Eleven-year trends in socioeconomic inequalities in the prevalence and incidence of pharmacologically treated type 2 diabetes in France, 2010-2020.

AIM: This study aimed to describe the association between socioeconomic inequalities and the prevalence and incidence of pharmacologically-treated type 2 diabetes in European France over the 2010-2020 period. METHODS: Diabetes cases were identified using a validated algorithm from the French National Health Data System. Analysis was restricted to adults aged 45 years and older to focus on type 2 diabetes. Socioeconomic inequalities were measured for all years in European France using the French deprivation index (FDep, 2015 version), which is an area-based deprivation indicator using population-weighted quintiles (Q1 corresponds to the least deprived municipalities). The relative risks of diabetes prevalence and incidence associated with FDep quintiles (Q1 as the reference) were estimated by sex using a log-linear Poisson model adjusted for year, age and French department. The study population was the French health consumers aged 45 years and over (from 24,228,526 in 2010 to 29,772,928 in 2020). RESULTS: A positive gradient was observed in the relative risks of type 2 diabetes prevalence and incidence by FDep quintiles over the study period. The strength of the estimated associations increased over the last decade for prevalence among men and women and for incidence among men in the two most deprived quintiles. CONCLUSION: Thus, type 2 diabetes prevention should include a proportionate universalism approach, proposing actions of greater intensity in the most deprived areas.

Spatiotemporal variation of childhood hyperthyroidism: a 10-year nationwide study.

Objective: Childhood hyperthyroidism is mostly caused by Graves' disease, a rare autoimmune disease in children. Epidemiological data are scarce and the variability of within-region incidence is unknown. We aimed to provide the first description of temporal trends in pediatric hyperthyroidism in France and to explore spatial trends, with a view to identifying possible environmental triggers. Design and methods: We performed an observational population-based study on data collected from the National Health Data System, covering the 2008-2017 period and the whole of France. We identified patients with an indicator reflecting incident cases of treated hyperthyroidism, in children aged 6 months-17.9 years, localized at the scale of the département (equivalent to a county) of residence. We performed descriptive analyses of incidence rate by sex, age, and year, and used a spatiotemporal model for estimation at département level. Results: We identified 4734 incident cases: 3787 girls (80%) and 947 boys (20%). The crude incidence rate was 3.35 (95% CI: 3.26; 3.45) per 100 000 person-years over the study period. We estimated the increase in incidence between 2008 and 2017 at 30.1% (19.0%; 42.3%). Annual incidence rate increased linearly over the 10-year period in both girls and boys, rising similarly in all age groups and in all départements. The spatial model highlighted marked heterogeneity in the risk of childhood hyperthyroidism across France. Conclusion: The trend toward increasing incidence observed may reflect changes in genetic and environmental interactions, and the marked spatial heterogeneity may reflect localized ethnic or environmental factors worthy of further investigation.

Increasing incidence and spatial hotspots of hospitalized endometriosis in France from 2011 to 2017.

Endometriosis is a female hormone-dependent disease, possibly related to endocrine disruptor exposure. We aimed to monitor this disease nationwide in France and analyze spatial trends at a fine scale to explore possible environmental contributing risk factors. We conducted a retrospective national descriptive study from 2011 to 2017 in females aged 10 years old and over, using comprehensive hospital discharge data. Cases were identified using ICD-10 N80 codes and were localized at their municipality of residence. We defined incident cases as the first hospital stay of patients, without a stay in at least the previous 5 years. We performed statistical analyses according to age and type of endometriosis, and we modeled the temporal, spatial and spatiotemporal trends. We identified 207,462 incident cases of all-type hospitalized endometriosis (83,112 for non-adenomyosis cases). The crude incidence rate for the study period was 9.85/10,000 person-years (3.95/10,000 for non-adenomyosis cases). From 2011 to 2017, the risk of all-type endometriosis increased by 8.5% (95% CI: 3.9; 13.4) (by 3.6% (95% CI: 0.6; 6.8) for non-adenomyosis cases). The risk was geographically heterogeneous, with 20 high-risk hotspots, showing similar results for non-adenomyosis cases. Shifting practice patterns, improved awareness and healthcare disparities interlinked with environmental risk factors could explain these trends.

