Persistent Organic Pollutant Exposure and Thyroid Function among 12-Year-Old Children.

INTRODUCTION: Polychlorobiphenyls (PCBs), organochlorine pesticides (OCPs), and per- and polyfluoroalkyl substances (PFASs) are persistent organic pollutants (POPs) having numerous toxicological properties, including thyroid endocrine disruption. Our aim was to assess the impact of POPs on thyroid hormones among 12-year-old children, while taking puberty into consideration. METHODS: Exposure to 7 PCBs, 4 OCPs, and 6 PFASs (in µg/L), and free tri-iodothyronine (fT3, pg/mL), free thyroxine (fT4, ng/dL), and thyroid-stimulating hormones (TSH, mIU/L) were assessed through blood-serum measurements at age 12 years in 249 boys and 227 girls of the PELAGIE mother-child cohort (France). Pubertal status was clinically rated using the Tanner stages. For each POP, associations were estimated using linear regression, adjusted for potential confounders. RESULTS: Among boys, hexachlorobenzene and perfluorodecanoic acid were associated with decreased fT3 (log-scale; ß [95% confidence interval] = -0.07 [-0.12,-0.02] and ß = -0.03 [-0.06,-0.00], respectively). Intermediate levels of perfluorohexanesulfonic acid (PFHxS) and PCB180 were associated, respectively, with increased and decreased fT4. After stratification on pubertal status, PCBs and OCPs were associated with decreased TSH only in the more advanced Tanner stages (3-5) and with decreased fT3 among early Tanner stages (1-2). Among girls, PFHxS was associated with decreased TSH (log-scale; ß = -0.15 [-0.29,-0.00]), and perfluorooctanoic acid was associated with decreased fT3 (ß2nd_tercile = -0.06 [-0.10,-0.03] and ß3rd_tercile = -0.04 [-0.08,-0.00], versus. 1st tercile). DISCUSSION: This cross-sectional study highlights associations between some POPs and thyroid function disruption, which appears consistent with the literature. Considering that the associations were sex-specific and moderated by pubertal status in boys, complex endocrine interactions are likely involved.

Prenatal exposure to persistent organic pollutants and molar-incisor hypomineralization among 12-year-old children in the French mother-child cohort PELAGIE.

BACKGROUND: Exceptional episodes of exposure to high levels of persistent organic pollutants have already been associated with developmental defects of enamel among children, but knowledge is still scarce concerning the contribution of background levels of environmental contamination. METHODS: Children of the French PELAGIE mother-child cohort were followed from birth, with collection of medical data and cord blood samples that were used to measure polychlorinated biphenyls (PCBs), organochlorine pesticides (OCs), and perfluorinated alkyl substances (PFASs). At 12 years of age, molar-incisor hypomineralization (MIH) and other enamel defects (EDs) were recorded for 498 children. Associations were studied using logistic regression models adjusted for potential prenatal confounders. RESULTS: An increasing log-concentration of ß-HCH was associated with a reduced risk of MIH and EDs (OR = 0.55; 95% CI, 0.32-0.95, and OR = 0.65; 95% CI, 0.43-0.98, respectively). Among girls, intermediate levels of p,p'-DDE were associated with a reduced risk of MIH. Among boys, we observed an increased risk of EDs in association with intermediate levels of PCB 138, PCB 153, PCB 187, and an increased risk of MIH with intermediate levels of PFOA and PFOS. CONCLUSIONS: Two OCs were associated with a reduced risk of dental defects, whereas the associations between PCBs and PFASs and EDs or MIH were generally close to null or sex-specific, with an increased risk of dental defects in boys. These results suggest that POPs could impact amelogenesis. Replication of this study is required and the possible underlying mechanisms need to be explored.

Pregnancy in women with multiple sclerosis in France from 2010 to 2015: Incidence, outcomes, and exposure to disease-modifying therapies.

