Description of two waterborne disease outbreaks in France: a comparative study with data from cohort studies and from health administrative databases.

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.

Physician practices in requesting stool samples for patients with acute gastroenteritis, France, August 2013-July 2014.

A better understanding of physician practices in requesting stool samples for patients with acute gastroenteritis (AG) is needed to more accurately interpret laboratory-based surveillance data. A survey was conducted in General Practitioners (GPs) between August 2013 and July 2014 to estimate the proportion of stool samples requested for patients with AG and to identify factors associated with GP requests for a stool sample. National health insurance (NHI) data together with surveillance data from a French Sentinel GP network were also used to estimate the proportion of stool samples requested. This proportion was estimated at 4·3% in the GP survey and 9·1% (95% confidence interval 8·7-9·6) using NHI data. Multivariate analysis indicated that the ratio of stool samples requested was almost five times higher in patients with bloody diarrhoea and 10-20 times higher in patients with a long duration of illness before consultation. Laboratory-based surveillance data underestimates the actual burden of disease as fewer than one in 10 AG cases consulting their GP will be requested to submit a stool sample for laboratory testing. This underestimation varies by pathogen as stool samples are more frequently requested for severe illness.

Burden of acute gastroenteritis and healthcare-seeking behaviour in France: a population-based study.

In France surveillance underestimates the true burden of acute gastroenteritis (AG). We conducted a population-based, retrospective cross-sectional telephone survey between May 2009 and April 2010 in order to obtain more accurate estimates of the incidence and the burden of AG and to describe healthcare-seeking behaviour for AG. Of the 10 080 persons included in the survey, 260 respondents reported 263 episodes of AG. The incidence rate of AG was estimated at 0·33 cases/person-year (95% CI 0·28-0·37). It was highest in children aged <5 years and declined with age. Thirty-three percent (95% CI 27-40) of the AG cases consulted a physician and 76% (95% CI 70-82) used medication. Our results indicate that there are more than 21 million episodes of AG each year in France. These results allow a more accurate interpretation of the data derived from existing AG surveillance systems.

Outbreak of haemolytic uraemic syndrome due to Shiga toxin-producing Escherichia coli O104:H4 among French tourists returning from Turkey, September 2011.

Eight cases of diarrhoea, including two cases of haemolytic uraemic syndrome (HUS), were identified among 22 French tourists who travelled to Turkey in September 2011. A strain of Escherichia coli O104:H4 stx2-positive, eae-negative, hlyA-negative, aggR-positive, ESBL-negative was isolated from one HUS case. Molecular analyses show this strain to be genetically similar but not indistinguishable from the E. coli O104:H4 2011 outbreak strain of France and Germany. Although the source of infection was not identified, we conclude that the HUS cases had probably been infected in Turkey.

Nationwide outbreak of Salmonella enterica serotype 4,[5],12:i:- infection associated with consumption of dried pork sausage, France, November to December 2011.

An outbreak of the monophasic variant of Salmonella enterica serotype 4,[5],12:i:- occurred in November and December 2011 in France. Epidemiological investigation and food investigation with the help of supermarket loyalty cards suggested dried pork sausage from one producer as the most likely source of the outbreak. Despite the absence of positive food samples, control measures including withdrawal and recall were implemented.

Estimating the burden of mucormycosis infections in France (2005-2007) through a capture-recapture method on laboratory and administrative data.

BACKGROUND: Mucormycoses are rare but severe fungal infections whose incidence is increasing, particularly in immunosuppressed and diabetic patients. Following a retrospective study on the characteristics and outcomes of cases who were identified through two sources of information, we carried out a capture-recapture method to estimate the actual burden of the disease in France, 2005-2007. METHODS: An administrative dataset from the national hospital discharge system and a laboratory dataset from the National Reference Centre for Mycoses and Antifungals were combined to identify patients from 2005 to 2007. We applied capture-recapture equations to estimate the number of cases missed by both sources and to assess the advantages of each dataset, especially in terms of sensitivity. RESULTS: There were 94 mucormycosis cases included in the study: 30 and 31 in each respective source and 33 common to both. Capture-recapture showed that 28 cases were missed (expected total: 122 cases, CI95: 102-142). Each dataset had a sensitivity value below 53%. The merged set yielded a 77% sensitivity (66%-92%). CONCLUSION: This study highlights the importance of combining available sources when analysing rare infectious diseases. The proportion of 23% missed cases might seem acceptable given the scarcity of the disease, for which further knowledge is needed. However this proportion could decrease in the future, through the sensitization of clinicians, pathologists and mycologists together with the improving quality of discharge datasets.

Initial risk perception and feeling of preparedness of primary care physicians regarding the COVID-19 pandemic in Belgium, France and Spain in February 2020.

BACKGROUND: The knowledge of risk perceptions in primary care could help health authorities to manage epidemics. METHODS: A European multi-center cross-sectional study was conducted in France, Belgium and Spain to describe the perceptions, the level of anxiety and the feeling of preparedness of primary healthcare physicians towards the COVID-19 infection at the beginning of the pandemic. The factors associated with the feeling of preparedness were studied using multivariate logistic regressions. RESULTS: A total of 511 physicians participated to the study (response rate: 35.2%). Among them, only 16.3% (n=82) were highly anxious about the pandemic, 50.6% (n=254) had the feeling to have a high level of information, 80.5% (n=409) found the measures taken by the health authorities suitable to limit the spread of COVID-19, and 45.2% (n=229) felt prepared to face the epidemic. Factors associated with feeling prepared were: being a Spanish practitioner (adjusted OR=4.34; 95%CI [2.47; 7.80]), being a man (aOR=2.57, 95%CI [1.69; 3.96]), finding the measures taken by authorities appropriate (aOR=1.72, 95%CI [1.01; 3.00]) and being highly informed (aOR=4.82, 95%CI [2.62; 9.19]). CONCLUSIONS: Regarding the dramatic evolution of the pandemic in Europe in the weeks following the study, it appears that information available at this time and transmitted to the physicians could have given a wrong assessment of the spread and the severity of the disease. It seems essential to better integrate the primary care physicians into the information, training and protection channels. A comparison between countries could help to select the most effective measures in terms of information and communication.

