (December 2014 to April 2015) including parents of all children vaccinated with the LAIV during the 2013-2014 influenza vaccination campaign at our university hospital. It was an opinion survey on the tolerance and acceptance of the LAIV. RESULTS: A standardized evaluation form was completed by 67/79 parents of all children who received the LAIV (mean age: 113±56 months; 64% with a chronic respiratory disease). The parents responded that vaccines in general were important (99%) but only 58% of them accepted the injectable route of administration. Of the 48 parents of children who had received both LAIV and IIV in the past, global opinion (P<0.0001) and tolerance (P<0.0001) were better for LAIV. For the future, 81% of parents would prefer LAIV, mainly because of needle absence and/or less painful character, and 18% IIV, mainly because of easier administration or habit. CONCLUSION: The better acceptance of a nasally administrated vaccine could increase vaccination coverage in the future for nasal vaccines.

Impact of mandatory vaccination extension on infant vaccine coverages: Promising preliminary results.

OBJECTIVE: In France infant vaccines protecting against 11 diseases have changed from a recommended to a mandatory status for all children born on or after January 1, 2018. Using the Vaccinoscopie survey, we measured the impact of this new vaccination policy on vaccine coverage rates (VCRs) and on mothers' perception of vaccination. METHODS: Online survey with 1000 mothers of 0- to 11-month-old infants. RESULTS: VCRs for at least one dose at the age of 6 months strongly progressed for diseases that previously did not meet Public Health objectives (+8 points for Hepatitis B and +31 points for meningococcal C vaccines). Mothers were more favorable to mandatory vaccination and better informed in 2018 than in 2017. CONCLUSION: These first results showed a positive impact of the extension of mandatory vaccination on mothers' opinion regarding vaccination and on infant VCRs.

Impact of the Sofia® Influenza A+B FIA rapid diagnostic test in a pediatric emergency department.

OBJECTIVE: The objective of this study was to evaluate the impact of a rapid diagnostic test for influenza (the Sofia® Influenza A+B FIA rapid diagnostic test [RDT]) in a pediatric emergency department (PED). METHODS: A retrospective, observational, cross-sectional study was conducted in the PED of the Lille University Hospital between 2013 and 2015. All patients under 18 years of age for whom influenza RDT was administered were included. Clinical data, management, and related hospitalizations were compared between positive and negative RDT groups. The length of stay in the PED (main outcome) and the number of additional tests (biological and radiographic tests) between the two groups were compared. RESULTS: A total of 238 tests were reported: 119 positive, 110 negative, nine invalid. The mean length of stay in the PED was significantly lower in the positive RDT group: 4.0h vs. 7.4h (P<10-6). Patients with positive RDT had significantly fewer biological tests (20% vs. 56%; P<10-7) and radiographs (23% vs. 52%; P<10-5). The prevalence of hospitalizations in a short-stay unit was significantly lower in patients with positive RDT (0.8% vs. 9.1%; P=0.009). CONCLUSIONS: This study showed a significant medical impact of the use of Sofia® Influenza RDT A+B FIA in a PED regarding the length of stay and the number of additional explorations.

Extended-spectrum ß-lactamase-producing Enterobacteriaceae, national study of antimicrobial treatment for pediatric urinary tract infection.

