Environmental health risks perceptions: results from cross-sectional surveys in Southeastern France

International audienceBackground: Arsenic is a toxic metalloid element frequently found in the environment. Chronic arsenic exposure is a critical public health issue in many countries since the identification of arsenic and its compounds as human carcinogens by the World Health Organization. After absorption, inorganic arsenic (iAs) is mainly methylated into monomethylated and dimethylated compounds (MMA, DMA), which are then excreted through the kidney together with unmethylated iAs. Whether the methylation process is to detoxify or potentiate arsenic toxicity, however, remains an ongoing debate. The purpose of this systematic review was to conduct a comprehensive meta-analysis to estimate the association between arsenic exposure and urothelial cancer. Methods: 10 observational studies met the inclusion criteria and were included in the systematic review. IAs%, MMA% and DMA% were extracted from each paper. Weighted Mean Differences with 95% confidence intervals were defined according to Cases minus Controls. Pooled risk estimates from individual studies were assessed using random effects models. Meta-regression analysis was performed to estimate the extent of urothelial cancer risk as a function of iAs%, MMA% and DMA%. Results: Results showed as patients with urothelial cancer presented higher level of urinary iAs% (WMD 2.70, 95%CI 0.64-4.76), MMA% (WMD 2.81, 95%CI 1.43-4.20) and DMA% (WMD-3.44, 95%CI-6.57-0.30). Conclusions: These findings suggest that higher level of iAs% and MMA% and lower level of DMA% were associated with an increased risk of urothelial cancer. Additional population based studies are needed to understand the role of arsenic in cancer development. Understanding the meaning of arsenic metabolism could improve the risk assessment of arsenic toxicity and provide a potential tool for disease prediction and prevention. Key messages: Higher level of iAs%, MMA% and DMA% were associated with an increased risk of urothelial cancer. Understanding the meaning of arsenic metabolism could improve the risk assessment of arsenic toxicity. Background: Heatwaves can lead to increased mortality. Portugal has a Heat-Health Warning System (HHWS) in place (ÍCARO system). Researchers at the Instituto Ricardo Jorge send a daily report with heat-related mortality forecasts to key stakeholders (e.g. Heat-Health Action Plans (HHAP) staff). HHAP practitioners issue warnings and implement measures to prevent heatwaves-related mortality. ICARO is amongst the recommended data sources to assess risk and issue warnings but its use and understanding is unknown. Therefore, we aimed to assess ÍCARO's use and understanding by key HHAP practitioners. Methods: We conducted semi-structured interviews with national and regional HHAP practitioners. Interviews were recorded, transcribed, and analysed using thematic content analysis. Intercoder reliability was applied to a sample of segments from 5 of 6 interviews. Results: We conducted 6 interviews with 9 professionals (mean time 52 minutes). We identified 4 categories: Report's content and presentation, Report's reception and communication, ÍCARO and risk assessment, Other issues. Practitioners use ÍCARO and perceived it as very relevant tool. However, they mentioned several questions on its interpretation. Practitioners also felt their questions were not fully answered, given researchers' use of statistical terms. Finally, practitioners referred the need to assess risk at the local level, information not currently provided. We also identified the need for improved communication and report's clarity. Conclusions: Our study stresses the need for an integrated collaboration between experts within HHWS and HHAP. Despite ICARO's understanding being challenging, practitioners consider it a relevant tool. Researchers should use less statistical language and clarify ÍCARO interpretation. Practitioners' needs should be considered when developing or revising tools. We are currently implementing some of these recommendations in an attempt to close the gap between researchers and practitioners

Study protocol for a pragmatic cluster randomized controlled trial to improve dietary diversity and physical fitness among older people who live at home (the “ALAPAGE study”)

