Point of Care Strategy for Rapid Diagnosis of Novel A/H1N1 Influenza Virus

Within months of the emergence of the novel A/H1N1 pandemic influenza virus (nA/H1N1v), systematic screening for the surveillance of the pandemic was abandoned in France and in some other countries. At the end of June 2009, we implemented, for the public hospitals of Marseille, a Point Of Care (POC) strategy for rapid diagnosis of the novel A/H1N1 influenza virus, in order to maintain local surveillance and to evaluate locally the kinetics of the pandemic.Two POC laboratories, located in strategic places, were organized to receive and test samples 24 h/24. POC strategy consisted of receiving and processing naso-pharyngeal specimens in preparation for the rapid influenza diagnostic test (RIDT) and real-time RT-PCR assay (rtRT-PCR). This strategy had the theoretical capacity of processing up to 36 samples per 24 h. When the flow of samples was too high, the rtRT-PCR test was abandoned in the POC laboratories and transferred to the core virology laboratory. Confirmatory diagnosis was performed in the core virology laboratory twice a day using two distinct rtRT-PCR techniques that detect either influenza A virus or nA/N1N1v. Over a period of three months, 1974 samples were received in the POC laboratories, of which 111 were positive for nA/H1N1v. Specificity and sensitivity of RIDT were 100%, and 57.7% respectively. Positive results obtained using RIDT were transmitted to clinical practitioners in less than 2 hours. POC processed rtRT-PCR results were available within 7 hours, and rtRT-PCR confirmation within 24 hours.The POC strategy is of benefit, in all cases (with or without rtRT-PCR assay), because it provides continuous reception/processing of samples and reduction of the time to provide consolidated results to the clinical practitioners. We believe that implementation of the POC strategy for the largest number of suspect cases may improve the quality of patient care and our knowledge of the epidemiology of the pandemic

Detection of Extensive Cross-Neutralization between Pandemic and Seasonal A/H1N1 Influenza Viruses Using a Pseudotype Neutralization Assay

BACKGROUND: Cross-immunity between seasonal and pandemic A/H1N1 influenza viruses remains uncertain. In particular, the extent that previous infection or vaccination by seasonal A/H1N1 viruses can elicit protective immunity against pandemic A/H1N1 is unclear. METHODOLOGY/PRINCIPAL FINDINGS: Neutralizing titers against seasonal A/H1N1 (A/Brisbane/59/2007) and against pandemic A/H1N1 (A/California/04/2009) were measured using an HIV-1-based pseudovirus neutralization assay. Using this highly sensitive assay, we found that a large fraction of subjects who had never been exposed to pandemic A/H1N1 express high levels of pandemic A/H1N1 neutralizing titers. A significant correlation was seen between neutralization of pandemic A/H1N1 and neutralization of a standard seasonal A/H1N1 strain. Significantly higher pandemic A/H1N1 neutralizing titers were measured in subjects who had received vaccination against seasonal influenza in 2008-2009. Higher pandemic neutralizing titers were also measured in subjects over 60 years of age. CONCLUSIONS/SIGNIFICANCE: Our findings reveal that the extent of protective cross-immunity between seasonal and pandemic A/H1N1 influenza viruses may be more important than previously estimated. This cross-immunity could provide a possible explanation of the relatively mild profile of the recent influenza pandemic

Revolutionizing Clinical Microbiology Laboratory Organization in Hospitals with In Situ Point-of-Care

BACKGROUND: Clinical microbiology may direct decisions regarding hospitalization, isolation and anti-infective therapy, but it is not effective at the time of early care. Point-of-care (POC) tests have been developed for this purpose. METHODS AND FINDINGS: One pilot POC-lab was located close to the core laboratory and emergency ward to test the proof of concept. A second POC-lab was located inside the emergency ward of a distant hospital without a microbiology laboratory. Twenty-three molecular and immuno-detection tests, which were technically undemanding, were progressively implemented, with results obtained in less than four hours. From 2008 to 2010, 51,179 tests yielded 6,244 diagnoses. The second POC-lab detected contagious pathogens in 982 patients who benefited from targeted isolation measures, including those undertaken during the influenza outbreak. POC tests prevented unnecessary treatment of patients with non-streptococcal tonsillitis (n = 1,844) and pregnant women negative for Streptococcus agalactiae carriage (n = 763). The cerebrospinal fluid culture remained sterile in 50% of the 49 patients with bacterial meningitis, therefore antibiotic treatment was guided by the molecular tests performed in the POC-labs. With regard to enterovirus meningitis, the mean length-of-stay of infected patients over 15 years old significantly decreased from 2008 to 2010 compared with 2005 when the POC was not in place (1.43±1.09 versus 2.91±2.31 days; p = 0.0009). Altogether, patients who received POC tests were immediately discharged nearly thrice as often as patients who underwent a conventional diagnostic procedure. CONCLUSIONS: The on-site POC-lab met physicians' needs and influenced the management of 8% of the patients that presented to emergency wards. This strategy might represent a major evolution of decision-making regarding the management of infectious diseases and patient care

