Introduction: The Aphekom project aimed to provide new, clear, and meaningful information on the health effects of air pollution in Europe. Among others, it assessed the health and monetary benefits of reducing short and long-term exposure to particulate matter (PM) and ozone in 25 European cities.Method: Health impact assessments were performed using routine health and air quality data, and a common methodology. Two scenarios were considered: a decrease of the air pollutant levels by a fixed amount and a decrease to the World Health Organization (WHO) air quality guidelines. Results were economically valued by using a willingness to pay approach for mortality and a cost of illness approach for morbidity.Results: In the 25 cities, the largest health burden was attributable to the impacts of chronic exposure to PM2.5. Complying with the WHO guideline of 10 mu g/m(3) in annual mean would add up to 22 months of life expectancy at age 30, depending on the city, corresponding to a total of 19,000 deaths delayed. The associated monetary gain would total some (sic)31 billion annually, including savings on health expenditures, absenteeism and intangible costs such as well-being, life expectancy and quality of life.Conclusion: European citizens are still exposed to concentrations exceeding the WHO recommendations. Aphekom provided robust estimates confirming that reducing urban air pollution would result in significant health and monetary gains in Europe. This work is particularly relevant now when the current EU legislation is being revised for an update in 2013. (C) 2013 Elsevier B.V. All rights reserved.

Au cours de ces dernières années, l’hésitation vaccinale s’est considérablement développée au sein des populations des pays occidentaux, notamment en raison de la multiplication récente de controverses sur l’utilité et la sécurité des vaccins ou de leurs adjuvants. Après un examen critique de la notion d’hésitation vaccinale, ainsi que de ses manifestations à travers l’histoire, nous nous intéresserons aux processus psychologiques et sociologiques qui permettent d’en comprendre la progression dans les sociétés contemporaines. D’une part, les données de la littérature récente montrent que l’hésitation vaccinale résulte généralement d’un arbitrage intuitif entre les risques et les bénéfices perçus chez les individus concernés par la vaccination, lesquels sont largement sujets à des biais cognitifs. D’autre part, deux phénomènes sociologiques permettent d’expliquer la multiplication des controverses autour de la vaccination. Le premier résulte d’une crise de confiance croissante vis-à-vis des pouvoirs publics en général et des autorités sanitaires en particulier. Le second procède de la transformation radicale du « marché » de l’information liée à l’émergence des médias électroniques. La conjugaison de ces deux phénomènes facilite la propagation rapide dans l’espace public de rumeurs et d’informations fausses ou invérifiables qui sont susceptibles de décourager le recours à la vaccination.In the last few years, vaccine hesitancy has considerably grown in the populations of western countries, particularly since controversies about the utility and safety of vaccines and their adjuvants recently multiplied. After a critical examination of the concept of “ vaccine hesitancy ” as well as its expressions through history, we will address the main psychological and sociological processes that could help us to better understand its development in modern societies. On the one hand, the evidence drawn from the existing literature shows that vaccine hesitancy typically derives from an intuitive trade-off between the perceived risks and benefits from the vaccination. Nevertheless, these perceptions have been repeatedly found to be prone to various cognitive biases. On the other hand, two sociological trends enable us to explain the proliferation of controversies about vaccines. The first stems from a growing feeling of distrust toward government institutions in general and the public health authorities in particular. The second comes from the radical evolution of the news “ market ” which is caused by the development of electronic media. The combination of these two phenomena facilitates the rapid propagation of a variety of rumors, and incorrect or suspicious information, which are likely to affect the acceptance of vaccines.

Purpose of the study. Precise quantifications of the health effects of air pollution were made available during the last 20 years. Cardiovascular health quickly gained much attention, as epidemiological and experimental studies showed that it was, as least as much as respiratory health, affected by air pollutants. Today, Much evidence is available, on the one hand, concerning the existence of deleterious effects of air pollution on cardiovascular health and, on the other hand, on the physiopathological mechanisms that may be responsible for such effects. The aim of the present study was to quantify the short-term effects of air pollution on cardiovascular-mortality and morbidity in French cities.Method. The short-term relationships between air pollution exposure indicators (NO2, PM10 and ozone) and cardiovascular health indicators (mortality and hospitalisations) were estimated by time series analyses. First, relative risks were estimated in each participating French city (nine for mortality and eight for hospital admission) and then a combined analysis was conducted. An excess relative risk (in percentage) was thus estimated.Results. Significant links were observed between the levels of all studied air pollution indicators and risks of cardiovascular and cardiac death. The hospitalisations for cardiovascular, cardiac and ischemic heart diseases were also significantly associated with the levels of NO2, and PM10 but not with ozone.Discussion. These results are intrinsically coherent kind consistent with the ones obtained in other epidemiological studies. Results from experimental and epidemiological studies provide some explanations for the underlying physiopathological mechanisms: oxidative stress, inflammation and alterations of the autonomous nervous system may he responsible for such effects. (C) 2009 Elsevier Masson SAS. All rights reserved.

