Optimizing the World Health Organization algorithm for HIV vertical transmission risk assessment by adding maternal self-reported antiretroviral therapy adherence.

Algorithms Anti-HIV Agents / therapeutic use Anti-Retroviral Agents / therapeutic use Female HIV Infections / prevention & control Humans Infant Infectious Disease Transmission, Vertical / prevention & control Male Pregnancy Pregnancy Complications, Infectious / drug therapy Retrospective Studies Risk Assessment Self Report World Health Organization
Enhanced post-natal prophylaxis HIV-exposed infants Mother-to-child transmission Paediatric HIV Prevention of mother-to-child transmission Vertical transmission

Journal

BMC public health
ISSN: 1471-2458
Titre abrégé: BMC Public Health
Pays: England
ID NLM: 100968562

Informations de publication

Date de publication:
08 07 2022
Historique:
received: 20 07 2021
accepted: 05 05 2022
entrez: 8 7 2022
pubmed: 9 7 2022
medline: 14 7 2022
Statut: epublish

Résumé

The World Health Organization (WHO) risk assessment algorithm for vertical transmission of HIV (VT) assumes the availability of maternal viral load (VL) result at delivery and early viral control 4 weeks after initiating antiretroviral treatment (ART). However, in many low-and-middle-income countries, VL is often unavailable and mothers' ART adherence may be suboptimal. We evaluate the inclusion of the mothers' self-reported adherence into the established WHO-algorithm to identify infants eligible for enhanced post-natal prophylaxis when mothers' VL result is not available at delivery. We used data from infants with perinatal HIV infection and their mothers enrolled from May-2018 to May-2020 in Mozambique, South Africa, and Mali. We retrospectively compared the performance of the WHO-algorithm with a modified algorithm which included mothers' adherence as an additional factor. Infants were considered at high risk if born from mothers without a VL result in the 4 weeks before delivery and with adherence <90%. At delivery, 143/184(78%) women with HIV knew their status and were on ART. Only 17(12%) obtained a VL result within 4 weeks before delivery, and 13/17(76%) of them had VL ≥1000 copies/ml. From 126 women on ART without a recent VL result, 99(79%) had been on ART for over 4 weeks. 45/99(45%) women reported suboptimal (< 90%) adherence. A total of 81/184(44%) infants were classified as high risk of VT as per the WHO-algorithm. The modified algorithm including self-adherence disclosure identified 126/184(68%) high risk infants. In the absence of a VL result, mothers' self-reported adherence at delivery increases the number of identified infants eligible to receive enhanced post-natal prophylaxis.

Sections du résumé

BACKGROUND
The World Health Organization (WHO) risk assessment algorithm for vertical transmission of HIV (VT) assumes the availability of maternal viral load (VL) result at delivery and early viral control 4 weeks after initiating antiretroviral treatment (ART). However, in many low-and-middle-income countries, VL is often unavailable and mothers' ART adherence may be suboptimal. We evaluate the inclusion of the mothers' self-reported adherence into the established WHO-algorithm to identify infants eligible for enhanced post-natal prophylaxis when mothers' VL result is not available at delivery.
METHODS
We used data from infants with perinatal HIV infection and their mothers enrolled from May-2018 to May-2020 in Mozambique, South Africa, and Mali. We retrospectively compared the performance of the WHO-algorithm with a modified algorithm which included mothers' adherence as an additional factor. Infants were considered at high risk if born from mothers without a VL result in the 4 weeks before delivery and with adherence <90%.
RESULTS
At delivery, 143/184(78%) women with HIV knew their status and were on ART. Only 17(12%) obtained a VL result within 4 weeks before delivery, and 13/17(76%) of them had VL ≥1000 copies/ml. From 126 women on ART without a recent VL result, 99(79%) had been on ART for over 4 weeks. 45/99(45%) women reported suboptimal (< 90%) adherence. A total of 81/184(44%) infants were classified as high risk of VT as per the WHO-algorithm. The modified algorithm including self-adherence disclosure identified 126/184(68%) high risk infants.
CONCLUSIONS
In the absence of a VL result, mothers' self-reported adherence at delivery increases the number of identified infants eligible to receive enhanced post-natal prophylaxis.

