Waterborne disease outbreak detection: an integrated approach using health administrative databases.

Hundreds of waterborne disease outbreaks (WBDO) of acute gastroenteritis (AGI) due to contaminated tap water are reported in developed countries each year. Such outbreaks are probably under-detected. The aim of our study was to develop an integrated approach to detect and study clusters of AGI in geographical areas with homogeneous exposure to drinking water. Data for the number of AGI cases are available at the municipality level while exposure to tap water depends on drinking water networks (DWN). These two geographical units do not systematically overlap. This study proposed to develop an algorithm which would match the most relevant grouping of municipalities with a specific DWN, in order that tap water exposure can be taken into account when investigating future disease outbreaks. A space-time detection method was applied to the grouping of municipalities. Seven hundred and fourteen new geographical areas (groupings of municipalities) were obtained compared with the 1,310 municipalities and the 1,706 DWN. Eleven potential WBDO were identified in these groupings of municipalities. For ten of them, additional environmental investigations identified at least one event that could have caused microbiological contamination of DWN in the days previous to the occurrence of a reported WBDO.

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.

Pilot simulation study using meat inspection data for syndromic surveillance: use of whole carcass condemnation of adult cattle to assess the performance of several algorithms for outbreak detection.

The objective of this study was to assess the performance of several algorithms for outbreak detection based on weekly proportions of whole carcass condemnations. Data from one French slaughterhouse over the 2005-2009 period were used (177 098 slaughtered cattle, 0.97% of whole carcass condemnations). The method involved three steps: (i) preparation of an outbreak-free historical baseline over 5 years, (ii) simulation of over 100 years of baseline time series with injection of artificial outbreak signals with several shapes, durations and magnitudes, and (iii) assessment of the performance (sensitivity, specificity, outbreak detection precocity) of several algorithms to detect these artificial outbreak signals. The algorithms tested included the Shewart p chart, confidence interval of the negative binomial model, the exponentially weighted moving average (EWMA); and cumulative sum (CUSUM). The highest sensitivity was obtained using a negative binomial algorithm and the highest specificity with CUSUM or EWMA. EWMA sensitivity was too low to select this algorithm for efficient outbreak detection. CUSUM's performance was complementary to the negative binomial algorithm. The use of both algorithms on real data for a prospective investigation of the whole carcass condemnation rate as a syndromic surveillance indicator could be relevant. Shewart could also be a good option considering its high sensitivity and simplicity of implementation.

Animal board invited review: Improving animal health and welfare in the transition of livestock farming systems: Towards social acceptability and sustainability.

The need to integrate more clearly societal expectations on livestock farming has led the authors of this article to consider that livestock farming systems must be redesigned to position health and welfare at the heart of their objectives. This article proposes a vision of the advances in knowledge required at different scales to contribute to this transformation. After defining health and welfare of animals, the article emphasises the need to consider health in a broader perspective, to deepen the question of positive emotional experiences regarding welfare, and raises the question of how to assess these two elements on farms. The positive interactions between health and welfare are presented. Some possible tensions between them are also discussed, in particular when improving welfare by providing a more stimulating and richer environment such as access to outdoor increases the risk of infectious diseases. Jointly improving health and welfare of animals poses a number of questions at various scales, from the animal level to the production chain. At the animal level, the authors highlight the need to explore: the long-term links between better welfare and physiological balance, the role of microbiota, the psycho-neuro-endocrine mechanisms linking positive mental state and health, and the trade-off between the physiological functions of production, reproduction and immunity. At the farm level, in addition to studying the relationships at the group level between welfare, health and production, the paper supports the idea of co-constructing innovative systems with livestock farmers, as well as analysing the cost, acceptability and impact of improved systems on their working conditions and well-being. At the production chain or territory levels, various questions are raised. These include studying the best strategies to improve animal health and welfare while preserving economic viability, the labelling of products and the consumers' willingness to pay, the consequences of heterogeneity in animal traits on the processing of animal products, and the spatial distribution of livestock farming and the organisation of the production and value chain. At the level of the citizen and consumer, one of the challenges is to better inter-relate sanitary and health perspectives on the one hand, and welfare concerns on the other hand. There is also a need to improve citizens' knowledge on livestock farming, and to develop more intense and constructive exchanges between livestock farmers, the livestock industry and citizens. These difficult issues plead for interdisciplinary and transdisciplinary research involving various scientific disciplines and the different stakeholders, including public policy makers through participatory research.