BACKGROUND:To test whether rates of emergency telephone calls for asthma attacks are associated with contextual socioeconomic deprivation in the Strasbourg metropolitan area (France).METHODS:Two mobile emergency medical service networks provided all data for 2000-2005 about emergency calls for asthma attacks, georeferenced by census block. Contextual deprivation was measured for each census block by a composite index, constructed by principal component analysis. Emergency call rates were calculated for each census block and for different age groups. Empirical Bayesian smoothing was used to reduce the instability of outlying rates.RESULTS:Positive spatial autocorrelation was detected in both the health and the socioeconomic datasets. In all age groups, rates of calls for asthma attacks increased linearly with deprivation. Correlation coefficients between these two factors varied according to age group: 0.53 for the group aged 0-9 years, 0.46 for 10-19 years, 0.65 for 20-39 years, 0.70 for 40-64 years, 0.68 for 65 and older, and 0.77 for the age-standardised incidence ratio. These correlation coefficients were highly significant (p<0.01), even after spatial autocorrelation was taken into account.CONCLUSION:The socioeconomic gradients observed are consistent with those observed for severe forms of asthma and asthma hospitalisations in Western countries.

Objectives: Little is known about the potential health effects of the coarse fraction of ambient particles. The aim of this study is to estimate the links between fine (PM2.5) and coarse particle (PM2.52-10) levels and cardiorespiratory hospitalisations in six French cities during 2000-2003.Methods: Data on the daily numbers of hospitalisations for respiratory, cardiovascular, cardiac and ischaemic heart diseases were collected. Associations between exposure indicators and hospitalisations were estimated in each city using a Poisson regression model, controlling for confounding factors (seasons, days of the week, holidays, influenza epidemics, pollen counts, temperature) and temporal trends. City-specific findings were combined to obtain excess relative risks (ERRs) associated with a 10 mu g/m(3) increase in PM2.5 and PM2.5-10 levels.Results: We found positive associations between indicators of particulate pollution and hospitalisations for respiratory infection, with an ERR of 4.4% (95% CI 0.9 to 8.0) for PM2.5-10 and 2.5% (95% CI 0.1 to 4.8) for PM2.5. Concerning respiratory diseases, no association was observed with PM2.5, whereas positive trends were found with PM2.5-10, with a significant association for the 0-14- year-old age group (ERR 6.2%, 95% CI 0.4 to 12.3). Concerning cardiovascular diseases, positive associations were observed between PM2.5 levels and each indicator, although some did not reach significance; trends with PM2.5-10 were weaker and non-significant except for ischaemic heart disease in the elderly (ERR 6.4%, 95% CI 1.6 to 11.4).Conclusions: In accordance with other studies, our results indicate that the coarse fraction may have a stronger effect than the fine fraction on some morbidity endpoints, especially respiratory diseases.

The relationship between air pollution and mortality is now admissible with a sufficiently high level of causality proven. This link allows for health impact assessment to be carried out with a significant degree of accuracy, such as the case for the results which are presented here from the nine French cities involved in the Apheis programme. This health impact assessment is based on the methodology developed by the World Health Organization. The number of avoidable deaths is contained between categories ranging from 2.0 to 4.3, 4.0 to 8.9, and from 15.0 to 31.5 per 100,000 inhabitants according to very short term effects, short term effects and long term effects, respectively. There are two scenarios which can be envisioned for the reduction of fine particles levels which are capable of obtaining similar results for both very short term and short term effects. The first involves diminishing the daily concentrations which are above 20 microg/m3 until they reach this value, and the second entails systematically decreasing the daily levels by 5 microg/m3. The first strategy of reducing values to stabilize at 20 microg/m3 has been shown to be the one most favourable and promising for the long term effects. This strategy therefore confirms the reliability and strength of the recommendation formulated at the national level.