Background : Diet and physical activity are key components of healthy aging. Current interventions that promote healthy eating and physical activity among the elderly have limitations and evidence of French interventions’ effectiveness is lacking. We aim to assess (i) the effectiveness of a combined diet/physical activity intervention (the “ALAPAGE” program) on older peoples’ eating behaviors, physical activity and fitness levels, quality of life, and feelings of loneliness; (ii) the intervention’s process and (iii) its cost effectiveness. Methods : We performed a pragmatic cluster randomized controlled trial with two parallel arms (2:1 ratio) among people ≥60 years old who live at home in southeastern France. A cluster consists of 10 people participating in a “workshop” (i.e., a collective intervention conducted at a local organization). We aim to include 45 workshops randomized into two groups: the intervention group (including 30 workshops) in the ALAPAGE program; and the waiting-list control group (including 15 workshops). Participants (expected total sample size: 450) will be recruited through both local organizations’ usual practices and an innovative active recruitment strategy that targets hard-to-reach people. We developed the ALAPAGE program based on existing workshops, combining a participatory and a theory-based approach. It includes a 7-week period with weekly collective sessions supported by a dietician and/or an adapted physical activity professional, followed by a 12-week period of post-session activities without professional supervision. Primary outcomes are dietary diversity (calculated using two 24-hour diet recalls and one Food Frequency Questionnaire) and lower-limb muscle strength (assessed by the 30-second chair stand test from the Senior Fitness Test battery). Secondary outcomes include consumption frequencies of main food groups and water/hot drinks, other physical fitness measures, overall level of physical activity, quality of life, and feelings of loneliness. Outcomes are assessed before the intervention, at 6 weeks and 3 months later. The process evaluation assesses the fidelity, dose, and reach of the intervention as its causal mechanisms (quantitative and qualitative data). Discussion : This study aims to improve healthy aging while limiting social inequalities. We developed and evaluated the ALAPAGE program in partnership with major healthy aging organizations, providing a unique opportunity to expand its reach

The extra cost of comorbidity: multiple illnesses and the economic burden of non-communicable diseases

Abstract Background The literature offers competing estimates of disease costs, with each study having its own data and methods. In 2007, the Dutch Center for Public Health Forecasting of the National Institute for Public Health and the Environment provided guidelines that can be used to set up cost-of-illness (COI) studies, emphasising that most COI analyses have trouble accounting for comorbidity in their cost estimations. When a patient has more than one chronic condition, the conditions may interact such that the patient’s healthcare costs are greater than the sum of the costs for the individual diseases. The main objective of this work was to estimate the costs of 10 non-communicable diseases when their co-occurrence is acknowledged and properly assessed. Methods The French Echantillon Généraliste de Bénéficiaires (EGB) database was used to assign all healthcare expenses for a representative sample of the population covered by the National Health Insurance. COIs were estimated in a bottom-up approach, through regressions on individuals’ healthcare expenditure. Two-way interactions between the 10 chronic disease variables were included in the expenditure model to account for possible effect modification in the presence of comorbidity(ies). Results The costs of the 10 selected chronic diseases were substantially higher for individuals with comorbidity, demonstrating the pattern of super-additive costs in cases of diseases interaction. For instance, the cost associated with diabetes for people without comorbidity was estimated at 1776 €, whereas this was 2634 € for people with heart disease as a comorbidity. Overall, we detected 41 cases of super-additivity over 45 possible comorbidities. When simulating a preventive action on diabetes, our results showed that significant monetary savings could be achieved not only for diabetes itself, but also for the chronic diseases frequently associated with diabetes. Conclusions When comorbidity exists and where super-additivity is involved, a given preventive policy leads to greater monetary savings than the costs associated with the single diagnosis, meaning that the returns from the action are generally underestimated

Comparison of pharmacy-based and diagnosis-based comorbidity measures from medical administrative data