BACKGROUND: Multiple sclerosis (MS) is usually diagnosed between 20-40 years old, when women often plan to have children. OBJECTIVE: Our objectives were to estimate pregnancy incidence rates in women with multiple sclerosis (MS), and to describe the use of disease-modifying therapies (DMTs) before conception and during pregnancy, and pregnancy outcomes. METHODS: This retrospective cohort study included all 15- to 49-year-old women with MS in the French national health insurance database over 2010-2015. A pregnancy was exposed if a DMT reimbursement claim occurred during pregnancy or in the 14 preceding days. We used zero-inflated negative binomial (ZINB) regression models to estimate incidence rates and ordinal and multinomial regression models to estimate DMT exposure and pregnancy outcomes. RESULTS: The pregnancy incidence rate was 4.5 per 100 person-years. The probability of having a DMT-exposed pregnancy increased from 0.22 in 2010 to 0.30 in 2015. The probability of live birth was 0.72 (95% CI = 0.70-0.74) for exposed pregnancies (varied considerably among DMTs), 0.77 (95% CI = 0.76-0.79) without treatment, and 0.81 (95% CI = 0.79-0.83) if treatment was stopped within the previous year. CONCLUSION: In this population-based study, we showed an increase of exposed pregnancies over time, beta-interferon and glatiramer acetate being the most used DMTs and associated with the highest probabilities of live birth. Interrupted exposed pregnancies may reflect undesired pregnancies or fear of an adverse outcome, while recent DMT stop probably reflects pregnancy planning.

Prenatal exposure to organophosphate pesticides and autism spectrum disorders in 11-year-old children in the French PELAGIE cohort.

BACKGROUND: Organophosphate (OP) pesticides act by inhibiting acetylcholinesterase activity at synaptic junctions and have already been linked with deleterious effects on neurodevelopment, including autism spectrum disorders (ASD). OBJECTIVES: To investigate the association of prenatal exposure to OP pesticides with traits related to ASD in 11-year-old children. METHODS: The "Childhood Autism Spectrum Test" (CAST) parent questionnaire was used to screen for autistic traits in 792 children from the French PELAGIE cohort. Prenatal maternal urine samples were collected <19 weeks of gestation in which metabolites of organophosphate insecticides were assessed for 185 of them. Negative binomial regression models were performed to explore the association between the CAST score and 8 groups of urine components, adjusted for potential ASD risk factors. RESULTS: In these urine samples, dialkylphosphates (DAP) were detected most often (>80%), terbufos and its metabolites least often (<10%). No association with ASD was found for DAP, terbufos or its metabolites. Incidence rate ratios (IRRs) increased with maternal urinary diazinon concentrations, from 1.11 (95% CI: 0.87-1.42) to 1.17 (95% CI: 0.94-1.46). Higher CAST scores were statistically significantly associated with the maternal urine samples in which chlorpyrifos or two of its metabolites (chlorpyrifos-oxon and 3,5,6-trichloro-2-pyridinol) were detected. The IRR for exposure to chlorpyrifos or chlorpyrifos-oxon was 1.27 (95%CI: 1.05-1.52) among all children, and 1.39 (95%CI: 1.07-1.82) among boys. CONCLUSION: These findings suggest an increase in autistic traits among 11-year-old children in association with prenatal maternal exposure to chlorpyrifos and possibly diazinon. These associations were previously suspected in the literature, in particular for chlorpyrifos. Further work establishing the causal mechanisms behind these risk association is needed.

Main outcomes from the first 2 years of France's screening programme for neonatal permanent hearing loss through a descriptive study.

AIM: This study aimed to evaluate the implementation of France's neonatal hearing loss screening programme years after its launch, and to estimate permanent bilateral neonatal hearing loss (PBNHL) prevalence and distribution by severity. METHODS: This descriptive study used aggregated regional data on all births in France in 2015-2016. Screening coverage, refusal rate, positive predictive value (PPV), proportion of children with suspected PBNHL, PBNHL prevalence and distribution by severity were calculated. RESULTS: Eight hundred thousand neonates were eligible for the screening programme per year. Between 2015 and 2016, screening coverage increased (83.3% vs. 93.8%; p < 0.001), and the refusal rate remained stable (0.1%). In 2016, when considering the additional tests performed several weeks after birth, the proportion of suspected PBNHL neonates decreased (1.4% vs. 0.9%) while the PPV increased (4.7% vs. 7.6%). In 2015, the estimated prevalence of PBNHL (moderate to profound) was 0.09% (95% CI 0.08-0.10). Among neonates with >= 41 decibels deficit, 56.8%, 16.6%, and 26.6% had moderate, severe and profound hearing loss, respectively. CONCLUSION: The national target of 90% screening coverage was exceeded. The additional test could be useful to avoid overcrowding in diagnostic structures. Diagnostic data quality must be improved to confirm PBNHL prevalence and distribution by severity.

Targeted vaccination campaigns of teenagers after two clusters of B invasive meningococcal disease in Brittany, France, 2017.