Insights on the carbon footprint of radiotherapy in France.

The French healthcare system is responsible for 8% of the national footprint. Achieving a net zero emissions scenario will require a 4-5 fold decrease of carbon emissions in the coming years. The carbon footprint of radiation therapy has not been specifically studied to date. In this review we summarize the content of the carbon footprint dedicated session at the annual meeting of the French society of radiation oncology (SFRO). We discuss the French healthcare system carbon footprint and its major drivers and our work on the estimation of the carbon footprint of external beam radiation therapy in the French setting. We developed a dedicated methodology to estimate the carbon footprint related to radiation therapies, and describe the main drivers of emissions based on a single centre as an example, namely patient's rides, accelerators acquisition and maintenance and data storage. Based on the carbon footprint calculated in our centres, we propose mitigation strategies and an estimation of their respective potential. Our results may be extrapolated to other occidental settings by adapting emission factors (kilograms of carbon per item or euro) to other national settings. External beam radiation therapy has a major carbon footprint that may be mitigated in many ways that may impact how radiation therapy treatments are delivered, as well as the national organization of the radiotherapy sector. This needs to be taken into account when thinking about the future of radiotherapy.

Global formal live poultry and hatching egg trade network (2004-2016): description and association with poultry disease reporting and presence.

As international trade constitutes one of the main spread pathways of diseases, a better understanding of the trade behaviors of countries will help identify strengths and areas for improvement in the approach of national authorities to controlling poultry diseases globally. Using data reported to the United Nations Comtrade and the World Organisation for Animal Health (OIE) between 2004 and 2016 by 193 countries, we used a network analysis on trade data of poultry hatching eggs, live poultry of less than 185 g and live poultry of 185 g or more to determine that: 1) quantities traded between countries are substantial, and tend to increase (average increase of 800,000 poultry heads and 21,000 tons of hatching eggs each year equivalent to an increase by 2-fold in 17 yr); 2) the stability of the networks was low (a quarter to half of trade relationships maintained between 2 consecutive years) and the subnetworks favorable to the spread of diseases were in general consistent with regional clustering, trade exchanges being equally at intracontinental and intercontinental levels; 3) countries with highest number of partners were located in the same world regions for the 3 poultry networks - Americas and Europe for export (up to 107 partners) and Africa, Asia and Europe for import (up to 36 partners); 4) for live poultry, biggest exporting countries shared more poultry disease surveillance data, and reported more disease presence than others, which did not stop them from trading. Biggest importers reported less poultry disease surveillance data and reported more disease presence than others; and 5) the main structural and trend characteristics of the international trade networks were in general similar for the 3 networks. The information derived from this work underlines the importance of applying the preventive measures advocated by the OIE and will support countries to reduce the risk of introduction of pathogens causing poultry diseases.

Seroprevalence and factors associated with Toxoplasma gondii infection in wild boar ( Sus scrofa) in a Mediterranean island.

Knowledge of the factors affecting the presence of Toxoplasma gondii in wildlife is limited. Here we analyse which local landscape characteristics are associated with the presence of toxoplasmosis in wild boar, Sus scrofa, on the island of Corsica, France. Meat juice samples from 1399 wild boars collected during two hunting seasons were tested for T. gondii antibodies using the modified agglutination test (titre 1:4). The overall seroprevalence was 0.55 (95% CI 0.50-0.59) for the first year and 0.33 (95% CI 0.29-0.35) for the second year. Seroprevalence varied according to age and county. At the county level, seropositivity in adults was related to farm density during year 1, and to habitat fragmentation, farm density and altitude during year 2. The exposure of wild boar to T. gondii is thus variable according to landscape characteristics and probably results in a variable risk of transmission of toxoplasmosis to humans.

The Wip1 phosphatase (PPM1D) antagonizes activation of the Chk2 tumour suppressor kinase.

