BackgroundWaterborne disease outbreaks (WBDO) associated with tap water consumption are probably underestimated in France.AimIn order to improve their detection, Santé publique France launched a surveillance system in 2019, based on the periodical analysis of health insurance data for medicalised acute gastroenteritis (mAGE).MethodsSpatio-temporal cluster detection methods were applied to mAGE cases to prioritise clusters for further investigation. These investigations determined the plausibility that infection is of waterborne origin and the strength of association.ResultsBetween January 2010 and December 2019, 3,323 priority clusters were detected (53,878 excess mAGE cases). They involved 3,717 drinking water supply zones (WSZ), 15.4% of all French WSZ. One third of these WSZ (33.4%; n = 1,242 WSZ) were linked to repeated clusters. Moreover, our system detected 79% of WBDO voluntarily notified to health authorities.ConclusionEnvironmental investigations of detected clusters are necessary to determine the plausibility that infection is of waterborne origin. Consequently, they contribute to identifying which WSZ are linked to clusters and for which specific actions are needed to avoid future outbreaks. The surveillance system incorporates three priority elements: linking environmental investigations with water safety plan management, promoting the systematic use of rainfall data to assess waterborne origin, and focusing on repeat clusters. In the absence of an alternative clear hypothesis, the occurrence of a mAGE cluster in a territory completely matching a distribution zone indicates a high plausibility of water origin.

The French national public health agency (Santé publique France) has used data from the national health insurance reimbursement system (SNDS) to identify medicalised acute gastroenteritis (mAGE) for more than 10 years. This paper presents the method developed to evaluate this system: performance and characteristics of the discriminatory algorithm, portability in mainland and overseas French departments, and verification of the mAGE database updating process. Pharmacy surveys with certified mAGE from 2012 to 2015 were used to characterise mAGE and to estimate the sensitivity and predictive positive value (PPV) of the algorithm. Prescription characteristics from these pharmacy surveys and from 2014 SNDS prescriptions in six mainland and overseas departments were compared. The sensitivity (0.90) and PPV (0.82) did not vary according to the age of the population or year. Prescription characteristics were similar within all studied departments. This confirms that the algorithm can be used in all French departments, for both paediatric and adult populations, with stability and durability over time. The algorithm can identify mAGE cases at a municipal level. The validated system has been implemented in a national waterborne disease outbreaks surveillance system since 2019 with the aim of improving the prevention of infectious disease risk attributable to localised tap water systems.

Adaptation to a warmer world is a priority, especially in large urban centers where the concentration of the population and the urban heat island increase heat-related risks. Cities are also willing to improve their air quality. This paper summarizes and discusses the current knowledge on how green spaces may be used to reduce heat-related health impacts, and on the potential co-benefits, especially through air quality. The literature shows that vegetation contributes to the creation of cool islands in cities, and to locally decrease temperature and air pollutant concentrations. Few epidemiological studies have investigated the associated health impacts, but they indicate that vegetation is probably a protective factor that reduces mortality and morbidity during heat waves. Green spaces can also contribute to the restoration and the building of resilience capacities, thus reducing the health impacts of heat and pollution. Current knowledge allows to develop green space strategies adapted to optimize the benefits in terms of urban heat island, thermal comfort and air quality, with potentially large health benefits. Only a part of those benefits can be quantified with the current health impact assessment tools.

Loss of biodiversity and globalized environmental degradation result in planetary-scale changes which impact human societies. This paper highlights the urgency for public health researchers to integrate a global change perspective into their daily work. The public health community needs to answer several questions, e.g., how to weight the health of present and future generations; how to balance between the possible immediate adverse impacts of mitigating climate change vs long-term adverse impacts of global change; how to limit the environmental impacts of public health intervention; and how to allocate resources. Public health practitioners are faced with a moral responsibility to address these challenges. Key elements to ensure long-lasting, innovative global change and health solutions include (i) empowering the population; (ii) tailoring the framing of global change and health impacts for different stakeholders; (iii) adopting less conservative approaches on reporting future scenarios; (iv) increasing accountability about the health impacts of mitigation and adaptation strategies; and (v) recognizing the limits of science.