BACKGROUND: In December 2016, three cases of serogroup B invasive meningococcal disease, including two children from the same middle school (11 to 15 years old pupils), occurred in the department (administrative district) Côtes-d'Armor (Brittany, France). They were infected by a rare strain (B:P1.7-2,4:F5-9:cc162), covered by the 4CMenB vaccine (Bexsero®). Four months later, two cases due to the same strain occurred in a high school in the same area (15 to 19 years old students). In accordance with French recommendations, vaccination was proposed to students of both schools and to all individuals aged 11-19 years living or studying in the hyperendemic area. We describe these vaccination campaigns, from the alert to the impact evaluation. METHODS: The target population included 8884 people: 579 in the middle school, 2007 in the high school and 6298 in the community. In both schools, vaccination sessions were organized directly on site. In the community, teenagers were vaccinated by general practitioners. The vaccination campaign took place from May to October 2017. An active pharmacovigilance follow-up was set up to document adverse effects of the vaccine. RESULTS: Considering the whole target population, the vaccination coverage was estimated at 43% for 1 dose and 34% for 2 doses. Higher vaccination coverage was observed in the schools (79% in the middle school and 42% in the high school for 2 doses) than in the community (27% for 2 doses). The reported adverse effects were consistent with the safety profile of the vaccine and no severe adverse effect was reported. CONCLUSIONS: This vaccination campaign was the third one implemented with Bexsero® in France and constitutes a reproducible approach for future targeted vaccination campaigns. No additional cases of the same strain have occurred since the end of the campaigns in the area.

Seasonal influenza vaccination coverage and its determinants among nursing homes personnel in western France.

BACKGROUND: Influenza-associated deaths is an important risk for the elderly in nursing homes (NHs) worldwide. Vaccination coverage among residents is high but poorly effective due to immunosenescence. Hence, vaccination of personnel is an efficient way to protect residents. Our objective was to quantify the seasonal influenza vaccination (IV) coverage among NH for elderly workers and identify its determinants in France. METHODS: We conducted a cross-sectional study in March 2016 in a randomized sample of NHs of the Ille-et-Vilaine department of Brittany, in western France. A standardized questionnaire was administered to a randomized sample of NH workers for face-to-face interviews. General data about the establishment was also collected. RESULTS: Among the 33 NHs surveyed, IV coverage for the 2015-2016 season among permanent workers was estimated at 20% (95% Confidence Interval (CI) 15.3%-26.4%) ranging from 0% to 69% depending on the establishments surveyed. Moreover, IV was associated with having previously experienced a "severe" influenza episode in the past (Prevalence Ratio 1.48, 95% CI 1.01-2.17), and varied by professional categories (p < 0.004) with better coverage among administrative staff. Better knowledge about influenza prevention tools was also correlated (p < 0.001) with a higher IV coverage. Individual perceptions of vaccination benefits had a significant influence on the IV coverage (p < 0.001). Although IV coverage did not reach a high rate, our study showed that personnel considered themselves sufficiently informed about IV. CONCLUSIONS: IV coverage remains low in the NH worker population in Ille-et-Vilaine and also possibly in France. Strong variations of IV coverage among NHs suggest that management and working environment play an important role. To overcome vaccine "hesitancy", specific communication tools may be required to be adapted to the various NH professionals to improve influenza prevention.

Prenatal Exposure to Perfluoroalkyl Substances and Child Behavior at Age 12: A PELAGIE Mother-Child Cohort Study.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are chemical substances spread throughout the environment worldwide. Exposure during pregnancy represents a specific window of vulnerability for child health. OBJECTIVE: Our objective was to assess the impact of prenatal exposure to multiple PFAS on emotional and behavioral functions in 12-y-old children. METHOD: In the PELAGIE mother-child cohort (France), prenatal exposure to nine PFAS was measured from concentrations in cord serum samples. Behavior was assessed at age 12 y using the parent-reported Strengths and Difficulties Questionnaire (SDQ) and the self-reported Dominic Interactive for Adolescents (DIA) for 444 children. Associations were estimated using negative binomial models for each PFAS. Bayesian kernel machine regression (BKMR) models were performed to assess the exposure mixture effect on children's behavior. RESULTS: In our study population, 73% of mothers had spent more than 12 y in education. Higher scores on SDQ externalizing subscale were observed with increasing cord-serum concentration of perfluorooctanoic acid (PFOA) and perfluorononanoic acid (PFNA) [adjusted mean ratio (aMR)=1.18, 95% confidence interval (CI): 1.03, 1.34, and aMR=1.14 (95% CI: 1.00, 1.29) for every doubling of concentration, respectively]. Results for the hyperactivity score were similar [aMR=1.20 (95% CI: 1.04, 1.40) and aMR=1.18 (95% CI: 1.02, 1.36), respectively]. With regard to major depressive disorder and internalizing subscales, perfluorodecanoic acid (PFDA) was associated with higher self-reported DIA scores [aMR=1.14 (95% CI: 1.01, 1.27) and aMR=1.11 (95% CI: 1.02, 1.21), respectively]. In terms of the anxiety subscale, PFDA and PFNA were associated with higher scores [aMR=1.11 (95% CI: 1.02, 1.21) and aMR=1.10 (95% CI: 1.01, 1.19), respectively]. Concurrent increases in the PFAS concentrations included in the BKMR models showed no change in the SDQ externalizing and DIA internalizing subscales scores. CONCLUSION: Prenatal exposure to PFNA and PFOA were associated with increasing scores for measures of externalizing behaviors, specifically hyperactivity. We also identified associations between PFNA and PFDA prenatal exposure levels and increasing scores related to internalizing behaviors (general anxiety and major depressive disorder), which adds to the as yet sparse literature examining the links between prenatal exposure to PFAS and internalizing disorders. https://doi.org/10.1289/EHP12540.