International audiencePurpose Health status is sometimes quantified by chronic condition (CC) scores calculated from medical administrative data. We sought to modify two pharmacy-based comorbidity measures and compare their performance in predicting hospitalization and/or death. The reference was a diagnosis-based score. Methods One of the two measures applied an updated approach linking specific ATC codes of dispensed drugs to 22 CCs; the other used a list of 37 drug categories, without linking them to specific CCs. Using logistic regressions that took repeated measures into account and hospitalization and/or death the following year as the outcome, we assigned weights to each CC/drug category. Comorbidity scores were calculated as the weighted sum of the 22 CCs/37 drug categories. We compared the performance of both measures in predicting hospitalization and/or death with that of a diagnosis-based score based on 30 groups of long-term illnesses (LTIs), a status granted in France to exempt beneficiaries with chronic diseases from copayments. We assessed the predictive performance of the scores with the quasi-likelihood under the independence model criterion (QIC), the c statistic and the Brier score. Results The two pharmacy-based scores performed better than the LTI score, with lower QIC and Brier scores and higher c statistics. Their predictive performance was very similar. Conclusions While there is no clear consensus or recommendations about the optimal choice of comorbidity measure, both pharmacybased scores may be useful for limiting confounding in observational studies among general populations of adults from health insurance databases

Multi-trajectories of antidepressant and antipsychotic use : a 11-year naturalistic study in a community-based sample

Objective To explore the temporal dynamic of antidepressant and antipsychotic co-prescribing in real-life conditions. Methods The study was performed using reimbursement data from the French Insurance Healthcare system in a cohort of 118 454 persons with at least one dispensing of antidepressants and/or antipsychotics over the period 2006-2016. Latent class analyses were used to identify homogeneous groups of persons following similar multi-trajectories of antidepressant and/or antipsychotic dispensing. Multivariate polynomial logistic regression models were used to explore the characteristics independently associated with distinct trajectories. Results Five multi-trajectories of antidepressant and/or antipsychotic dispensing were identified: more than half of the sample (58%) had very low antidepressant and antipsychotic use; two groups had chronic (12%) or decreasing (11%) antidepressant use with very low antipsychotic use; two groups used both antidepressants and antipsychotics simultaneously either in an increasing (12%) or chronic (7%) way. Persons with chronic antidepressant-antipsychotic use presented with markers of poor social and mental health conditions. Conclusions Most persons using antipsychotics over the follow-up also used antidepressants over the same period. The benefit/risk ratio of these prescribing practices should be further explored as the long-term efficacy of antidepressant-antipsychotic polypharmacy is poorly documented, while this combination increases the risk of adverse effects

Seasonal influenza vaccination among people with diabetes : influence of patients' characteristics and healthcare use on behavioral changes

Annual seasonal influenza vaccination (SIV) is recommended for people with diabetes, but vaccine coverage remains low. We estimated the probabilities of stopping or starting SIV, their correlates, and the expected time spent in the vaccinated state over 10 seasons for different patient profiles. We set up a retrospective cohort study of patients with diabetes in 2006 (n = 16,026), identified in a representative sample of beneficiaries of the French National Health Insurance Fund. We followed them up over 10 seasons (2005/06-2015/16). We used a Markov model to estimate transition probabilities and a proportional hazards model to study covariates. Between two consecutive seasons, the probabilities of starting (0.17) or stopping (0.09) SIV were lower than those of remaining vaccinated (0.91) or unvaccinated (0.83). Men, older patients, those with type 1 diabetes, treated diabetes or more comorbidities, frequent contacts with doctors, and with any hospital stay for diabetes or influenza during the last year were more likely to start and/or less likely to stop SIV. The mean expected number of seasons with SIV uptake over 10 seasons (range: 2.6-7.9) was lowest for women = 65 years with type 1 diabetes. Contacts with doctors and some clinical events may play a key role in SIV adoption. Healthcare workers have a crucial role in reducing missed opportunities for SIV. The existence of empirical patient profiles with different patterns of SIV uptake should encourage their use of tailored educational approaches about SIV to address patients' vaccine hesitancy

Trajectories of seasonal influenza vaccination uptake in French people with diabetes from 2006 to 2015