High Burden of Non-Influenza Viruses in Influenza-Like Illness in the Early Weeks of H1N1v Epidemic in France

BACKGROUND: Influenza-like illness (ILI) may be caused by a variety of pathogens. Clinical observations are of little help to recognise myxovirus infection and implement appropriate prevention measures. The limited use of molecular tools underestimates the role of other common pathogens. OBJECTIVES: During the early weeks of the 2009-2010 flu pandemic, a clinical and virological survey was conducted in adult and paediatric patients with ILI referred to two French University hospitals in Paris and Tours. Aims were to investigate the different pathogens involved in ILI and describe the associated symptoms. METHODS: H1N1v pandemic influenza diagnosis was performed with real time RT-PCR assay. Other viral aetiologies were investigated by the molecular multiplex assay RespiFinder19®. Clinical data were collected prospectively by physicians using a standard questionnaire. RESULTS: From week 35 to 44, endonasal swabs were collected in 413 patients. Overall, 68 samples (16.5%) were positive for H1N1v. In 13 of them, other respiratory pathogens were also detected. Among H1N1v negative samples, 213 (61.9%) were positive for various respiratory agents, 190 in single infections and 23 in mixed infections. The most prevalent viruses in H1N1v negative single infections were rhinovirus (62.6%), followed by parainfluenza viruses (24.2%) and adenovirus (5.3%). 70.6% of H1N1v cases were identified in patients under 40 years and none after 65 years. There was no difference between clinical symptoms observed in patients infected with H1N1v or with other pathogens. CONCLUSION: Our results highlight the high frequency of non-influenza viruses involved in ILI during the pre-epidemic period of a flu alert and the lack of specific clinical signs associated with influenza infections. Rapid diagnostic screening of a large panel of respiratory pathogens may be critical to define and survey the epidemic situation and to provide critical information for patient management

Likely Correlation between Sources of Information and Acceptability of A/H1N1 Swine-Origin Influenza Virus Vaccine in Marseille, France

BACKGROUND: In France, there was a reluctance to accept vaccination against the A/H1N1 pandemic influenza virus despite government recommendation and investment in the vaccine programme. METHODS AND FINDINGS: We examined the willingness of different populations to accept A/H1N1 vaccination (i) in a French hospital among 3315 employees immunized either by in-house medical personnel or mobile teams of MDs and (ii) in a shelter housing 250 homeless persons. Google was used to assess the volume of enquiries concerning incidence of influenza. We analyzed the information on vaccination provided by Google, the website of the major French newspapers, and PubMed. Two trust Surveys were used to assess public opinion on the trustworthiness of people in different professions. Paramedics were significantly more reluctant to accept immunisation than qualified medical staff. Acceptance was significantly increased when recommended directly by MDs. Anecdotal cases of directly observed severe infections were followed by enhanced acceptance of paramedical staff. Scientific literature was significantly more in favour of vaccination than Google and French newspaper websites. In the case of the newspaper websites, information correlated with their recognised political reputations, although they would presumably claim independence from political bias. The Trust Surveys showed that politicians were highly dis-trusted in contrast with doctors and pharmacists who were considered much more trustworthy. CONCLUSIONS: The low uptake of the vaccine could reflect failure to convey high quality medical information and advice relating to the benefits of being vaccinated. We believe that the media and internet contributed to this problem by raising concerns within the general population and that failure to involve GPs in the control programme may have been a mistake. GPs are highly regarded by the public and can provide face-to-face professional advice and information. The top-down strategy of vaccine programme management and information delivered by the Ministry of Health could have aggravated the problem, because the general population does not always trust politicians

Mise en place d un tableau de bord de suivi des indicateurs de prévention systématique et non orientée (audit de pratique chez les médecins généralistes de Gennevilliers, Asnières et Villeneuve-la-Garenne dans le cadre de l expérimentation des nouveaux modes de rémunération (eNMR))