Waterborne disease outbreaks (WBDOs) remain a public health issue in developed countries, but to date the surveillance of WBDOs in France, mainly based on the voluntary reporting of clusters of acute gastrointestinal infections (AGIs) by general practitioners to health authorities, is characterized by low sensitivity. In this context, a detection algorithm using health insurance data and based on a space–time method was developed to improve WBDO detection. The objective of the present simulation-based study was to evaluate the performance of this algorithm for WBDO detection using health insurance data. The daily baseline counts of acute gastrointestinal infections were simulated. Two thousand simulated WBDO signals were then superimposed on the baseline data. Sensitivity (Se) and positive predictive value (PPV) were both used to evaluate the detection algorithm. Multivariate regression was also performed to identify the factors associated with WBDO detection. Almost three-quarters of the simulated WBDOs were detected (Se = 73.0%). More than 9 out of 10 detected signals corresponded to a WBDO (PPV = 90.5%). The probability of detecting a WBDO increased with the outbreak size. These results underline the value of using the detection algorithm for the implementation of a national surveillance system for WBDOs in France.

The impact of climate change on the health of individuals raises fears of significant long-term effects. Certain repercussions are already evident. Health professionals, particularly those working with vulnerable people, play a key role in health promotion and taking into account the challenges posed by hot weather. They need to be better trained in order to promote behaviours more favourable to health.

Time series studies (TSS) can be viewed as an inexpensive way to tackle the non-epidemic health risk from fecal pathogens in tap water in urban areas. Following the PRISMA recommendations, I reviewed TSS addressing the endemic risk of acute gastroenteritis risk according to drinking water operation conditions in urban areas of developed countries. Eighteen studies were included, covering 17 urban sites (seven in North-America and 10 in Europe) with study populations ranging from 50,000 to 9 million people. Most studies used general practitioner consultations or visits to hospitals for acute gastroenteritis (AGE) as health outcomes. In 11 of the 17 sites, a significant and plausible association was found between turbidity (or particle count) in finished water and the AGE indicator. When provided and significant, the interquartile excess of relative risk estimates ranged from 3–13%. When examined, water temperature, river flow, and produced flow were strongly associated with the AGE indicator. The potential of TSS for the study of the health risk from fecal pathogens in tap water is limited by the lack of specificity of turbidity and its site-sensitive value as an exposure proxy. Nevertheless, at the DWS level, TSS could help water operators to identify operational conditions most at risk, almost if considering other water operation indicators, in addition to turbidity, as possible relevant proxies for exposure.

Objectives: Understanding the dynamics of the temperature-mortality relationship is an asset to support public health interventions. We investigated the lag structure of the mortality response to cold and warm temperatures in 18 French cities between 2000 and 2010. Methods: A distributed lag non-linear generalized model using a quasi-Poisson distribution and controlling for classical confounding factors was built in each city. A fitted meta-analytical model combined the city-specific models to derive the best linear unbiased prediction of the association, and a meta-regression explored the influence of background characteristics of the cities. The fraction of mortality attributable to cold and heat was estimated with reference to the minimum mortality temperature. Results: Between 2000 and 2010, 3.9% [CI 95% 3.2:4.6] of the total mortality was attributed to cold, and 1.2% [1.1:1.2] to heat. The immediate increase in mortality following high temperatures was partly compensated by a harvesting effect when temperatures were below the 99.2 percentiles of the mean temperature distributions. Discussion: Cold represents a significant public health burden, mostly driven by moderate temperatures (between percentiles 2.5 and 25). The population is better adapted to warm temperatures, up to a certain intensity when heat becomes an acute environmental health emergency (above percentile 99). The rapid increase in mortality risk at very high temperatures percentiles calls for an active adaptation in a context of climate change.