Abstract dans revueInternational audienceIntroductionSeasonal influenza vaccine (SIV) is recommended in France for people aged 65 years or older and those with clinical risk factors, including diabetes. The French National Health Insurance Fund (NHIF) can identity these individuals and send them a voucher so they can obtain the vaccine free of charge. Despite this, SIV coverage remains below the target of 75% and has progressively decreased since the 2009 pandemic. We aimed to identify temporal trajectories (T) over a 10-year period of SIV uptake (SIVU) among patients with diabetes and to describe their correlates.MethodsWe identified patients with diabetes in 2006 (n = 17,259) among a representative sample of French NHIF beneficiaries. We followed them from 2006 through 2015, using SIV reimbursement claims and group-based trajectory modeling to identify SIVU-T and drug reimbursement claims to assess diabetes severity and comorbidity status. A multinomial logistic regression allowed us to study characteristics associated with the SIVU-T.ResultsWe found 6 SIVU-T: (1) “never” T (prevalence: 32%): people with quasi null SIVU probabilities (≤ 5%); (2) “late increasing” T (4%): SIVU probability varying from ≤ 10% before 2011/12 to 85% in 2015/16; (3) “early increasing” T (8%): probability varying from ≤ 10% in 2006/07 to ≥ 80% starting in 2009/10; (4) “regular” T (33%): probability always ≥ 95%; (5) “progressively non-vaccinated” T (14%): probability decreasing from 90% in 2006/07 to 20% in 2015/16; (6) “post-pandemic decreasing” T (9%): probability decreasing right after the 2009/10 season.Overall, compared to the “never” T group, people in all other trajectories had poorer health at inclusion and/or over the study period (severe diabetes, high comorbidity score), people in the “late increasing” T group were more likely to have received newly free vaccination vouchers and/or changed general practitioners (GPs) during follow-up, and those in the “early increasing” T more likely to have received newly free vaccination vouchers and to have been hospitalized for an influenza-like illness during the follow-up. Those with “regular” T were slightly older than those with “never” T and less likely to have been hospitalized due to diabetes; those with a “progressively non-vaccinated” T were oldest (mean age at inclusion = 80 ± 7 years versus 65 ± 14 in the study population). Finally, people with a “post-pandemic decreasing” T were more frequently women, more likely to have been hospitalized due to an influenza-like illness, and to have changed GPs during the follow-up.ConclusionsSIVU behavior was stable in most people with diabetes over the study period: one third were vaccinated regularly and another third never. The latter were globally healthier than the other groups and may feel less vulnerable to it, despite their clinical risk. About 25% became less inclined toward vaccination in one of two different patterns: the “progressively non-vaccinated” T may reflect the patient and/or healthcare professional's doubts about the benefits of SIV after a certain age (in part due to immunoscenescence); those in the “post-pandemic decreasing” T may have lost confidence in SIV after controversies in France during the 2009 mass vaccination campaign against the pandemic. About 10% became more likely to be vaccinated during the study period; our results suggest that receiving free vouchers for the first time might have triggered or fostered this behavioral change. Changing GPs and hospitalization for an influenza-like illness were associated with both increasing and decreasing trajectories. These events may represent key opportunities to foster or prevent behavioral changes toward SIV. Further research is needed to better understand the chronology of these events and potential causal pathways. These results should help stakeholders to adapt public health interventions to specific subgroups

Eight-Year Follow-up of Hypnotic Delivery by Adults Aged 50 and Older from an Insurance Database