Greening is a promising but likely insufficient adaptation strategy to limit the health impacts of extreme heat.

BACKGROUND: Adapting the urban environment to heat is a public health priority in the context of climate change. Cities are now considering interventions on specific urban characteristics known to contribute to the urban heat island (UHI) such as vegetation and imperviousness. OBJECTIVES: To explore how these urban characteristics influence the temperature-mortality relationship in the Paris region. METHODS: We modeled the temperature-mortality relationship for the 1300 municipalities of the region from 1990 to 2015, while including an interaction with indicators that summarize the municipalities' main urban characteristics. Four indicators were tested: lack of green spaces, lack of trees, proportion of impervious surface, and overexposed population to a potential night UHI. RESULTS: The shape of the temperature-mortality relationship was similar across all municipalities, but with a higher slope at the highest temperatures in municipalities with less green spaces, less trees, and more impervious soil. For instance, in Paris and its close suburbs, the relative risk associated with a temperature in the 99th percentile of the temperature distribution (compared to the 50th percentile) was 2.17 [IC95% 1.98:2.38] in municipalities with 40% of their surface covered by trees compared to 2.57 [IC 95% 2.47:2.68] in municipalities with only 3% of their surface covered by trees. DISCUSSION: A lack of vegetation and a high degree of imperviousness were associated with a higher risk of heat-related mortality in the Paris region. Therefore, we can assume that interventions targeting these characteristics could reduce the health impacts of extreme heat. Such interventions should be coupled with other initiatives such as protecting the most vulnerable and promoting appropriate behaviors.

Waterborne Disease Outbreak Detection: A Simulation-Based Study.

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.

Urinary levels of pyrethroid pesticides and determinants in pregnant French women from the Elfe cohort.

Pyrethroids are insecticides which are widely used for agricultural and domestic purposes. The general population can be exposed to them. Given the suspected effects of pesticides on the development of the foetus, exposure to pyrethroids during pregnancy is a major public health concern. The objective of this paper is to describe the urinary levels of the following five pyrethroid metabolites and their associated determinants among pregnant French women in 2011 enrolled in the Elfe cohort (n = 1077): a) 3-phenoxy benzoic (3-PBA), b) 4­fluoro­3­phenoxy benzoic acid (4-F-3-PBA), c) Cis­3­(2,2dibromovinyl)­2,2­dimethyl cyclopropane-carboxylic acid (Cis-DBCA); d) Cis­3­(2,2dichlorovinyl)­2,2­dimethyl cyclopropane-carboxylic acid (Cis-DCCA) and e) Trans-3­(2,2dichlorovinyl)­2,2­dimethyl cyclopropane-carboxylic acid (Trans-DCCA). The distribution levels were estimated for each pyrethroid metabolite. Multivariable analyses helped determine the predictors of these levels. All metabolites except 4-F-3-PBA were detected in all the urine samples. The mean urinary concentration of the sum of the metabolites (3-PBA, Cis-DBCA, Cis-DCCA, Trans-DCCA) was 1.18 µg/L, with the highest concentrations observed for 3-PBA. A comparison of these levels with other studies showed that pregnant French women tend to be more exposed to pyrethroids than their American counterparts, less exposed than Chinese and Caribbean mothers, and have similar exposure to Japanese mothers. In our study, urinary levels of pyrethroid metabolites were positively related to smoking during pregnancy, consuming fish and alcohol, domestic pesticide use and living in the vicinity of crops during pregnancy. These findings highlight the importance of non-dietary pathways when evaluating exposure to pyrethroids.

Prenatal exposure to lead in France: Cord-blood levels and associated factors: Results from the perinatal component of the French Longitudinal Study since Childhood (Elfe).