In France, 95% of people are supplied with chlorinated tap water. Due to the presence of natural organic matter that reacts with chlorine, the concentrations of chlorination by-products (CBPs) are much higher in chlorinated water produced from surface water than from groundwater. Surface water supplies 33% of the French population. Until the 1980s, almost all surface water utilities pre-chlorinated water at the intake. Pre-chlorination was then gradually banned from 1980 to 2000. Trihalomethanes (THMs) are the only regulated CBP in France. Since 2003, THMs have been monitored at the outlet of all utilities. This study assessed current (2005–2011) and past (1960–2000) exposure of the French population to THMs. We developed an original method to model THM concentrations between 1960 and 2000 according to current concentrations of THMs, concentration of total organic carbon in raw and finished water, and the evolution of water treatments from 1960 onward. Current and past mean exposure of the French population to THMs was estimated at 11.7 µg·L−1 and 17.3 µg·L−1, respectively. In the past, approximately 10% of the French population was exposed to concentrations >50 µg·L−1 vs. 1% currently. Large variations in exposure were observed among France’s 100 administrative districts, mainly depending on the water origin (i.e., surface vs. ground), ranging between 0.2 and 122.1 µg·L−1 versus between 1.8 and 38.6 µg·L−1 currently.

The impact of climate change on the health of individuals raises fears of significant long-term effects. Certain repercussions are already evident. Health professionals, particularly those working with vulnerable people, play a key role in health promotion and taking into account the challenges posed by hot weather. They need to be better trained in order to promote behaviours more favourable to health.

Les effets à long terme de la pollution atmosphérique (PA) sur la mortalité ont été démontrés dans de nombreux pays. En France, ces données sont peu fréquentes. L’objectif de l’étude était d’évaluer le lien entre 25 ans d’exposition à la PA et le risque de mortalité toutes causes non accidentelles et pour causes cardiovasculaires et respiratoires à partir des données de la cohorte française Gazel. L’échantillon de l’étude était composé de 20 327 adultes volontaires travailleurs d’EDF-GDF suivis de 1989 à 2013. L’exposition annuelle aux PM10, PM2,5, NO2, O3, SO2 et benzène a été évaluée au lieu de résidence des participants en utilisant un modèle de chimie transport en prenant en compte le calendrier résidentiel. Les excès de risques, exprimés en hazard ratio (HR), ont été estimés à l’aide d’un modèle de régression à risques proportionnels de Cox en ajustant sur les facteurs de confusion potentiels individuels et contextuels. Les HR ont été calculés pour une augmentation de l’intervalle interquartile de la distribution des concentrations des polluants. Le nombre de décès survenus en fin de période était de 1967 (9,7 %) pour la mortalité toutes causes non accidentelles, 165 (0,8 %) pour causes cardiovasculaires et 284 (1,4 %) pour causes respiratoires. Une exposition à long terme aux PM2,5, PM10–25, NO2 et benzène était associée à une augmentation de la mortalité non accidentelle lorsque l’exposition était prise en compte à l’inclusion. Pour les PM2,5, le HR était de 1,09 (intervalle de confiance [IC] 95 % : 0,99–1,20) pour une augmentation de 5,9 μg/m3 ; pour les PM10−25, HR = 1,09 (IC 95 % : 1,04–1,15) pour une augmentation de 2,2 μg/m3 ; pour le NO2, HR = 1,14 (IC 95 % : 0,99–1,31) pour une augmentation de 19,3 μg/m3 ; et pour le benzène, HR = 1,10 (IC à 95 % : 1,00–1,22) pour une augmentation de 1,7 μg/m3. L’association la plus forte était observée pour les PM10, HR = 1,14 (IC 95 % : 1,05–1,25) pour une augmentation de 7,8 μg/m3. Aucune association n’a été observée entre l’exposition à long terme à la PA et la mortalité cardiovasculaire et respiratoire. Une exposition à long terme aux particules fines, dioxyde d’azote, dioxyde de soufre et benzène est associée à un risque accru de mortalité non accidentelle en France. Nos résultats sont concordants avec les données existantes de la littérature et confirment que la pollution de l’air extérieur est un important facteur de risque environnemental de mortalité.