Au cours de l'ete 2003, la France a connu une vague de chaleur exceptionnelle par son ampleur et sa duree, dont les consequences ont ete une surmortalite observee particulierement elevee. Parallelement, un episode de pollution photochimique de grande ampleur lie a des conditions meteorologiques favorables a sevi sur la quasi-totalite du pays. Le role de la pollution par l'ozone dans la surmortalite observee lors de cette vague de chaleur a souvent ete evoque. Une evaluation d'impact sanitaire, a partir de relations entre l'exposition a l'ozone et la mortalite calculees anterieurement en France, semblait peu valide. Une nouvelle etude incluant la periode de la vague de chaleur de l'ete 2003 a ete initiee afin de calculer de nouvelles relations expositions risques permettant la realisation de l'evaluation d'impact sanitaire et l'estimation de l'exces de risque de deces lie conjointement a l'ozone et aux temperatures et la part relative de chaque facteur dans cet effet conjoint.

BACKGROUND:A heatwave occurred in France in August 2003, with an accompanying excess of all-cause mortality. This study quantifies this excess mortality and investigates a possible harvesting effect in the few weeks after the heatwave. METHODS:A time-series study using a Poisson regression model with regression splines to control for nonlinear confounders was used to analyze the correlation between heatwave variable and mortality in 9 French cities. RESULTS:After controlling for long-term and seasonal time trends and the usual effects of temperature and air pollution, we estimated that 3,096 extra deaths resulted from the heatwave. The maximum daily relative risk of mortality during the heatwave (compared with expected deaths at that time of year) ranged from 1.16 in Le Havre to 5.00 in Paris. There was little evidence of mortality displacement in the few weeks after the heatwave, with an estimated deficit of 253 deaths at the end of the period. CONCLUSIONS:The heatwave in France during August 2003 was associated with a large increase in the number of deaths. The impact estimated using a time-series design was consistent with crude previous estimates of the impact of the heatwave. This finding suggests that neither air pollution nor long-term and seasonal trends confounded previous estimates. There was no evidence to suggest that the extras deaths associated with the heatwave were simply brought forward in time.

P-449 Introduction: Around two non-ferrous smelters in Northern France where more than 10% of the children had lead levels higher than 100 μg L−1 of blood (25% in the closest city), environmental surveys conducted by the Ministry of Health have underlined the importance of lead in dust found within and around houses and schools of this area. This work was carried out in a school near one of these closed smelters. The aim of this study is to evaluate the exposure of young children to lead and cadmium in school environment and in particular, to determine the contamination of children’s hands with dust. Methods: Two days of sampling were conducted in a class with eighteen 4 year old children. Dust was collected on their hands using two methods: collection with wet wipes and washing with 500 mL deionizer water and acidification after. We quantified the amounts of lead and cadmium on children’s hands at different daytimes depending on their indoor and outdoor school activities (teaching or recreation). Dust was sampled in the building and the outdoor playground. Samples of soil and lawn were also taken. Data analysis was based on linear mixed models for repeated measurements. Results: Lead contains measured after the outdoor activities appear higher than the value obtain after the activities in classroom. The same tendency is observed for the cadmium. In addition, the median of lead concentration appears also higher after a recreation passed on the playground that after recreation passed on the lawn. That is true for the two studies metals. The comparison of the values measured after the classroom activity does not allow observing distinct variations according to the method of sampling. Discussion and Conclusions: The experiment reported here constitutes an original approach: various exposure scenarios according to children’s activities were considered (indoor and outdoor). We also sought to evaluate the effectiveness of a simple washing technique for sampling of dust on the children’s hands, little used in this kind of studies compared to the sampling by means of wet wipes. The measurements of various compartments of the environment of the school (interior dust, lawn, playground, soils) were undertaken. We will extend our approach to three schools located in variously contaminated industrial environments and to a school in urban environment. This new study will allow us to verify these preliminary results.