BACKGROUND: As a result of the ban on lead in gasoline on 2nd January 2000, the French population's exposure to lead has decreased in recent years. However, because of the acknowledged harmful cognitive effects of lead even at low levels, lead exposure remains a major public health issue. In France, few biomonitoring data are available for exposure to lead in pregnant women and newborn. The purpose of the perinatal component of the French human biomonitoring (HBM) program was to describe levels of various biomarkers of exposure to several environmental pollutants, including lead, among mother-baby pairs. In this paper, we aimed to describe the distribution of cord blood lead levels (CBLL) in French mother-baby pairs, and to estimate the contribution of the main lead exposure risk factors to these levels. METHOD: A total of 1968 mother-baby pairs selected from the participants of the perinatal component of the French HBM program were included in the study on lead. Lead levels were analyzed in cord blood collected at child delivery by inductively coupled plasma-mass spectrometry (ICP-MS). The data collected included biological sample, socio-demographic characteristics, environmental and occupational exposure, and information on dietary factors. RESULTS: CBLL were quantified for 99.5% of the sample. The CBLL geometric mean was 8.30 µg/l (95% CI [7.94-8.68]) with a 95th percentile of 24.3 µg/l (95% CI [20.7-27.1]). Factors significantly associated with CBLL were tap water consumption, alcohol consumption, shellfish consumption, vegetable consumption, bread consumption, smoking, and the mother being born in countries where lead is often used. CONCLUSION: This study provides the first reference value for CBLL in a random sample of mother-baby pairs not particularly exposed to high levels of lead (24.3 µg/l). A substantial decrease in CBLL over time was observed, which confirms the decrease of exposure to lead among the general population. CBLL observed in this French study were in the range of those found in recent surveys conducted in other countries.

Cancer incidence in adults living in the vicinity of nuclear power plants in France, based on data from the French Network of Cancer Registries.

Nuclear power plants (NPPs) release toxic emissions into the environment that may affect neighboring populations. This ecologic study was designed to investigate the possibility of an excess incidence of cancer in the vicinity of French NPPs by examining the incidence by municipality of 12 types of cancer in the population aged 15 years and older during the 1995-2011 period. Population exposure to pollution was estimated on the basis of distance from towns of residence to the NPP. Using regression models, we assessed the risk of cancer in a 20-km zone around NPPs and observed an excess incidence of bladder cancer (Relative Risk (RR), 95% Credibility Interval (95% CI)) in men and women (RRmen = 1.08; 95% CI: 1.00, 1.17 and RRwomen = 1.19; 95% CI: 1.02, 1.39). Women living within the 20-km proximity areas had a significantly reduced risk of thyroid cancer (RRwomen = 0.86; 95% CI: 0.77, 0.96). No excess risk of hematologic malignancies in either sex was seen. The higher than expected incidence of bladder cancer may be due to an excess incidence localized around the Flamanville NPP and the nearby La Hague nuclear waste treatment center, which is a source of chemical contaminants, many (including arsenic) of them known risk factors for bladder cancer. Differences in medical practices could explain the reduced risk of thyroid cancer. In this first study of adults living near NPPs in France, cancer incidence is significantly higher than in the references populations for one of the cancer types studied: bladder cancer.

The mortality impacts of fine particles in France.

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 10µg/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 950,000years 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 (10µg/m(3)), the total mortality could be decreased by 3%, corresponding to 400,000years 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.

Semen quality trends in French regions are consistent with a global change in environmental exposure.

A retrospective study carried out recently in a large sample of men, close to the general population, has reported a significant and strong decline in sperm concentration and morphology in the whole of France between 1989 and 2005. We studied these trends within each region of France. Data were obtained from the Fivnat database. The study sample comprised male partners of sterile women in whom both tubes were absent or blocked. They were located at the assisted reproductive technology center. A Bayesian spatio-temporal model with parametric time trends, adjusted for age, was used to model overall time trends for each region. The results show that sperm concentration decreased in almost all regions of France. Among them, Aquitaine showed the highest decrease and Midi-Pyrénées had the lowest average for the whole period. Regarding total motility, most regions showed a slight increase while Bourgogne showed a steep and significant decrease. While considering sperm morphology, there was a decrease in most of the regions. The decrease in Aquitaine and Midi-Pyrénées was stronger when compared with the overall trend. In conclusion, a decrease in sperm concentration and morphology, already shown at the French metropolitan territory level, was observed in most regions of France. This is consistent with a global change in environmental exposure, according to the endocrine disruptor hypothesis especially. Indeed, ubiquitary exposure to chemicals has been growing in the general population of France since the 1950s, and the results do not appear to support the lifestyle hypothesis. The highest decreases and lowest values are consistently observed in two proximate regions that are both highly agricultural and densely populated.