We previously demonstrated that type 2C protein phosphatases (PP2C) Ptc2 and Ptc3 are required for DNA checkpoint inactivation after DNA double-strand break repair or adaptation in Saccharomyces cerevisiae. Here, we show the conservation of this pathway in mammalian cells. In response to DNA damage, ataxia telangiectasia mutated (ATM) phosphorylates the Chk2 tumour suppressor kinase at threonine 68 (Thr68), allowing Chk2 kinase dimerization and activation by autophosphorylations in the T-loop. The oncogenic protein Wip1, a PP2C phosphatase, binds Chk2 and dephosphorylates phospho-Thr68. Consequently, Wip1 opposes Chk2 activation by ATM after ionizing irradiation of cells. In HCT15 colorectal cancer cells corrected for functional Chk2 activity, Wip1 overexpression suppressed the contribution of Chk2 to the G2/M DNA damage checkpoint. These results indicate that Wip1 is one of the phosphatases regulating the activity of Chk2 in response to DNA damage.

Milk yield, age at first calving, and the risk of BSE: an analysis at the farm level in France.

The epidemic of bovine spongiform encephalopathy (BSE) in France, as in the UK, has affected dairy cattle much more than beef cattle. However, the intensification of dairy herd management as a risk factor for BSE has not to date been analyzed. For this purpose, two databases were merged: the French Milk Records database, and the French BSE database, which can be considered as being devoid of notification bias since July 2001, when systematic tests were implemented. Only pure Holstein herds were considered, which represent the vast majority of total and BSE-affected dairy herds in France. A case-control study was designed so that 20 control herds were matched to each case herd according to the location of the farm and the year of birth of the index case. Three thousand and forty five farms were included, among which 145 with a BSE case notified between July 2001 and July 2003, and 2900 controls. With respect to the risk of BSE, odds ratios for each class of milk yield and age at first calving were estimated by using conditional logistic regression models with appropriate adjustments to herd size. The two main results were the following: firstly, whereas most Holstein herds, with average production between 7000 and 10,000kg, had nearly the same BSE risk, a small category of very intensive herds, with annual milk yields above 10,000kg, were significantly more at risk than the other herds. Secondly, a very early first calving (under 26 months of age) was found to be at risk for BSE as compared to other categories, independently of the milk yield. These results are discussed in the light of the known age-dependent susceptibility to BSE.

Estimates of the prevalence of transmissible spongiform encephalopathies in sheep and goats in France in 2002.

An active surveillance programme for transmissible spongiform encephalopathies (TSES) in sheep and goats was implemented in France in 2002 at abattoirs and rendering plants. The analysis of the results of this programme highlighted three biases: a potentially non-random sampling scheme in both rendering plants and abattoirs, a heterogeneous geographical sampling ratio, and the use of two diagnostic tests of unequal sensitivity. Simulations were run to estimate the prevalence of TSES by taking these biases into account. A comparison of the prevalence of TSES calculated from the raw data with the simulation results showed that the effects of non-random sampling were minor in comparison with the effects of the heterogeneous geographical sampling ratio and the use of two diagnostic tests.

Past, present and future of bovine spongiform encephalopathy in France.

The bovine spongiform encephalopathy (BSE) epidemic has been monitored in France since the end of 1990. The surveillance has been considerably enhanced since 2000, and today every cow aged 2 years or more is tested at the time of slaughter, culling or death. As of 1 May 2002, 613 native cases have been identified, 287 of them by the mandatory reporting system of suspect clinical cases or complementary programs, 213 by active surveillance of fallen stock and 113 by testing at the abattoir. The analysis of reported BSE cases shows a higher number of cases born between 1993 and 1995, which can be linked to a greater exposure at that time and to an increase in surveillance efficiency. When the clinical onset related to overexposure ends, the future trend of the BSE epidemic in France will depend on the efficiency of the control measures implemented since 1996. An indicator of this will be the number of BSE cases born among recent cohorts. Bovine spongiform encephalopathy (BSE) was described first in 1987 in Great Britain (Wells et al. 1987), where a huge epidemic started, and more than 180,000 cases have been detected since then in this country. A risk analysis undertaken in France in 1990, in part because of the amount of meat and bone meal (MBM) imported from Great Britain during the 1980s, led to the conclusion that BSE might have spread to France, and that sporadic cases might be observed (Savey et al. 1991). Epidemiological surveillance was therefore set up at the end of 1990, and control measures were taken to prevent the development of the disease. The trends in the number of BSE cases detected in France must be analyzed in the light of both the detection system and the control measures, as well as their changes over time.