OBJECTIVE: To evaluate clinical practices for ESBL-producing urinary tract infection (UTI) in France. METHODS: We performed an observational, retrospective, cross-sectional, hospital-based study in 22 pediatric departments of university or secondary care hospitals. We collected data of the last five patients presenting with ESBL-producing UTI in 2012 and the physicians' therapeutic approach to two case vignettes of acute non-septic ESBL-producing pyelonephritis (7-month-old girl) and cystitis (30-month-old girl). The adequacy of the therapeutic decision was analyzed by a panel of independent infectious disease experts. RESULTS: A total of 80 case patients of ESBL-producing UTI were collected: 54 with acute pyelonephritis (mean age: 28 months, female: 66%), of whom 98% received an intravenous ESBL-adapted antibiotic treatment and 55% a two-drug antibiotic therapy. Carbapenems were used in 56% of cases and aminoglycosides in 36%. Of the 26 cystitis patients (mean age: 5 years, female: 73%), 85% were treated with antibiotics, including three intravenously (carbapenems=2). For the case vignettes, physicians (n=85) would have treated the pyelonephritis patient with carbapenems (76%) and/or aminoglycosides (68%); 71% would have used a two-drug antibiotic treatment. The cystitis patient would have been treated intravenously by 29% of physicians; 8% would have used a two-drug antibiotic treatment, 16% would have prescribed carbapenems, and 11% aminoglycosides. Antibiotic treatments were deemed appropriate in 37% of cases. CONCLUSIONS: Antimicrobial treatment for ESBL-producing UTI greatly varies, and carbapenems are excessively prescribed. Specific guidelines for ESBL infections are required.

Vaccination of pregnant women in France.

OBJECTIVE: Vaccination of pregnant women against seasonal influenza is recommended in France since 2010. We currently do not have any vaccination coverage (VC) data to assess the implementation of this recommendation. METHODS: Vaccinoscopie® is an annual study conducted online using a self-administered questionnaire. A section dedicated to parents' vaccination was included in 2014 and aimed at interviewing 300 mothers of infants aged<12 months to assess their opinion of vaccination with regard to their last and future pregnancies. The study also aimed to measure the influenza VC of these mothers during their last pregnancy. RESULTS: While 56% of mothers reported to have been informed of the importance of vaccination by a healthcare professional (HCP) during their last pregnancy, only 11% reported having been informed of the importance of influenza vaccination. Overall, 49% of mothers reported willing to be vaccinated during their next pregnancy to protect their baby, if the vaccination were to be recommended by a HCP. However, this rate was only 32% for influenza vaccination. In contrast, 52% of mothers reported willing to be vaccinated against pertussis during pregnancy if the vaccination were to be recommended by a HCP. The influenza VC estimates in pregnant women was 7%. CONCLUSION: Although influenza vaccination has been recommended for all French pregnant women for the past five years, HCPs rarely recommend this vaccination - hence, the low VC. Informing and raising awareness among HCPs seems to be crucial to improve this coverage.

[Is the simplification of the immunization schedule applied? Review 2 years after its implementation]. / La simplification du calendrier vaccinal est-elle appliquée ? Bilan 2ans après sa mise en place.

Repeating evaluations of vaccine coverage (VC) is essential to measure the implementation and effectiveness of vaccination policy. We report the results of VC in infants from the Vaccinoscopie® study in 2014 to assess the changes secondary to the new 2013 immunization schedule. METHOD: Study conducted on Internet among a representative sample of mothers reporting their child's vaccination record. RESULTS: The removal of the dose of DTPa-Hib at the age of 3 months was quickly adopted since only 1 % of children aged 6 months had received three doses of DTPa in 2014 compared to 96 % in 2012. The booster dose is administered earlier for the DTPa and hepatitis B components. The shift of MMR vaccination from 9 months of age for children participating in community structures to 12 months for all children was closely followed since only 2 % of 9- to 11-month-old children received a MMR vaccine in 2014 compared to 33 % in 2012. The second dose of MMR recommended at 16-18 months of age rather than between 13 and 24 months was actually followed by an earlier administration of this dose. At 18-20 months of age, 60 % received two doses of MMR in 2014 versus 41 % in 2012. Finally, for meningitis C vaccination, a significant increase of VC was observed in children 15-23 months of age (66 % in 2014 versus 44 % in 2012). CONCLUSION: The simplification of the infant immunization schedule was quickly applied and received excellent support from healthcare professionals. However, this measure alone is still not sufficient to meet the CV objectives defined by the HCSP.