Identifiants

DOI: 10.1186/s12889-022-13543-9 PMID: 35804333 PMC: PMC9264598
pubmed: 35804333
doi: 10.1186/s12889-022-13543-9
pii: 10.1186/s12889-022-13543-9
pmc: PMC9264598
doi:

Substances chimiques

Anti-HIV Agents 0
Anti-Retroviral Agents 0

Types de publication

Journal Article Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

IM

Pagination

1312

Subventions

Organisme : NIAID NIH HHS
ID : P30 AI073961
Pays : United States

Investigateurs

Paolo Rossi (P)
Carlo Giaquinto (C)
Silvia Faggion (S)
Daniel Gomez Pena (DG)
Inger Lindfors Rossi (IL)
William James (W)
Alessandra Nardone (A)
Paolo Palma (P)
Paola Zangari (P)
Carla Paganin (C)
Eleni Nastouli (E)
Moira J Spyer (MJ)
Anne-Genevieve Marcelin (AG)
Vincent Calvez (V)
Pablo Rojo (P)
Alfredo Tagarro (A)
Sara Dominguez (S)
Maria Angeles Munoz (MA)
Caroline Foster (C)
Savita Pahwa (S)
Anita De Rossi (A)
Mark Cotton (M)
Nigel Klein (N)
Deborah Persaud (D)
Rob J De Boer (RJ)
Juliane Schroeter (J)
Adriana Ceci (A)
Viviana Giannuzzi (V)
Kathrine Luzuriaga (K)
Nicolas Chomont (N)
Nicola Cotugno (N)
Louise Kuhn (L)
Andrew Yates (A)
Avy Violari (A)
Kennedy Otwombe (K)
Paula Vaz (P)
Maria Grazia Lain (MG)
Elisa López-Varela (E)
Tacilta Nhamposssa (T)
Denise Naniche (D)
Ofer Levy (O)
Philip Goulder (P)
Mathias Lichterfeld (M)
Holly Peay (H)
Pr Mariam Sylla (PM)
Almoustapha Maiga (A)

Informations de copyright

© 2022. The Author(s).

Références

UNAIDS. (Joint United Nations Programme on HIV/AIDS), “Communities at the centre,”; 2019. https://doi.org/10.2307/j.ctt1t898kc.12 .
doi: 10.2307/j.ctt1t898kc.12
World Heath Organization (WHO), “WHO | Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants,” 2010. https://www.who.int/hiv/pub/mtct/antiretroviral2010/en/ (Accessed 21 Oct 2020).
UNAIDS, “Start Free stay free AIDS free 2019,” 2019.
UNAIDS (Joint United Nations Programme on HIV/AIDS), “on the Fast-Track To an Aids-Free Generation,” 2016. http://www.unaids.org/sites/default/files/media_asset/GlobalPlan2016_en.pdf .
Hodgson I, et al. A systematic review of individual and contextual factors affecting ART initiation, adherence, and retention for HIV-infected pregnant and postpartum women. PLoS One. 2014;9(11). https://doi.org/10.1371/journal.pone.0111421 .
Drake AL, Wagner A, Richardson B, John-Stewart G. Incident HIV during Pregnancy and Postpartum and Risk of Mother-to-Child HIV Transmission: A Systematic Review and Meta-Analysis. PLoS Med. 2014;11(2). https://doi.org/10.1371/journal.pmed.1001608 .
Kalk E, Slogrove A, Speert DP, Bettinger JA, Cotton MF, Esser M. HIV sero-conversion during late pregnancy - when to retest. Southern African J HIV Med. 2013;14(2):90–2. https://doi.org/10.7196/SAJHIVMED.903 .
doi: 10.7196/SAJHIVMED.903
De Schacht C, et al. High HIV incidence in the postpartum period sustains vertical transmission in settings with generalized epidemics: a cohort study in southern Mozambique. J Int AIDS Soc. 2014;17(1):18808. https://doi.org/10.7448/IAS.17.1.18808 .
doi: 10.7448/IAS.17.1.18808 pubmed: 24629842 pmcid: 3946505
Nachega JB, et al. Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis. AIDS. 2012;26(16):2039–52. https://doi.org/10.1097/QAD.0b013e328359590f .
doi: 10.1097/QAD.0b013e328359590f pubmed: 22951634
Abuogi LL, et al. Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. J Virus Erad. 2018;4(Suppl 2):33–9 Accessed 17 June 2020. Available: http://www.ncbi.nlm.nih.gov/pubmed/30515312 .
doi: 10.1016/S2055-6640(20)30343-5
Lain MG, Chicumbe S, Couto A, Karajeanes E, Giaquinto C, Vaz P. High proportion of unknown HIV exposure status among children aged less than 2 years: An analytical study using the 2015 National AIDS Indicator Survey in Mozambique. PLoS One. 2020;15(4). https://doi.org/10.1371/journal.pone.0231143 .
Coovadia HM, et al. Efficacy and safety of an extended nevirapine regimen in infant children of breastfeeding mothers with HIV-1 infection for prevention of postnatal HIV-1 transmission (HPTN 046): a randomised, double-blind, placebo-controlled trial. Lancet. 2012;379(9812):221–8. https://doi.org/10.1016/S0140-6736(11)61653-X .
doi: 10.1016/S0140-6736(11)61653-X pubmed: 22196945
Fowler MG, et al. Efficacy and safety of an extended nevirapine regimen in infants of breastfeeding mothers with HIV-1 infection for prevention of HIV-1 transmission (HPTN 046): 18-month results of a randomized, double-blind, placebo-controlled trial. J Acquir Immune Defic Syndr. 2014;65(3):366–74. https://doi.org/10.1097/QAI.0000000000000052 .
doi: 10.1097/QAI.0000000000000052 pubmed: 24189151 pmcid: 3945386
Kumwenda NI, et al. Extended antiretroviral prophylaxis to reduce breast-milk HIV-1 transmission. N Engl J Med. 2008;359(2):119–29. https://doi.org/10.1056/NEJMoa0801941 .
doi: 10.1056/NEJMoa0801941 pubmed: 18525035
Nielsen-Saines K, et al. Three postpartum antiretroviral regimens to prevent intrapartum HIV infection. N Engl J Med. 2012;366(25):2368–79. https://doi.org/10.1056/NEJMoa1108275 .
doi: 10.1056/NEJMoa1108275 pubmed: 22716975 pmcid: 3590113
Beste S, et al. Optimal antiretroviral prophylaxis in infants at high risk of acquiring HIV: a systematic review. Pediatr Infect Dis J. 2018;37(2):169–75. https://doi.org/10.1097/INF.0000000000001700 .
doi: 10.1097/INF.0000000000001700 pubmed: 29319636
Lallemant M, et al. Perinatal antiretroviral intensification to prevent intrapartum HIV transmission when antenatal antiretroviral therapy is initiated less than 8 weeks prior to delivery. JAIDS J Acquir Immune Defic Syndr. 2020. https://doi.org/10.1097/QAI.0000000000002350 .
World Health Organization, Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. 2016.
“WHO | HIV diagnosis and ARV use in HIV-exposed infants: a programmatic update.” https://www.who.int/hiv/pub/paediatric/diagnosis-arv-infants/en/ (Accessed 19 June 2020).
Komtenza B, et al. Identifying high or low risk of mother to child transmission of HIV: how Harare City, Zimbabwe is doing? PLoS One. 2019;14(3):e0212848. https://doi.org/10.1371/journal.pone.0212848 .
doi: 10.1371/journal.pone.0212848 pubmed: 30865646 pmcid: 6415877
S. Swannet et al., “Journey towards universal viral load monitoring in Maputo, Mozambique: many gaps, but encouraging signs,” Int Health, vol. 9, no. 4, pp. 206–214, Jul. 2017, doi: https://doi.org/10.1093/inthealth/ihx021 .
M. S. M. Arpadi, S. Shiau, E. P. De Gusmao, and A. Violari, “Routine viral load monitoring in HIV-infected infants and children in low- and middle-income countries: Challenges and opportunities: Challenges,” Journal of the International AIDS Society, vol. 20, no. Suppl 7. Wiley Blackwell, pp. 32–36, Nov. 01, 2017, doi: https://doi.org/10.1002/jia2.25001 .
J. R. Millar et al., “HIGH-FREQUENCY failure of combination antiretroviral therapy in paediatric HIV infection is associated with unmet maternal needs causing maternal NON-ADHERENCE,” EClinicalMedicine, vol. 22, p. 100344, May 2020, doi: https://doi.org/10.1016/j.eclinm.2020.100344 .
Myer L, et al. Frequency of Viremic episodes in HIV-infected women initiating antiretroviral therapy during pregnancy: a cohort study. Clin Infect Dis. 2016;p. ciw792:Dec. https://doi.org/10.1093/cid/ciw792 .
doi: 10.1093/cid/ciw792
E. Bobrow, L. Mugwaneza, Placidie; Ndayisaba, Gilles; Ndatimana, Dieudonne; Gill, Michelle; Hoffman, Heather; Baribwira, Cyprien; Guay, and A. Asiimwe, “Maternal Viral Load in the Context of PMTCT B+ Within the Kabeho Study in Kigali | Request PDF.” https://www.researchgate.net/publication/299347124_Maternal_Viral_Load_in_the_Context_of_PMTCT_B_Within_the_Kabeho_Study_in_Kigali (Accessed 19 June 2020).
Chetty T, Newell ML, Thorne C, Coutsoudis A. Viraemia before, during and after pregnancy in HIV-infected women on antiretroviral therapy in rural KwaZulu-Natal, South Africa, 2010–2015. Trop Med Int Heal. 2018;23(1):79–91. https://doi.org/10.1111/tmi.13001 .
doi: 10.1111/tmi.13001
Republica de Moçambique. Ministério da Saúde, “Tratamento Antiretroviral e Infecções Oportunistas do Adulto, Adolescente, Grávida e Criança,” 2016. http://www.misau.gov.mz/index.php/guioes# .
Ministério da Saúde (MISAU). Comité TARV., “Circular normas clínicas actualizadas,” 2019. https://comitetarvmisau.co.mz/docs/orientacoes_nacionais/Circular_Normas_Clínicas_Actualizadas_29_11_19.pdf (Accessed 22 Sept 2020).
“R: The R Project for Statistical Computing.” https://www.r-project.org/ (Accessed 19 June 2020).
Mafaune HW, et al. Effectiveness of maternal transmission risk stratification in identification of infants for HIV birth testing: lessons from Zimbabwe. J Acquir Immune Defic Syndr. 2020;84(1):S28–33. https://doi.org/10.1097/QAI.0000000000002373 .
doi: 10.1097/QAI.0000000000002373 pubmed: 32520912 pmcid: 7302327
“WHO recommends dolutegravir as preferred HIV treatment option in all populations.” https://www.who.int/news/item/22-07-2019-who-recommends-dolutegravir-as-preferred-hiv-treatment-option-in-all-populations (Accessed 15 July 2021).
Drain PK, et al. Point-of-Care HIV Viral Load Testing: an Essential Tool for a Sustainable Global HIV/AIDS Response. Clin Microbiol Rev. 2019;32(3). https://doi.org/10.1128/CMR.00097-18 .
Shi L, Liu J, Koleva Y, Fonseca V, Kalsekar A, Pawaskar M. Concordance of adherence measurement using self-reported adherence questionnaires and medication monitoring devices. Pharmacoeconomics. 2010;28(12):1097–107. https://doi.org/10.2165/11537400-000000000-00000 .
doi: 10.2165/11537400-000000000-00000 pubmed: 21080735
Atanga PN, et al. Using a composite adherence tool to assess ART response and risk factors of poor adherence in pregnant and breastfeeding HIV-positive Cameroonian women at 6 and 12 months after initiating option B+. BMC Pregnancy Childbirth. 2018;18(1):418. https://doi.org/10.1186/s12884-018-2058-9 .
doi: 10.1186/s12884-018-2058-9 pubmed: 30359239 pmcid: 6202832
Phillips TK, et al. Decreases in self-reported ART adherence predict HIV viremia among pregnant and postpartum south African women. J Acquir Immune Defic Syndr. 2019;80(3):247–54. https://doi.org/10.1097/QAI.0000000000001909 .
doi: 10.1097/QAI.0000000000001909 pubmed: 30422906 pmcid: 6375758

Auteurs

Sheila Fernández-Luis (S)

Centro de Investigação em Saúde de Manhiça (CISM), Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique. sheila.fernandez@isglobal.org.
ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain. sheila.fernandez@isglobal.org.

Maria Grazia Lain (MG)

Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique. mlain@arielglaser.org.mz.

Miquel Serna-Pascual (M)

Pediatrics Department, Pediatric Research and Clinical Trials Unit (UPIC), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain.

Sara Domínguez-Rodríguez (S)

Pediatrics Department, Pediatric Research and Clinical Trials Unit (UPIC), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain.

Louise Kuhn (L)

Gertrude H. Sergievsky Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA.

Afaaf Liberty (A)

Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Shaun Barnabas (S)

Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.

Elisa Lopez-Varela (E)

Centro de Investigação em Saúde de Manhiça (CISM), Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique.
ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.

Kennedy Otwombe (K)

Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Siva Danaviah (S)

Africa Health Research Institute (AHRI), Durban, KwaZulu-Natal, South Africa.

Eleni Nastouli (E)

Great Ormond Street Institute for Child Health (GOS ICH), University College London (UCL), London, UK.

Paolo Palma (P)

Research Unit in Clinical Immunology and Vaccinology, Bambino Gesu' Children's Hospital, 00165, Rome, Italy.
Chair of Pediatrics, Department of Systems Medicine, University of Rome "Tor Vergata", 00133, Rome, Italy.

Nicola Cotugno (N)

Research Unit in Clinical Immunology and Vaccinology, Bambino Gesu' Children's Hospital, 00165, Rome, Italy.
Chair of Pediatrics, Department of Systems Medicine, University of Rome "Tor Vergata", 00133, Rome, Italy.

Moira Spyer (M)

Great Ormond Street Institute for Child Health (GOS ICH), University College London (UCL), London, UK.

Viviana Giannuzzi (V)

Fondazione per la Ricerca Farmacologica Gianni Benzi onlus, Valenzano, Italy.

Carlo Giaquinto (C)

Department of Mother and Child Health, University of Padova, Padova, Italy.

Avy Violari (A)

Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Mark F Cotton (MF)

Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.

Tacilta Nhampossa (T)

Centro de Investigação em Saúde de Manhiça (CISM), Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique.
Instituto Nacional de Saúde (INS), Mozambique, Maputo, Mozambique.

Nigel Klein (N)

Africa Health Research Institute (AHRI), Durban, KwaZulu-Natal, South Africa.
Great Ormond Street Institute for Child Health (GOS ICH), University College London (UCL), London, UK.

Nastassja Ramsagar (N)

Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

Anita Janse van Rensburg (AJ)

Family Center for Research with Ubuntu, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.

Osee Behuhuma (O)

Africa Health Research Institute (AHRI), Durban, KwaZulu-Natal, South Africa.

Paula Vaz (P)

Fundação Ariel Glaser Contra o SIDA Pediátrico, Maputo, Mozambique.

Almoustapha Issiaka Maiga (AI)

Department of Medical Biology, Gabriel Toure University Hospita, Bamako, Mali.

Andrea Oletto (A)

Fondazione Penta ONLUS, Padova, Italy.

Denise Naniche (D)

Centro de Investigação em Saúde de Manhiça (CISM), Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique.
ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.

Paolo Rossi (P)

Academic Department of Pediatrics, Children's Hospital Bambino Gesù, Rome, Italy.

Pablo Rojo (P)

Pediatrics Department, Pediatric Research and Clinical Trials Unit (UPIC), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain.

Alfredo Tagarro (A)

Pediatrics Department, Pediatric Research and Clinical Trials Unit (UPIC), Fundación para la Investigación Biomédica del Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (IMAS12), Madrid, Spain.
Pediatrics Department, Hospital Universitario Infanta Sofía; Infanta Sofia University Hospital and Henares University Hospital Foundation for Biomedical Research and Innovation (FIIB HUIS HHEN), San Sebastián de los Reyes, Madrid, Spain.
Pediatrics Research Group, Universidad Europea de Madrid, Madrid, Spain.

Articles similaires

[Redispensing of expensive oral anticancer medicines: a practical application].

Lisanne N van Merendonk, Kübra Akgöl, Bastiaan Nuijen
1.00
Humans Antineoplastic Agents Administration, Oral Drug Costs Counterfeit Drugs

Smoking Cessation and Incident Cardiovascular Disease.

Jun Hwan Cho, Seung Yong Shin, Hoseob Kim et al.
1.00
Humans Male Smoking Cessation Cardiovascular Diseases Female

Evaluation of Low-Value Services Across Major Medicare Advantage Insurers and Traditional Medicare.

Ciara Duggan, Adam L Beckman, Ishani Ganguli et al.
1.00
Humans United States Aged Cross-Sectional Studies Medicare Part C

Effectiveness of Virtual Yoga for Chronic Low Back Pain: A Randomized Clinical Trial.

Hallie Tankha, Devyn Gaskins, Amanda Shallcross et al.
1.00
Humans Yoga Low Back Pain Female Male

Classifications MeSH

questionsmedicales.fr › Sciences de l'information › Méthodologies informatiques › Algorithmes › Optimizing the World Health Organization...
questionsmedicales.fr › Actions chimiques et utilisations › Actions pharmacologiques › Utilisations thérapeutiques › Anti-infectieux › Antiviraux › Antirétroviraux › Agents antiVIH › Optimizing the World Health Organization...
questionsmedicales.fr › Actions chimiques et utilisations › Actions pharmacologiques › Utilisations thérapeutiques › Anti-infectieux › Antiviraux › Antirétroviraux › Optimizing the World Health Organization...
questionsmedicales.fr › Maladies du système immunitaire › Déficits immunitaires › Infections à VIH › Optimizing the World Health Organization...
questionsmedicales.fr › Eucaryotes › Animaux › Chordés › Vertébrés › Mammifères › Eutheria › Primates › Haplorhini › Catarrhini › Hominidae › Humains › Optimizing the World Health Organization...
questionsmedicales.fr › Personnes › Tranches d'âge › Nourrisson › Optimizing the World Health Organization...
questionsmedicales.fr › Environnement et santé publique › Santé publique › Transmission de maladie infectieuse › Transmission verticale de maladie infectieuse › Optimizing the World Health Organization...
questionsmedicales.fr › Phénomènes physiologiques des appareils urinaire et reproducteur › Phénomènes physiologiques de la reproduction › Reproduction › Grossesse › Optimizing the World Health Organization...
questionsmedicales.fr › Maladies urogénitales › Maladies de l'appareil urogénital féminin et complications de la grossesse › Complications de la grossesse › Complications infectieuses de la grossesse › Optimizing the World Health Organization...
questionsmedicales.fr › Environnement et santé publique › Santé publique › Méthodes épidémiologiques › Caractéristiques des études épidémiologiques › Études épidémiologiques › Études de cohortes › Études rétrospectives › Optimizing the World Health Organization...
questionsmedicales.fr › Environnement et santé publique › Santé publique › Méthodes épidémiologiques › Statistiques comme sujet › Probabilité › Risque › Appréciation des risques › Optimizing the World Health Organization...
questionsmedicales.fr › Environnement et santé publique › Santé publique › Méthodes épidémiologiques › Collecte de données › Enquêtes et questionnaires › Autorapport › Optimizing the World Health Organization...
questionsmedicales.fr › Organisations et économie des soins de santé › Organismes › Agences internationales › Nations Unies › Organisation mondiale de la santé › Optimizing the World Health Organization...