[The bovine spongiform encephalopathy in the UK and France: an epidemiological perspective]. / Point de vue épidémiologique sur l'encéphalopathie spongiforme bovine au Royaume Uni et en France.

Epidemiology is aimed at the study of the health status of human and animal populations. The present review shows how epidemiologists in the UK and France, contributed to a better knowledge of the bovine spongiform encephalopathy (BSE), its probable origin, and its associated risk factors. Following case studies and case-control surveys, the role of meat and bone meal (MBM) as the source of infection for cattle has been well established. Other epidemiological studies have shown the absence of horizontal transmission, but on the other hand a cohort study concluded to a possible vertical transmission. Backcalculation models, which intend to infer the characteristics of infection from the observations, agree on two results : first, the BSE infects young animals, under 2 years. Secondly, the peak of the French BSE epizootic, probably in the nineteen-eighties, was ignored. Successive measures concerningMBMfailed to completely abolish the epizootic. The analysis of born-after-the-ban (BAB) cases shows that their spatial distribution in France is not random, which argues against a sporadic origin. The French BAB cases may result from two nonexclusive events : residual contaminations of cattle by feed intended for pigs and poultry, and mother-to-calf prion transmission, likely at a low rate. If a total eradication of BSE is not obtained, it will be the task of epidemiologists in particular, to figure out the source of the residual infection.

Qualitative interaction between the observer and the observed in veterinary epidemiology.

The phenomenon of qualitative interaction between the research activity and the studied object exists in veterinary epidemiology, as in all observation-based disciplines. Observational studies carried out under farm conditions strongly involve the farmers and the farm's usual advisors in the data collection. This leads to various biological and sociological interactions between the observer and the observed that can modify the results of the study. Some methodological considerations are proposed in order to consider such qualitative interaction, from the designing of the study through to the interpretation of the results. Examples are presented to illustrate these ideas.

An overview of techniques for dealing with large numbers of independent variables in epidemiologic studies.

Many studies of health and production problems in livestock involve the simultaneous evaluation of large numbers of risk factors. These analyses may be complicated by a number of problems including: multicollinearity (which arises because many of the risk factors may be related (correlated) to each other), confounding, interaction, problems related to sample size (and hence the power of the study), and the fact that many associations are evaluated from a single dataset. This paper focuses primarily on the problem of multicollinearity and discusses a number of techniques for dealing with this problem. However, some of the techniques discussed may also help to deal with the other problems identified above. The first general approach to dealing with multicollinearity involves reducing the number of independent variables prior to investigating associations with the disease. Techniques to accomplish this include: (1) excluding variables after screening for associations among independent variables; (2) creating indices or scores which combine data from multiple factors into a single variable; (3) creating a smaller set of independent variables through the use of multivariable techniques such as principal components analysis or factor analysis. The second general approach is to use appropriate steps and statistical techniques to investigate associations between the independent variables and the dependent variable. A preliminary screening of these associations may be performed using simple statistical tests. Subsequently, multivariable techniques such as linear or logistic regression or correspondence analysis can be used to identify important associations. The strengths and limitations of these techniques are discussed and the techniques are demonstrated using a dataset from a recent study of risk factors for pneumonia in swine. Emphasis is placed on comparing correspondence analysis with other techniques as it has been used less in the epidemiology literature.

Postpartum anestrus in French beef cattle: an epidemiological study.

Postpartum anestrus of lactating beef cows was studied by means of an epidemiological study carried out on 878 lactating beef cows in 60 French herds. The cows calved between October 1992 and March 1993 and were housed 2 mo after calving, when the anestrus status was determined by progesterone radioimmunoassays. Data analysis was performed using a multiple logistic model in order to adjust for confounding and interaction. Fifty-one percent of the primiparous and 23% of the multiparous cows were found to be in anestrus. Factors significantly related to anestrus were parity (primiparous); breed (Charolais); housing type (tie housing); suckling (compared to weaning at birth); and, among those that were under the control of the farmer, calving conditions (manual exploration of the birth canal); body condition score at calving (3 or less, on a 5-point scale); and loss in body condition score after calving (1 point or more within 2 mo). Previous reproductive performance for multiparous cows such as a long calving interval and induced estrus in the previous year also appeared to be related to anestrus.