Ecological study on hospitalizations for cancer, cardiovascular, and respiratory diseases in the industrial area of Etang-de-Berre in the South of France.

The Etang-de-Berre area is a large industrialized area in the South of France, exposing 300,000 inhabitants to the plumes of its industries. The possible associated health risks are of the highest concern to the population, who asked for studies investigating their health status. A geographical ecological study based on standardized hospitalizations ratios for cancer, cardiovascular, and respiratory diseases was carried out over the 2004-2007 period. Exposure to air pollution was assessed using dispersion models coupled with a geographic information system to estimate an annual mean concentration of sulfur dioxide (SO2) for each district. Results showed an excess risk of hospitalization for myocardial infarction in women living in districts with medium or high SO2 exposure, respectively, 38% [CI 95% 4 : 83] and 54% [14 : 110] greater than women living in districts at the reference level exposure. A 26% [2 : 57] excess risk of hospitalization for myocardial infarction was also observed in men living in districts with high SO2 levels. No excess risk of hospitalization for respiratory diseases or for cancer was observed, except for acute leukemia in men only. Results illustrate the impact of industrial air pollution on the cardiovascular system and call for an improvement of the air quality in the area.

Increase in psychotropic drug deliveries after the Xynthia storm, France, 2010.

INTRODUCTION: During the night of February 27 and the early morning of February 28, 2010, 15 coastal municipalities situated in two French departments, Vendée and Charente-Maritime, were violently stricken by a severe windstorm named "Xynthia." This storm caused the death of 12 individuals in Charente-Maritime and 29 people in Vendée. Houses, agricultural fields, and shellfish companies were severely flooded with seawater. Several thousand people temporarily had to leave their homes. The objective of this study was to estimate the short-term mental health impact of Xynthia, in terms of psychotropic drug delivery, on the resident population of the 15 coastal municipalities severely hit by the flooding. METHODS: The French national health insurance database was used to calculate a daily number of new psychotropic treatments from September 1, 2008 through December 24, 2010. New treatments were calculated for each of the following European Pharmaceutical Marketing Research Association (EphMRA) classes: tranquilizers (N05C), hypnotics (N05B), and antidepressants (N06A). A period of three weeks following the storm was defined as the exposure period. A generalized additive model with a Poisson distribution that allows for over-dispersion was used to analyze the correlation between the Xynthia variable and the number of new psychotropic treatments. RESULTS: With a relative risk (RR) of 1.54 (95% CI, 1.39-1.62) corresponding to an estimate of 409 new deliveries of psychotropic drugs during the three weeks following the storm, this study confirms the importance of the psychological impact of Xynthia. This impact is seen on all three classes of psychotropic drugs studied. The impact is greater for tranquilizers (RR of 1.78; 95% CI, 1.59-1.89) than for hypnotics (RR of 1.53; 95% CI, 1.31-1.67) and antidepressants (RR of 1.26; 95% CI, 1.06-1.40). The RR was higher for females than for males. CONCLUSION: This study shows the importance of the psychological impact of the storm as observed clinically by health workers who intervened in the field during the aftermath of Xynthia. It confirms that administrative databases can be used to show a health impact of a disaster even at a local level. This is one more step in the direction of a comprehensive strategy of collecting information to allow the assessment of the health impact of an extreme event, the detection of vulnerable populations, and the orientation of the short-, mid- and long-term public health response.

Does arsenic in soil contribute to arsenic urinary concentrations in a French population living in a naturally arsenic contaminated area?

A cross sectional study using environmental and biological samples was implemented to assess the association between arsenic (As) concentrations in the environment and urinary As levels of residents living in an area where the soil is naturally As rich. As was measured in drinking water, atmospheric particulate matter, and soil and a geographic information system was used to assign environmental concentrations closest to the participants' dwellings and the sum of inorganic As and metabolites in urine samples. The only potential source of As environmental contamination was from soil with a range of 13-131 mg As/kg of dry matter. As(V) was the only species present among As extracted from the analyzed soil samples. The chemical extraction showed a poor mobility of As soil. There was no difference between child and teenager, and adult urinary As concentrations, though men had higher urinary As concentrations than women (p<0.001). Given the important differences in lifestyle between 7-18 year olds, men, and women, these groups were analyzed separately. Whilst we were unable to find a stable model for the 7-18 year old group, for the adult men group we found that seafood consumption in the 3 days prior to the investigation (p=0.02), and beer (p=0.03) and wine consumption in the 4 days before the study, were associated with As urinary levels (µg/L). In adult women, creatinine was the only variable significantly associated with As urinary concentration (µg/L). The concentrations we measured in soils were variable and although high, only moderately so and no link between As concentrations in the soil and urinary As concentrations could be found for either men or women. Some individual factors explained half of the variability of adult men urinary As levels. The unexplained part of the variability should be searched notably in As mobility in soil and uncharacterized human behavior.