Assessing the Risk of Relapse Requiring Corticosteroids After In Vitro Fertilization in Women With Multiple Sclerosis.

BACKGROUND AND OBJECTIVES: Several studies have shown an increased risk of relapse after In Vitro Fertilization (IVF) in women with Multiple Sclerosis (MS), especially when a GnRH agonists stimulation protocol was used. Our objective was to investigate the risk of relapse after IVF in women with multiple sclerosis, overall and according to stimulation protocol (GnRH agonists vs antagonists), using data from the French national health insurance database. METHODS: This retrospective cohort study included all women with MS who have benefited from IVF between January 1, 2010 and December 31, 2015 in France. Three-month exposed periods after IVF were compared to unexposed periods before IVF, each woman being her own control. Four outcomes were considered: annualized relapse rate (ARR), proportion of IVF with relapse, difference in the number of relapse "after - before" and the delay from IVF to the first relapse. Relapses were identified by an algorithm based on MS-related hospital admissions and use of corticosteroid therapy. Stimulation protocols and disease-modifying therapies (DMT) were identified using drugs claims. Zero-inflated Poisson regression models adjusted for age at IVF and presence of DMT were used. A random effect on the woman was included because women may have multiple IVF procedures. Subgroup analyses by stimulation protocol and IVF outcome (pregnancy or failure) were conducted. RESULTS: A total of 225 women accounting for 338 IVF were included (mean age at first IVF 34.6 ± 4.5 years; 36% of women had at least two IVF during the period). No increase in the risk of relapse after IVF was found overall (before vs. after IVF: respectively 0.20 vs. 0.18 relapse per patient-year; resp. 7.7% vs. 7.1% of IVF with women having at least one relapse) and in subgroups. A lower ARR before and after IVF was observed among women who remained treated until IVF. DISCUSSION: The maintenance of DMT until IVF appeared to be a determining factor in reducing the risk of relapse. Women with MS should be reassured as we did not show an increased risk of relapse requiring use of corticosteroids therapy after IVF neither with GnRH agonists nor with GnRH antagonists.

Prescribing Trends for Valproate Among Pregnant Women: A Cross-sectional Study in 2013 and 2016 Using the French Health Insurance Database.

BACKGROUND AND OBJECTIVE: To describe the prescribing trends for sodium valproate (VPA) and alternative drugs during and around pregnancy, comparing 2016 (after the recommendations on valproate for women were reinforced by the European Medicines Agency [EMA]) with 2013 (before the recommendations). METHODS: Using the French National Health Insurance Database, a cross-sectional study was carried out in 2013 and in 2016, including women who became pregnant and had at least 1 reimbursement claim for VPA in the 2 years prior to pregnancy or during pregnancy. Exposure to VPA and its alternatives was then measured for each quarter, in the 2 years before pregnancy (preconception), during pregnancy, and in the year after pregnancy (postpartum). RESULTS: Among pregnant women with epilepsy (n = 2,607 pregnancies), the proportion exposed to VPA during pregnancy decreased from 26.4% to 9.3% between 2013 and 2016, alongside an increase in lamotrigine and levetiracetam use. Among pregnant women with bipolar disorder (n = 4,278 pregnancies), the proportion of women exposed during pregnancy decreased from 3.7% in 2013 to 1.9% in 2016, without any switch to alternative drugs. In both populations, fewer than one third had consulted a specialist before pregnancy. DISCUSSION: As recommended by the EMA, a change in practice over the 2013-2016 period was observed, with fewer women exposed to VPA during pregnancy and before pregnancy. However, in 2016, a large number of women were exposed to VPA in the first trimester of pregnancy (n = 471), which could suggest that the timing of pregnancy should be better planned when possible.