International audienceStudy objectives: This study sought to (1) identify patterns of hypnotic use among persons aged 50 and older for 8 years and (2) describe characteristics and correlates associated with them. Methods: A representative sample of national health insurance system beneficiaries was followed up from 2006 through 2013; individuals were grouped according to hypnotic delivery trajectories by latent class mixed models. Results: We identified four different temporal trajectories of hypnotic delivery among users. Delivery was occasional for 40% and regular for 60% (quasicontinuous "use": 27%; increasingly frequent over time: 17%; decreasingly frequent: 16%). Quasi-continuous "users" received hypnotics for more than 70% of the follow-up period and occasional "users" for less than 8%. We found no clear evidence of dose escalation. The three regular-delivery trajectories shared similar correlates (psychiatric disorders, somatic comorbidity, and coprescriptions of antidepressants or antipsychotics), but association with somatic comorbidity was highest by far for quasi-continuous "users." Conclusions: Our results suggest that chronic hypnotic use covers different patterns resulting from different long-term temporal delivery trajectories. Because difficulties in stopping or reducing use may vary greatly according to these trajectories, patients may need individualized management approaches

Antipsychotic prescribing in youths: a French community-based study from 2006 to 2013

International audienceThe objectives were to explore in a community-based sample of persons aged 0-25 years: (1) trends in antipsychotic prescribing, (2) characteristics of the zone of residence associated with antipsychotic prescribing rates, and (3) the pattern of antipsychotic prescribing. The study was performed using reimbursement data from the French Insurance Healthcare system. Prescribing trends were investigated over the period 2006-2013. An ecological design was used to assess the impact of the socio-economical and health resource characteristics of the zone of residence (n = 96 administrative subdivisions of French territory) on antipsychotic prescribing rates. The pattern of antipsychotic prescribing was explored in a cohort of youths newly treated with antipsychotics. Over the period 2006-2013, antipsychotic dispensing rates were stable in persons aged 0-25 years (4.8 per 1,000 in 2006 and 4.9 per 1,000 in 2013). First-generation antipsychotic dispensing rates decreased from 3.1 to 2.6 per 1,000 (OR = 0.96, 95% CI 0.94-0.98), while second-generation antipsychotic dispensing rates increased from 2.7 to 3.4 per 1,000 (OR = 1.03, 95% CI 1.01-1.05). Antipsychotic prescribing rates were impacted by health resource characteristics of the zone of residence in children aged 10 years and under and by socio-economical characteristics in those aged 16-20 years. In all the age groups, antipsychotics were principally started by hospital practitioners (47%) and general practitioners (34%). The rates of psychostimulants concomitantly prescribed with antipsychotics were lower than 5%. In conclusion, rates of youths exposed to second-generation antipsychotics are still rising. The impact of environmental characteristics on antipsychotics prescribing and appropriateness of these prescriptions in youths should be further investigated. s should be further investigated

Phylogenetic relationship between the endosymbiont “Candidatus Riesia pediculicola” and its human louse host

International audienceThe human louse ( Pediculus humanus ) is a haematophagous ectoparasite that is intimately related to its host. It has been of great public health concern throughout human history. This louse has been classified into six divergent mitochondrial clades (A, D, B, F, C and E). As with all haematophagous lice, P. humanus directly depends on the presence of a bacterial symbiont, known as “ Candidatus Riesia pediculicola”, to complement their unbalanced diet. In this study, we evaluated the codivergence of human lice around the world and their endosymbiotic bacteria. Using molecular approaches, we targeted lice mitochondrial genes from the six diverged clades and Candidatus Riesia pediculicola housekeeping genes . Methods The mitochondrial cytochrome b gene ( cytb ) of lice was selected for molecular analysis, with the aim to identify louse clade. In parallel, we developed four PCR primer pairs targeting three housekeeping genes of Candidatus Riesia pediculicola: ftsZ , groEL and two regions of the rpoB gene ( rpoB -1 and rpoB -2). Results The endosymbiont phylogeny perfectly mirrored the host insect phylogeny using the ftsZ and rpoB -2 genes, in addition to showing a significant co-phylogenetic congruence, suggesting a strict vertical transmission and a host–symbiont co-speciation following the evolutionary course of the human louse. Conclusion Our results unequivocally indicate that louse endosymbionts have experienced a similar co-evolutionary history and that the human louse clade can be determined by their endosymbiotic bacteria. Graphical Abstrac