Risk of cancer in the vicinity of municipal solid waste incinerators: importance of using a flexible modelling strategy.

BACKGROUND: We conducted an ecological study in four French administrative departments and highlighted an excess risk in cancer morbidity for residents around municipal solid waste incinerators. The aim of this paper is to show how important are advanced tools and statistical techniques to better assess weak associations between the risk of cancer and past environmental exposures. METHODS: The steps to evaluate the association between the risk of cancer and the exposure to incinerators, from the assessment of exposure to the definition of the confounding variables and the statistical analysis carried out are detailed and discussed. Dispersion modelling was used to assess exposure to sixteen incinerators. A geographical information system was developed to define an index of exposure at the IRIS level that is the geographical unit we considered. Population density, rural/urban status, socio-economic deprivation, exposure to air pollution from traffic and from other industries were considered as potential confounding factors and defined at the IRIS level. Generalized additive models and Bayesian hierarchical models were used to estimate the association between the risk of cancer and the index of exposure to incinerators accounting for the confounding factors. RESULTS: Modelling to assess the exposure to municipal solid waste incinerators allowed accounting for factors known to influence the exposure (meteorological data, point source characteristics, topography). The statistical models defined allowed modelling extra-Poisson variability and also non-linear relationships between the risk of cancer and the exposure to incinerators and the confounders. CONCLUSION: In most epidemiological studies distance is still used as a proxy for exposure. This can lead to significant exposure misclassification. Additionally, in geographical correlation studies the non-linear relationships are usually not accounted for in the statistical analysis. In studies of weak associations it is important to use advanced methods to better assess dose-response relationships with disease risk.

Risk for non Hodgkin's lymphoma in the vicinity of French municipal solid waste incinerators.

BACKGROUND: Dioxin emissions from municipal solid waste incinerators are one of the major sources of dioxins and therefore are an exposure source of public concern. There is growing epidemiologic evidence of an increased risk for non-Hodgkin's lymphoma (NHL) in the vicinity of some municipal solid waste incinerators with high dioxin emission levels. The purpose of this study was to examine this association on a larger population scale. METHODS: The study area consisted of four French administrative departments, comprising a total of 2270 block groups. NHL cases that had been diagnosed during the period 1990-1999, and were aged 15 years and over, were considered. Each case was assigned a block group by residential address geocoding. Atmospheric Dispersion Model System software was used to estimate immissions in the surroundings of 13 incinerators which operated in the study area. Then, cumulative ground-level dioxin concentrations were calculated for each block group. Poisson multiple regression models, incorporating penalized regression splines to control for covariates and dealing with Poisson overdispersion, were used. Five confounding factors were considered: population density, urbanisation, socio-economic level, airborne traffic pollution, and industrial pollution. RESULTS: A total of 3974 NHL incident cases was observed (2147 among males, and 1827 among females) during the 1990-1999 time period. A statistically significant relationship was found at the block group level between risk for NHL and dioxin exposure, with a relative risk (RR) of 1.120 (95% confidence interval [CI] 1.002 - 1.251) for persons living in highly exposed census blocks compared to those living in slightly exposed block groups. Population density appeared positively linked both to risk for NHL and dioxin exposure. Subgroup multivariate analyses per gender yielded a significant RR for females only (RR = 1.178, 95% CI 1.013 - 1.369). CONCLUSION: This study, in line with previous results obtained in the vicinity of the incinerator located in Besançon (France), adds further evidence to the link between NHL incidence and exposure to dioxins emitted by municipal solid waste incinerators. However, the findings of this study cannot be extrapolated to current incinerators, which emit lower amounts of pollutants.