We analysed 25 years of general practitioner (GP) visits for acute gastroenteritis (AG) surveillance in France, by the GP Sentinelles network. We searched for time trends of acute gastroenteritis incidence during winter periods. Data from emergency departments and drug reimbursement were additional data sources. A time-series analysis was performed using a generalised additive model for all data sources for the winter period. Virological data were incorporated and compared with the three data sources. The cumulative incidence of GP visits for winter AG exhibited an increasing trend from 1991 until 2008, when it reached 6,466 per 100,000 inhabitants. It decreased thereafter to 3,918 per 100,000 inhabitants in 2015. This decreasing trend was observed for all age groups and confirmed by the generalised additive model. For emergency department visits a decreasing trend was observed from 2004. Drug reimbursement data analyses demonstrated a decreasing trend from when data began in 2009. The incidence reported by GPs and emergency departments was lower following the emergence of norovirus GII.4 2012 (p < 0.0001). Winter AG incidences seem to follow long-term rising and decreasing trends that are important to monitor through continuous surveillance to evaluate the impact of prevention strategies, such as future immunisation against acute viral gastroenteritis.

Introduction: Worldwide, air pollution has become a main environmental cause of premature mortality. This burden is largely due to fine particles. Recent cohort studies have confirmed the health risks associated with chronic exposure to PM2.5 for European and French populations. We assessed the mortality impact of PM2.5 in continental France using these new results.Methods: Based on a meta-analysis of French and European cohorts, we computed a shrunken estimate of PM2.5 mortality relationship for the French population (RR 1.15 [1.05:1.25] for a 10 mu g/M-3 increase in PM2.5). This RR was applied to PM2.5 annual concentrations estimated at a fine spatial scale, using a classical health impacts assessment method. The health benefits associated with alternative scenarios of improving air quality were computed for 36,219 French municipalities for 2007-2008.Results: 9% Of the total mortality in continental France is attributable to anthropogenic PM2.5. This represents >48,000 deaths per year, and 950,000 years of life lost per year, more than half occurring in urban areas larger than 100,000 inhabitants. If none of the municipalities exceeded the World Health Organization guideline value for PM2.5 (10 mu g/m(3)), the total mortality could be decreased by 3%, corresponding to 400,000 years of life saved per year.Conclusion: Results were consistent with previous estimates of the long-term mortality impacts of fine particles in France. These findings show that further actions to improve air quality in France would substantially improve health. (C) 2016 Elsevier B.V. All rights reserved.

SUMMARY Waterborne disease outbreaks (WBDO) of acute gastrointestinal illness (AGI) are a public health concern in France. Their occurrence is probably underestimated due to the lack of a specific surveillance system. The French health insurance database provides an interesting opportunity to improve the detection of these events. A specific algorithm to identify AGI cases from drug payment reimbursement data in the health insurance database has been previously developed. The purpose of our comparative study was to retrospectively assess the ability of the health insurance data to describe WBDO. Data from the health insurance database was compared with the data from cohort studies conducted in two WBDO in 2010 and 2012. The temporal distribution of cases, the day of the peak and the duration of the epidemic, as measured using the health insurance data, were similar to the data from one of the two cohort studies. However, health insurance data accounted for 54 cases compared to the estimated 252 cases accounted for in the cohort study. The accuracy of using health insurance data to describe WBDO depends on the medical consultation rate in the impacted population. As this is never the case, data analysis underestimates the total number of AGI cases. However this data source can be considered for the development of a detection system of a WBDO in France, given its ability to describe an epidemic signal.