PARIS7-Xavier Bichat (751182101) / SudocSudocFranceF

Evaluation des pratiques professionnelles en médecine générale

PARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

L'évaluation et la validation des étudiants en TCEMG dans les facultés d'Ile de France

Pratique ancestrale et universelle, le piercing connaît depuis quelques années un réel engouement. Comment et par qui est-il réalisé ? Quelle est l'ampleur du phénomène et sa signification ? Représente-t-il un risque pour la santé individuelle ou collective ? Le médecin est-il concerné ? Nous souhaitons apporter quelques éléments de réponses, à travers une revue de la littérature médicale constituée à partir du mot-clef " piercing ", la lecture d'ouvrages de sciences humaines consacrées aux modifications corporelles, la consultation de sites sur internet concernant le piercing et la réalisation d'une enquête auprès de jeunes lycéens et étudiants. Cette enquête tend à confirmer l'ampleur du phénomène et sa probable poursuite dans les années à venir. En effet 21,5 % des 418 jeunes interrogés ont un piercing ailleurs qu'aux lobes des oreilles et 25,8 % de 248 jeunes non percés comptent se faire percer prochainement. Les complications secondaires sont nombreuses, principalement loco-régionales, infectieuses et allergiques. Le risque de contamination par les virus des hépatites et du SIDA est établi et dépend essentiellement des conditions d'hygiène et de stérilisation. Un guide de bonne pratique a été adressé aux professionnels du piercing, mais aucune législation ne permet actuellement de vérifier l'application de ces recommandations. La pratique du piercing est donc toujours un problème de santé publique. Le médecin généraliste peut-être sollicité avant ou après la réalisation d'un piercing. Son rôle consiste à dépister les contre-indications, vérifier les vaccinations, rappeler les risques encourus et donner des conseils pour permettre une bonne cicatrisation et éviter les surinfections. Il doit se familiariser avec les dispositifs implantés, afin de pouvoir les retirer, le cas échéant, sans traumatiser inutilement les tissus.PARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Parler de sexualité avec son médecin généraliste (un problème pour les 15-18 ans)

PARIS7-Xavier Bichat (751182101) / SudocSudocFranceF

Action de promotion de la santé auprès des locataires de la résidence sociale AFTAM à Gennevilliers, Hauts-de-Seine

Nous avons effectué une action de promotion de la santé auprès des locataires de la résidence sociale AFTAM de Gennevilliers (Hauts de Seine), qui accueille une clientèle en situation de précarité. Dès l'ouverture de la résidence en fin 2001, plusieurs incidents de santé ont amené les gestionnaires du site à faire appel à des professionnels pour : - faire le point sur la santé des résidents, évaluer leur situation de précarité, les intégrer dans les circuits de soins de la ville et proposer des actions visant à renforcer leur accompagnement médico-social. Pour atteindre ces objectifs, il fallait : - mobiliser les résidents grâce à des entretiens individuels et à une réunion plénière sur le site. - Constituer un dossier médico-social exhaustif à partir des données de la littérature sur le dépistage et la prévention et de 4 dossiers utilisés dans des réseaux spécialisés dans la santé et la précarité. Contacter des médecins du secteur et travailler en parallèle avec une assistante sociale. Nous avons pu mobiliser 29 résidents sur 97 ( 30 %) et avons fait le point sur leur situation. Bien qu'ils soient tous affiliés à la sécurité sociale, les résidents cumulent plusieurs vulnérabilités, présentent des problèmes répandus dans les populations précaires (vaccins, dents, yeux, intertrigo des orteils), une fréquence élevée de certaines pathologies chroniques (DNID, BPCO, cardiopathies ischémiques) et un manque de conscience de l'importance de la prévention. Nous avons pu insérer 4 résidents dans les circuits de soin de ville (sur les 9 qui n'avaient pas de médecins traitants) et améliorer la régularité du suivi sanitaire de 7 autres résidents. Pour renforcer l'accompagnement médico-social, nous proposons d'élire un représentant des résidents, d'améliorer les conditions de travail du responsable d'hébergement, d'organiser des actions ponctuelles (campagne de vaccination, camion bucco-dentaire, consultation ophtalmologique avec correction) et des réunions d'éducation sur la santé avec explication de certains termes élémentaires, insistant sur l'importance de la prévention et d'un suivi médical régulier. L'efficacité de notre action aurait pu être majorée par la mise en œuvre sur place d'examens complémentaires (radiographie et bilan biologique) à l'instar de l'action menée en mars 2004 dans un foyer SONACOTRA à ColombesPARIS7-Xavier Bichat (751182101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF