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Background: Delay in seeking treatment at the hospital is a major challenge in current Buruli ulcer control; it is associated with severe sequelae and functional limitations. Choosing alternative treatment and psychological, social and practical factors appear to influence delay. Objectives were to determine potential predictors for pre-hospital delay with Leventhal's commonsense model of illness representations, and to explore whether the type of available dominant treatment modality influenced individuals' perceptions about BU, and therefore, influenced pre-hospital delay. Methodology: 130 healthy individuals aged >18 years, living in BU-endemic areas in Benin without any history of BU were included in this cross-sectional study. Sixty four participants from areas where surgery was the dominant treatment and sixty six participants from areas where antibiotic treatment was the dominant treatment modality were recruited. Using a semi-structured interview we measured illness perceptions (IPQ-R), knowledge about BU, background variables and estimated pre-hospital delay. Principal Findings: The individual characteristics 'effectiveness of treatment' and 'timeline acute-chronic' showed the strongest association with pre-hospital delay. No differences were found between regions where surgery was the dominant treatment and regions where antibiotics were the dominant treatment modality. Conclusions: Individual characteristics, not anticipated treatment modality appeared predictors of pre-hospital delay. Author Summary: Delay in seeking treatment for Buruli ulcer (BU) is a major challenge in current BU control. Research to date shows that several factors relate to delay, including a lack of knowledge about BU and its treatment, beliefs in a supernatural cause of the disease, feelings of fear and worry regarding the treatment, fear of surgery, direct and indirect costs, social isolation as a consequence of unbearable costs to the patients' family, a lack of confidence in the treatment, and stigma. This study focused upon the relationship between Illness perceptions and pre-hospital delay by using the Illness Perceptions Model of Moss-Morris et al in a sample of healthy community members living in 3 endemic areas for Buruli ulcer in Benin. We found that a chronic timeline perspective on Buruli ulcer and a higher perceived effectiveness of the treatment were independently associated with pre-hospital delay. The available dominant treatment modality in endemic areas (surgery or antibiotics) did not influence pre-hospital delay, a finding contrary to the previous suggestion that a fear of surgery would be related to delay in presenting to the hospital. This study has identified several individual characteristics which can form the basis of future interventions. [ABSTRACT FROM AUTHOR]

• The choice of vaccines presentation is a challenging decision for immunization programs. • This study examines the transition from a single to a 4-dose vaccine vial presentation for pneumococcal conjugate vaccine-13 in Benin. • This article highlights an important effort to better understand the impact of changing the vial size of vaccines on system and health outcomes. Benin, a country eligible for Gavi support, changed the presentation of the 13-valent pneumococcal vaccine (PCV13) from the single-dose vial (SDV) to the multi-dose vial (MDV). The present work aims to evaluate the process of making this decision as well as programmatic and logistic impacts. WHO protocol for post-introduction evaluation (PIE) was used. Programmatic impact was evaluated by comparing PCV13 coverage and dropout rates with a comparator vaccine administered simultaneously over similar 6-month periods prior to and after the transition. This impact was also appreciated from observation of multi-dose vial management practices during immunization sessions. Logistic impact was measured from the analysis of storage capacities, waste management and vaccine losses. Decision to move to PCV13 MDV was taken at EPI level. Activities planned to support this switch were partially implemented. Impact on vaccination coverage and PCV13 dropout rates in relation with the transition to PCV13 MDV was not detected. The study found that 63% of the health staff surveyed knew and applied WHO's multidose vial policy (MDVP). Vaccines opened vials were found in 83% of health facilities visited. PCV13 MDV (37%) was one of the 3 main vaccines found with open vials in health facility refrigerators. Vaccination risky practices were observed during immunization sessions in 83% of health facilities. The main risky practice was the lack of indication of the date and hour of opening vials (56%). There was a reduction of the volume occupied by vaccines at central store by 47%. Net storage volume per fully immunized child (FIC) decreased from 69.5 to 41 m3. PCV13 MDV allows for 40% reduction in the amount of waste produced by vaccination. PCV13 open vial loss rate has increased from 3 to 7%. Benin's experience in transition to an MDV presentation of PCV13 reveals the need for better preparation and planning. [ABSTRACT FROM AUTHOR]