Introduction: Long-term exposure to air pollution (AP) has been shown to have an impact on mortality in numerous countries, but since 2005 no data exists for France.Objectives: We analyzed the association between long-term exposure to air pollution and mortality at the individual level in a large French cohort followed from 1989 to 2013.Methods: The study sample consisted of 20,327 adults working at the French national electricity and gas company EDF-GDF. Annual exposure to PM10, PM10-2.5, PM2.3, NO2, O-3, SO2, and benzene was assessed for the place of residence of participants using a chemistry-transport model and taking residential history into account. Hazard ratios were estimated using a Cox proportional-hazards regression model, adjusted for selected individual and contextual risk factors. Hazard ratios were computed for an interquartile range (IQR) increase in air pollutant concentrations.Results: The cohort recorded 1967 non-accidental deaths. Long-term exposures to baseline PM2.3, Phil(10-25), NO2 and benzene were associated with an increase in non-accidental mortality (Hazard Ratio, HR = 1.09; 95% Cl: 0.99, 120 per 5.9 mu g/m(3), PM10-25; HR = 1.09; 95%CI: 1.04, 1.15 per 2.2 mu g/m(3), NO2: HR = 1.14; 95% CI: 0.99, 131 per 19.3 mu g/m(3) and benzene: HR= 1.10; 95% CI: 1.00, 122 per 1.7 mu g/m(3)).The strongest association was found for PM10: HR = 1.14; 95% CI: 1.05, 125 per 7.8 mu g/m(3). PM10, PM10-25 and SO2 were associated with non-accidental mortality when using time varying exposure. No significant associations were observed between air pollution and cardiovascular and respiratory mortality.Conclusion: Long-term exposure to fine particles, nitrogen dioxide, sulfur dioxide and benzene is associated-with an increased risk of non-accidental mortality in France. Our results strengthen existing evidence that outdoor air pollution is a significant environmental risk factor for mortality. Due to the limited sample size and the nature of our study (occupational), further investigations are needed in France with a larger representative population sample. (C) 2015 Elsevier Ltd. All rights reserved.

This pilot study was conducted to assess the utility of using a health insurance database for the automated detection of waterborne outbreaks of acute gastroenteritis (AGE). The weekly number of AGE cases for which the patient consulted a doctor (cAGE) was derived from this database for 1,543 towns in three French districts during the 2009-2012 period. The method we used is based on a spatial comparison of incidence rates and of their time trends between the target town and the district. Each municipality was tested, week by week, for the entire study period. Overall, 193 clusters were identified, 10% of the municipalities were involved in at least one cluster and less than 2% in several. We can infer that nationwide more than 1,000 clusters involving 30,000 cases of cAGE each year may be linked to tap water. The clusters discovered with this automated detection system will be reported to local operators for investigation of the situations at highest risk. This method will be compared with others before automated detection is implemented on a national level.

Introduction On 6-18 March 2014, a major episode of air pollution (PM10 concentrations exceeding 100 µg/m3 locally for several days) affected almost all France as well as other European countries, with impact in French media and policy-makers. We monitored health impact in France and consulted on actions taken in other countries. Methods From 6 to 25 March 2014, we monitored selected morbidity indicators a priori linked to air pollution using the French syndromic surveillance system SurSaUD® that covers 70% of emergency department visits and almost all doctors' house calls. On May 6, we sent a short questionnaire to 15 international experts asking how their countries/cities assessed the health impacts of such episodes. Results At the national level, no health impact could be detected during and after the episode. However, in the Paris area that faced the highest levels of air pollution, reported emergency department visits for asthma increased with a peak on 20 March (n=152), three times higher than during the reference period. Fourteen of 15 international experts indicated that they assess health impacts of such episodes a posteriori through time series analyses, while one reported real-time syndromic surveillance during the episode. Discussion Even if syndromic surveillance gives timely information on potential local health problems, international experts reported difficulties detecting real-time impact. Dialogue is needed with authorities requesting real-time health impact assessments as waiting for reported health outcome may delay prevention measures. But can the science of epidemiology better meet the authorities' needs?