Epidemiological status of BSE in France - update on born after the ban cases.

Despite measures taken in France since 1990 to control the spread of bovine spongiform encephalopathy (BSE), the incidence of BSE cases notified in France by the BSE Epidemiological Surveillance Network has been rising in recent years. By 1 July 2000, 103

Prevalence of BSE in cattle found dead, euthanased or emergency slaughtered on farms in western France in 2000, 2001 and 2002.

The overall trend and the trend within birth cohorts of the prevalence of bovine spongiform encephalopathy (BSE) in cattle found dead, euthanased or emergency slaughtered on farms in the Bretagne, Basse Normandie and Pays de la Loire regions of France, during the periods from August 7 to December 22 in 2000, 2001 and 2002, were analysed by non-conditional logistic regression, adjusted for the region and for the type of animals. The overall prevalence of BSE during these three periods decreased from 2.71 per 1000 in 2000 to 1.41 per 1000 in 2001 and 0.42 per 1000 in 2002. The prevalence within birth cohorts started to decrease for the cohort born between July 1, 1995 and June 30, 1996 (cohort 95/96) and the trend was reinforced for cohort 96/97, suggesting that the exposure of animals to the BSE agent had started to decrease for animals born after July 1995, that is, one year before the ban on specified risk materials in meat and bone meal was implemented in France. However, considering that most of the animals would have been infected at between six and 18 months of age, the decrease may have been due, at least partly, to this control measure.

Questionnaire analysis of BSE cases in France detected by active surveillance and the reasons for non-notification.

A mandatory reporting system (MRS) was set up in France in December 1990 to detect animals showing clinical signs of bovine spongiform encephalopathy (BSE). Since June 2000, four active surveillance programmes dedicated to fallen stock and slaughtered cattle have been implemented to reinforce the MRS. The clinical status of the cases detected through these programmes was investigated to understand why the MRS had failed to detect them. Up to September 1, 2002, 181 cases had been analysed (126 fallen stock and 55 slaughtered cattle). Almost all the fallen stock cases were animals which had been showing clinical signs, and two thirds of them had shown signs which should have led to a suspicion of BSE. No clinical signs had been reported for two thirds of the slaughtered cattle cases and 10 (8 per cent) of the fallen stock cases.

Targeted surveillance to assess the prevalence of BSE in high-risk populations in western France and the associated risk factors.

A pilot study was set up for the first time in France in August 2000, to obtain more precise estimates on the BSE epidemic in France. Three categories of cattle at risk of BSE (found dead on-farm, euthanased and emergency slaughtered) were sampled exhaustively from August 7 to December 22, 2000, in the three regions assumed to be the most affected with BSE in France (Basse-Normandie, Bretagne and Pays de la Loire). The samples were checked by using Prionics tests, and positive samples were confirmed by Western blot or immunohistochemistry. The overall prevalence of positive cattle was 0.16 per cent. Multifactorial logistic regression showed that there was a significantly higher prevalence among cattle from the birth cohorts July 1993 to June 1994 and July 1994 to June 1995, than among those born before July 1993, and among the categories 'euthanased' and 'emergency slaughtered' than among the category 'dead on-farm, and a higher prevalence in the regions Pays de la Loire and Bretagne than in Basse-Normandie. No significant differences in the prevalence of BSE were observed between dairy, beef suckler and mixed herds.

[Audit and standardization of allergologic practices for urticaria]. / Audit et harmonisation des pratiques allergologiques dans l'urticaire.

In November 1997, by the initiative of allergists and ANAICE commissions of harmonization and allergy practice were created to improve the quality of care. The summary of the results is reported of one of the commissions, that on urticaria. The common attitudes and disagreements between the allergists from different faculties and who worked in different towns are presented. The work has also shown the importance of interactions between urticaria and mind in chronic urticaria in adults and has analysed invalidated indications. The work has obtained the support of the principal representative structures of liberal allergy: the SNAF, ANAFORCAL and ANAICE. It needs to be followed by scientific and rigorous methodology, like the audits of ambulatory medical practice. The harmonization commissions have done preliminary work which is indispensable for introduction of audits in the different sectors of activity in allergy.