P-035 Introduction: We studied the association between particulate matter <10 μm (PM10), nitrogen dioxide (NO2), ozone and hospitalizations for heart diseases in eight French cities (Bordeaux, Lille, Le Havre, Lyon, Marseille, Paris, Rouen et Toulouse) within the 1998–2003 period. Methods: We computed the daily levels of PM10, NO2 and ozone as arithmetic means of the daily mean levels recorded by background monitoring stations of each city. From the French hospital information system (PMSI), we extracted the daily number of hospital admissions in each city, according to the main cause of hospitalization, recorded at the hospital discharge. We selected hospitalizations for all heart diseases (ICD-10 codes: I00-I52) and for ischemic heart diseases (ICD-10 codes: I20-I24). The length of the study period ranged from 41 to 71 months depending on the city. We estimated the magnitude of the association between each pollutant (mean level of the current day and the day before) and the daily number of admissions by fitting in each city a Poisson regression model, allowing for overdispersion, controlling for day of week and holidays effects and using penalized splines to control for season, temperature and influenza epidemics. City-specific results were combined by inverse variance weighting. Results: Daily number of hospitalizations for all heart diseases was associated with daily PM10 levels (0.8% increase for a 10 μg/m3 increase in exposure, 95% confidence interval (CI): 0.2%, 1.5%), with NO2 (1.1% increase for a 10 μg/m3 increase in exposure, 95% CI: 0.6%, 1.6%) but not with ozone (0.1% increase, 95% CI: −0.2%, 0.5%). The association between hospitalizations for all heart diseases and both PM10 and NO2 (respectively 1.5% increase, 95% CI: 0.7%, 2.2% and 2.4%, 95% CI: 1.1%, 3.6%) was stronger in elderly (over 65 years of age) people. For both the general population and elderly people, associations were stronger when we considered only hospitalizations for ischemic heart diseases. Discussion and Conclusions: Our study suggests that the levels of air pollutants currently experienced in the eight French cities, which are close to European air quality guidelines, are still linked to a short term increase of hospitalization for heart diseases. Our results are consistent with epidemiological and toxicological data on the cardiovascular effects of particulate matter.

P-678 Introduction: A large primary lead smelter started production in 1894 in Noyelles-Godault (Pas-de-Calais, France). It was producing some 100,000 tonnes per year of lead. In spite of a large decline, lead emissions into the atmosphere were still significant until the close-down of the smelter in the beginning of 2003. Soil lead contamination exceed 1,000 mg/kg on more than 1 km2 and can top several thousands of mg/kg. Methods: A lead exposure prevention program has been established in 1999, including five annual campaigns of blood lead screening of children at their admission to nursery schools in five towns close to the smelter. Participation rate remained steady around 80% and the number of 2–4 years old children in each campaign ranged from 300 to 407 (total number 1,821). Analysis of blood lead concentration was performed by atomic absorption spectrometry. We examined the contribution of selected variables to the prediction of log blood lead concentration by using multiple linear regression models with continuous variables entered as natural splines. Results: Before the close-down of the smelter, prevalence of elevated blood levels (blood lead above or equal to 10 μg/dL) remained unchanged around 11%. Children with higher blood lead level were more likely to come from a family with a lower maternal level of education, a father working in the plant and a residence closer to the plant. Prevalence of elevated blood levels was about 30% in the downwind town. After the close-down, we observed a marked decrease of children's blood lead levels: only 2% of the children during the 2003–2004 and 2004–2005 campaigns had an elevated blood lead level (8% in the downwind town). This blood lead decrease could not be explained by changes in potential confounding factors. Discussion and Conclusions: An exposure modelling exercise was made before the close-down with the EPA's Integrated Exposure Uptake Biokinetic (IEUBK) model and population scenarios based on available environmental data. Model predictions were lightly overestimated but consistent with observed data at the population level. The results showed the key role played by soil and house dust. However, considering the persistence of soil pollution around the site, they did not allow to anticipate the marked decrease in blood lead levels after the close-down of the smelter. We need a better understanding of the impact of the close-down of the plant on lead transfer between the different environmental compartments.