We used a Poisson regression to compare daily hospital admissions of elderly people for acute gastrointestinal illness in Boston against daily variations in drinking water quality over an 11-year period, controlling for weather, seasonality and time trends. The Massachusetts Water Resources Authority (MWRA), which provides non-filtered water to 1.5 million people in the greater Boston area, changed its disinfection method from chlorination to ozonation during the study period so we were also able to evaluate changes in risk associated with the change in disinfection method. Other available water quality data from the MWRA included turbidity, fecal coliforms, UV-absorbance, and planktonic algae and cyanobacteriae concentrations. Daily weather, rainfall data and water temperature were also available. Low water temperature, increases in turbidity and, to a lesser extent, in fecal coliform and cyanobacteriae were associated with a higher risk of hospital admissions, while the shift from chlorination to ozonation has possibly reduced the health risk. The MWRA complied with US drinking water regulations throughout the study period.

Long-term exposure to air pollution (LTEAP) has been associated with mortality in numerous studies. In this study we aimed at analysing the link between air pollution and mortality at the individual level, assessing exposure to various air pollution indicators over 20 years. In specific, we studied the association between LTEAP and mortality in a large cohort recruited from the employees of the French national electricity and gas company, Électricité de France-Gaz de France (EDF-GDF) and followed from 1989 to 2008. The study population consisted of 20327 participants (1243 deaths at the end of the period). Exposure to PM10, PM10-2.5, PM2.5, NO2, O3, SO2, and C6H6 were assessed at the zip code of participants using determinist and geostatistical models taking into account residential history. Hazard ratios were estimated using Cox proportional-hazards regression model adjusted on selected individual and ecologic risk factors. An interquartile range (IQR) elevation in PM10 (7.8) and PM10-2.5 (2.2) at the baseline was respectively associated with an increase in all-cause mortality (ACM) 13% (95% CI, 1-27%) and 9% (95% CI, 2-16%). Annual moving average and cumulative exposure to PM10, PM10-2.5 and SO2 were also significantly associated with ACM. Regarding O3 we found significant negative associations with ACM. Non-significant associations were found with cardiovascular and respiratory mortality. In this cohort, long-term exposures to PM10, PM10-2.5 and SO2 were associated with increased risks of all-cause mortality. These results strengthen the evidence that air pollution, through particulate matter and sulfur dioxide, remains an important environmental risk factor for all-cause mortality. Acknowledgements This work is dedicated to the memory of Christophe Declercq for his valuable contribution to this project as the former coordinator of the surveillance program on air pollution and health at the French Institute for Public Health Surveillance (InVS).

Le changement climatique est un facteur de modification des risques sanitaires et environnementaux pouvant avoir des impacts importants en termes de santé publique. La surveillance épidémiologique devrait contribuer activement au développement des politiques d’adaptation : 1) en alertant sur les situations à risque, 2) en assurant la production continue de données de qualité utiles à la recherche et à la gestion, 3) en identifiant et hiérarchisant les besoins d’adaptation, 4) en évaluant l’efficacité des mesures d’adaptation. L’InVS a proposé une méthode pour mieux anticiper les effets envisageables du changement climatique pour différents risques sanitaires, et identifier les évolutions nécessaires des systèmes de surveillance, en intégrant les déterminants environnementaux, démographiques et sociaux. Le cas des évènements climatiques extrêmes illustre le propos. Ces événements ont des impacts sanitaires à court et long termes, qui pourraient être réduits grâce à une prévention efficace. Pour comprendre ces impacts et orienter la prévention, des études interdisciplinaires sont de plus en plus nécessaires.