Prenatal exposure to glycol ethers and visual contrast sensitivity in 6-year-old children in the PELAGIE mother-child cohort.

BACKGROUND: Maternal occupational exposure to organic solvents during pregnancy has been associated with decreased visual function in offspring. Glycol ethers (GEs) belong to oxygenated solvents and are widely used both in occupational and domestic contexts. OBJECTIVES: We aimed to assess associations between prenatal GEs exposure and contrast sensitivity in children. METHODS: Six GE alkoxy carboxylic acidic metabolites (methoxyacetic acid [MAA], ethoxyacetic acid [EAA], ethoxyethoxyacetic acid [EEAA], butoxyacetic acid [BAA], phenoxyacetic acid [PhAA], and 2-methoxypropionic acid [2-MPA]) were measured in first morning void urine samples collected from 220 early-pregnancy women, in the mother-child PELAGIE cohort (France). Trained investigators administered the Functional Acuity Contrast Test (FACT) to the 6-year-old children, providing scores for 5 spatial frequencies (1.5-18 cycles per degree (cpd)). We standardized biomarker urinary concentrations on urine sampling conditions. Values below the LOD were imputed based on log-normal distribution, generating five datasets for multiple imputation. Linear regression models were adjusted for potential confounders. RESULTS: GE metabolites were detected in 70-98% of maternal urine samples. Phenoxyacetic acid (PhAA) had the highest median concentration (0.33 mg/L), and 2-methoxypropionic acid (2-MPA) the lowest (0.01 mg/L). Children with higher prenatal PhAA concentrations had poorer FACT scores at various spatial frequencies (fourth vs. first quartile: ß18cpd = -0.90 (95% confidence interval CI = -1.64, -0.16), ß12cpd = -0.92 (95%CI = -1.55, -0.29) and ß1.5cpd = -0.69 (95%CI = -1.19, -0.20)). The 2-MPA log-scale concentration was negatively associated with the FACT score at the 3-cpd stimulus. DISCUSSION: PhAA is the metabolite of ethylene glycol monophenyl ether present in many cosmetics. 2-MPA is the metabolite of an isomer of propylene glycol methyl ether commonly present in household and industrial cleaning products. Although evidence of biological plausibility is lacking, the study suggests adverse impact of ubiquitous prenatal exposure to some GE on visual functioning among children.

[The heat wave of August 2003: what happened?]. / La vague de chaleur d'août 2003: que s'est-il passe?

A heat wave of exceptional intensity occurred in France in August 2003, 2003 was the warmest of the last 53 years in terms of minimal, maximal and average temperatures, and in terms of duration. In addition, high temperatures and sunshine, causing the emission of pollutants, significantly increased the atmospheric ozone level. Some epidemiological studies were rapidly implemented during the month of August in order to asses the health impact of this heat wave. Excess mortality was estimated at about 14 800 additional deaths. This is equivalent to a total mortality increase of 60% between August 1st and 20th, 2003 (Inserm survey). Almost the whole country was concerned by this excess-mortality, even in locations where the number of very hot days remained low. Excess-mortality clearly increased with the duration of extreme temperatures. These studies also described the features of heat-related deaths. They showed that the death toll was at its highest among seniors and suggested that less autonomous or disabled or mentally ill people were more vulnerable. So, they provided essential information for the setting up of an early warning system in conjunction with emergency departments. The public health impact of the Summer 2003 heat wave in various European countries was also assessed. Different heat waves in term of intensity had occurred at different times in many countries with each time deaths in excess. But, it does seem that France was the most affected country. However, implementation of standardized methods of data collection through all countries is necessary to afford further comparisons. Collaborative studies will be conducted in this way. After theses first descriptive studies, further etiologic studies on risk factors and heat-related deaths were launched and are now in progress. Considering the health impact of the heat wave, national health authorities decided to launch an Heat Wave National Plan including a provisional Heat Watch Warning System (HWWS) for 2004. Developed in collaboration with Metéo France, this HWWS is based upon an analysis of historical daily mortality data and meteorological indicators in 14 French cities in order to define the best indicators and triggers. The public health impact of the heat wave of August 2003 was major. This exceptional event raises questions about anticipating phenomena which are difficult to predict. The collaborative efforts which were developed and the group of actions and studies which were implemented in a context of emergency are now useful for the setting up of early warning strategies and thus efficient prevention.