Outbreak of Salmonella enterica serotype Muenster infections associated with goat's cheese, France, March 2008.

Salmonella enterica serotype Muenster (hereafter referred to as S. Muenster) is rare in France and in Europe. In France, a nationwide outbreak of gastrointestinal illness due to S. Muenster occurred during March and April 2008. Twenty-five laboratory-confirmed cases of S. Muenster were documented by telephone using a trawling questionnaire. Four patients were admitted to hospital and no death was recorded. Among the 21 interviewed cases, 16 reported consumption of goat's cheese in the days prior to symptoms. The investigation incriminated goat's cheese from producer X as being the most likely source of the outbreak. S. Muenster was isolated from both cases and the incriminated goat's cheese. The pulsed-field gel electrophoresis profiles of the food isolates of producer X and the isolates from cases were indistinguishable. Following the withdrawal of the contaminated batch of cheese, the number of cases decreased to its usual level. To our knowledge, this is the first published outbreak of S. Muenster associated with food consumption in Europe.

[BCG vaccine coverage in private medical practice: First data in children below two years old, seven months after the end of compulsory vaccination in France]. / Couverture vaccinale BCG en médecine libérale : premières données chez le nourrisson, sept mois après la levée de l'obligation vaccinale en France.

OBJECTIVES: In July 2007, compulsory BCG vaccination for all children was replaced by a strong recommendation to vaccinate children at high risk of tuberculosis (children who live in Ile-de-France [IDF] or Guyana regions, who were born or whose parents were born in tuberculosis endemic countries, with a family history of tuberculosis or living in conditions defined as at risk by the doctor). In the absence of tools to detect an early decrease in vaccine coverage (VC) in this specific group, we conducted a survey with the main objective of measuring BCG VC in high risk children for which BCG is now recommended and who were born after the change in BCG vaccine policy. METHODS: Cross-sectional survey performed amongst physicians registered at "Infovac-France", a network of general practitioners and paediatricians particularly aware of recent changes in the field of vaccinations. Each doctor was asked to recruit, during his medical consultation, between six and 12 children aged 2-7 months (born after the end of compulsory BCG vaccination in July 2007) and 8-23 months (born after the withdrawal from the market of the multipuncture form of BCG [Monovax] in January 2006 and before the end of compulsory BCG vaccination in July 2007). Doctors were asked to fill in a structured online questionnaire. Data were standardized and analysed with Stata 9.2. RESULTS: A total of 2536 children, recruited by 279 general practitioners and paediatricians (6.5% of all contacted doctors), were included. VC in the target group of high risk children for who BCG is still recommended and who were seen by doctors working in a private medical practice was: overall 68%; 58% in children born after the end of compulsory BCG vaccination (68% in IDF, 48% outside IDF); 77% in those born after the withdrawal of Monovax from the market and before the end of compulsory BCG vaccination; 90% in children living in IDF born after the end of compulsory vaccination and considered as particularly at risk of tuberculosis (presence of vaccination criteria other than residing in IDF) and 60% in the same category of children whose sole criteria for vaccination was residing in IDF. Of doctors who worked in a private medical practice: 75% used to perform the BCG vaccination themselves and 58% had recommended or suggested vaccination to children at risk who were not yet vaccinated. Seventy-six percent of parents of children at risk of tuberculosis not yet vaccinated accepted BCG vaccination when recommended by their doctor. CONCLUSION: Our survey showed, on the one hand, insufficient VC in children seen in a private medical practice and born after the end of compulsory vaccination for whom BCG is still recommended. This should encourage the Ministry of Health to reinforce its communication concerning this new policy. On the other hand, the survey showed encouraging results concerning both the coverage of children at particularly high risk in IDF and the adherence of doctors and families to the new vaccine policy. These results should be interpreted with caution, taking into account the methodological limitations of this survey.

Demographic features and trends in tuberculosis cases in the European Region, 1995-2005.

In 2005, 426,457 tuberculosis (TB) cases were notified in the World Health Organization (WHO) European Region, with a wide variation and an incremental west-to-east gradient in notification rates also reflected in TB mortality rates. In the enlarged European Union ('EU-27') and other western countries--where 19% of cases were of foreign origin in 2005 (>50% in 13 countries)--overall TB notification rates decreased by 2.4% yearly between 2000 and 2005, compared to 1.6% in 1995-2000, reflecting a declining incidence in all age groups and in most countries. Half the cases notified by the 12 ex-republics of the former Soviet Union in the East in 2005 were reported by the Russian Federation. In the East, the mean annual increase in 1995-2000 (10.0%) was higher than in 2000-2005 (3.9%), and in recent years the number of new cases stabilised while previously treated cases have increased. Efforts are still needed to improve and standardise TB surveillance across the Region. The collection of additional data on risk factors of TB may be useful for surveillance and control.