Pertussis vaccination coverage among French parents of infants after 10years of cocoon strategy.

OBJECTIVES: The cocoon strategy against pertussis has been recommended in France since 2004 to indirectly protect young infants who are not yet vaccinated. We aimed to measure vaccination coverage among French parents of infants. METHODS: A representative sample of 300 mothers and 200 fathers of infants aged <12 months completed a self-administered online questionnaire. They all provided their own vaccination records. RESULTS: Overall, 87% of mothers believed vaccination against pertussis to be important; 83% reported being immunized against pertussis but their vaccination records showed that a third of them was wrong (34%). On the basis of our sample, the 2009-2014 vaccination coverage against pertussis among mothers increased from 22 to 61% (P<0.005); over the same period of time, vaccination coverage against diphtheria, tetanus, and polio remained stable (80%). Vaccination coverage against pertussis among fathers increased from 21 to 42% between 2010 and 2013 (P=0.009). In 2013, one couple out of four (26%) was adequately immunized against pertussis. CONCLUSION: The cocoon strategy was implemented 10years ago in France but vaccination coverage remains suboptimal among parents of young infants. Healthcare professionals must recommend vaccination against pertussis to young adults and check that their vaccination status is up to date.

The impact of the web and social networks on vaccination. New challenges and opportunities offered to fight against vaccine hesitancy.

OBJECTIVE: Vaccine hesitancy is a growing and threatening trend, increasing the risk of disease outbreaks and potentially defeating health authorities' strategies. We aimed to describe the significant role of social networks and the Internet on vaccine hesitancy, and more generally on vaccine attitudes and behaviors. METHODS: Presentation and discussion of lessons learnt from: (i) the monitoring and analysis of web and social network contents on vaccination; (ii) the tracking of Google search terms used by web users; (iii) the analysis of Google search suggestions related to vaccination; (iv) results from the Vaccinoscopie(©) study, online annual surveys of representative samples of 6500 to 10,000 French mothers, monitoring vaccine behaviors and attitude of French parents as well as vaccination coverage of their children, since 2008; and (v) various studies published in the scientific literature. RESULTS: Social networks and the web play a major role in disseminating information about vaccination. They have modified the vaccination decision-making process and, more generally, the doctor/patient relationship. The Internet may fuel controversial issues related to vaccination and durably impact public opinion, but it may also provide new tools to fight against vaccine hesitancy. CONCLUSION: Vaccine hesitancy should be fought on the Internet battlefield, and for this purpose, communication strategies should take into account new threats and opportunities offered by the web and social networks.

Impact of the 13-valent pneumococcal conjugate vaccine on the incidence of pneumococcal meningitis in children.

The impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on the incidence of pneumococcal meningitis (PM) in children is unknown. To determine this impact, a descriptive multicentre retrospective cohort study was conducted from 2008 to 2013 in northern France. All laboratory-confirmed PM in children aged <18 years in all hospitals of the area with paediatric units were included. Two independent databases were used for exhaustive identification of cases: medical plus laboratory records at each hospital and discharge codes. The corrected incidence of PM was determined by a capture-recapture analysis using these two databases. Sixty-two cases were found over the 6-year period. A decrease of the PM corrected incidence was observed in the global population (P = 0·07), significant only for children aged <2 years, from 11·9/100 000 in 2008 in 1·9/100 000 in 2013 [6·4 fold-decrease, 95% confidence interval (CI) 1·4-41, P = 0·01] between years 2008 and 2013. When comparing the pre- and post-PCV13 periods, this decrease was still statistically significant for children aged <2 years [7·32/100 000 (95% CI 4·39-10·25) to 2·78/100 000 (95% CI 0·96-4·60), P = 0·01]. Only three (5%) cases of PM caused by vaccine serotypes could have been prevented. After the introduction of the PCV13 vaccine, a decrease in the incidence of PM cases in children in northern France was observed.