P-034 Introduction: Health Impact Assessments (HIA) of long-term exposure to PM10 conducted in 9 French cities as part of the APHEIS European project (APHEIS, Air pollution and health, a European information system, June 2005 www.apheis.net) were based on exposure-response functions obtained using gravimetric measurements of PM10 levels (Pope CA 3rdet al. Lung cancer, cardiopulmonary mortality, and long-term exposure to fine particulate air pollution. JAMA. 2002 6;287(9):1132–41). In France, PM10 levels are routinely monitored using Tapered Element Oscillating Microbalances (TEOM) and APHEIS recommended the use of correction factors in order to compensate for losses of volatile compounds. Nevertheless, there is no consensus regarding the method that should eventually be used for correction. The objective of this study was therefore to assess the sensitivity of HIA results to the use of various correction methods. Methods: Data on mortality and annual mean concentrations of PM10 for year 2001 were collected in 9 French cities. Long-term HIAs for a reduction of PM10 annual mean level to 20μg/m3 were conducted using both non-corrected and corrected PM10 levels. Three correction methods were used: the default European correction factor (http://europa.eu.int/comm/environment/air/pdf/finalwgreporten.pdf) (1.3); local seasonal conversion factors; and local polynomial regressions derived from parallel gravimetric and TEOM measurements (Jean-Luc Houdret, François Mathe. Programme pilote national de surveillance des particules PM10 et PM2,5). Results: Among the nine cities, local correction factors ranged from 1 to 1.18 during winter, and from 1.13 to 1.37 during summer. Annual mean levels of PM10 measured with TEOM ranged from 21 to 29 μg/m3. Corrected annual mean levels ranged respectively from 27 to 38 μg/m3, 23 to 31 μg/m3 and 22 to 33 μg/m3 when European, local seasonal and local polynomial corrections were used. When compared to the HIA results obtained using PM10 levels corrected with local seasonal correction factors, the direct use of levels measured with TEOM induced an underestimation varying from 17 to 82%, depending on the city. The total number of attributable cases over the nine cities was estimated to 1034 (95%CI [628; 1460]) when TEOM measures were used directly, whereas it was estimated to 3286 [1986; 4665], 2268 [1374; 3211] and 2501 [1514; 3543] when European, local seasonal or local polynomial corrections were used, respectively. Discussion and conclusion: The use of a correction has a non-negligible impact on HIA results. Non-specific correction factors do not seem appropriate, as the proportion of volatile matter varies according to localization-dependent factors. Local correction methods derived from parallel measurements seem more appropriate, but are not systematically available. For the future, the improvement of automatic methods of measurement minimizing losses of volatile compounds seems promising.

Résumé La relation entre pollution atmosphérique et mortalité est maintenant admise avec un niveau de causalité qui permet de réaliser des évaluations d’impact sanitaire telle que celle présentée dans ce travail pour neuf villes françaises participant au programme Apheis et concernant les particules. Cette évaluation d’impact sanitaire est basée sur la méthodologie élaborée par l’OMS. Le nombre de décès évitables est compris entre 2,0 et 4,3, 4,0 et 8,9, et 15,0 et 31,5 pour 100 000 habitants respectivement pour les effets à très court terme, à court terme et à long terme. Deux scénarii de réduction des concentrations de particules, l’un abaissant les niveaux journaliers dépassant 20 µg/m 3 jusqu’à cette valeur seuil, l’autre diminuant les niveaux journaliers de 5 µg/m 3 systématiquement, sont proches pour les effets à très court terme et court terme. La stratégie de réduction à 20 µg/m 3 se montre la plus favorable pour les effets à long terme. Cette stratégie confirme donc l’intérêt de la recommandation formulée au niveau national.

Aims and Methods:Long term effects of air pollution on mortality were studied in 14 284 adults who resided in 24 areas from seven French cities when enrolled in the PAARC survey (air pollution and chronic respiratory diseases) in 1974. Daily measurements of sulphur dioxide, total suspended particles, black smoke, nitrogen dioxide, and nitric oxide were made in 24 areas for three years (1974–76). Cox proportional hazards models controlling for individual confounders (smoking, educational level, body mass index, occupational exposure) were applied, and frailty models used to take into account spatial correlation. Indicators of air pollution were the mean concentration.Results:Models were run before and after exclusion of six area monitors influenced by local traffic (NO/NO2>3 in ppb). After exclusion of these areas, analyses showed that adjusted risk ratios (95% CI) for TSP, BS, NO2, and NO for non-accidental mortality were 1.05 (1.02 to 1.08), 1.07 (1.03 to 1.10), 1.14 (1.03 to 1.25), and 1.11 (1.05 to 1.17) for 10 μg/m3respectively. Consistent patterns for lung cancer and cardiopulmonary causes were observed.Conclusions:Urban air pollution assessed in the 1970s was associated with increased mortality over 25 years in France.