Pattern of encounters to emergency departments for suicidal attempts in France: Identification of high-risk days, months and holiday periods.

INTRODUCTION: Seasonal change in patterns of suicidal attempts is not well known in France and may differ from other western countries. We aimed to determine the peak times (days, months and holiday periods) of suicidal attempts in France. METHODS: We carried out a multicentre retrospective epidemiological study, using data from the Organization for Coordinated Monitoring of Emergencies (OSCOUR®) network. We aggregated daily data from January 1, 2010, to December 31, 2019. Variations in suicidal attempts on specific days were investigated by comparing their frequencies (ad hoc Z-scores). RESULTS: 114,805,488 ED encounters were recorded including 233,242 ED encounters regarding suicidal attempts. Men accounted for 45.7%. A significantly higher frequency of ED encounters for suicidal acts were found on Sundays in the months of May-June for both sexes and on New Year's Day for all genders and age groups. An increased risk was also noted on July 14th (National Day) and June 22nd (Summer Solstice). A protective effect was noted on the day after Valentine's Day, on Christmas Day and Christmas time (in particular December 24 and 26). CONCLUSION: Sundays, June, New Year's Day were at increased risk of suicidal attempts in France requiring a strengthening of prevention.

Reactive surveillance of suicides during the COVID-19 pandemic in France, 2020 to March 2022.

AIMS: Mitigation actions during the COVID-19 pandemic may impact mental health and suicide in general populations. We aimed to analyse the evolution in suicide deaths from 2020 to March 2022 in France. METHODS: Using free-text medical causes in death certificates, we built an algorithm, which aimed to identify suicide deaths. We measured its retrospective performances by comparing suicide deaths identified using the algorithm with deaths which had either a Tenth revision of the International Classification of Diseases (ICD-10) code for 'intentional self-harm' or for 'external cause of undetermined intent' as the underlying cause. The number of suicide deaths from January 2020 to March 2022 was then compared with the expected number estimated using a generalized additive model. The difference and the ratio between the observed and expected number of suicide deaths were calculated on the three lockdown periods and for periods between lockdowns and after the third one. The analysis was stratified by age group and gender. RESULTS: The free-text algorithm demonstrated high performances. From January 2020 to mid-2021, suicide mortality declined during France's three lockdowns, particularly in men. During the periods between and after the two first lockdowns, suicide mortality remained comparable to the expected values, except for men over 85 years old and in 65-84 year-old age group, where a small number of excess deaths was observed in the weeks following the end of first lockdown, and for men aged 45-64 years old, where the decline continued after the second lockdown ended. After the third lockdown until March 2022, an increase in suicide mortality was observed in 18-24 year-old age group for both genders and in men aged 65-84 years old, while a decrease was observed in the 25-44 year-old age group. CONCLUSIONS: This study highlighted the absence of an increase in suicide mortality during France's COVID-19 pandemic and a substantial decline during lockdown periods, something already observed in other countries. The increase in suicide mortality observed in 18-24 year-old age group and in men aged 65-84 years old from mid-2021 to March 2022 suggests a prolonged impact of COVID-19 on mental health, also described on self-harm hospitalizations and emergency department's attendances in France. Further studies are required to explain the factors for this change. Reactive monitoring of suicide mortality needs to be continued since mental health consequences and the increase in suicide mortality may be continued in the future with the international context.

Expert consultation using the on-line Delphi method for the revision of syndromic groups compiled from emergency data (SOS Médecins and OSCOUR®) in France.

BACKGROUND: Consultation data from emergency general practitioners known as SOS Médecins and emergency departments (ED) from OSCOUR® network to the French syndromic surveillance system SurSaUD® (Surveillance sanitaire des urgences et décès). These data are aggregated and monitored on a daily basis through groupings of one or more medical symptoms or diagnoses ("syndromic groups" (SG)). The objective of this study was to evaluate, revise and enrich the composition of SGs through a consensus of experts who contributed or have experience in syndromic surveillance. METHODS: Three rounds of a Delphi survey were organised, involving 15 volunteers from SOS Médecins and 64 ED physicians in the OSCOUR® network as well as 8 international epidemiologists. Thirty-four SOS Médecins and 40 OSCOUR® SGs covering major medical specialities were put to the experts, along with their diagnostic codes and their surveillance objectives. In each round, the experts could retain or reject the codes according to the surveillance objective. The panel could also put forward new diagnostic codes in the 1st round, included in subsequent rounds. Consensus was reached for a code if 80% of participants had chosen to keep it, or less than 20% to reject it. RESULTS: A total of 12 SOS Médecins doctors (80%), 30 ED doctors (47%) and 4 international experts (50%) participated in the three rounds. All of the SGs presented to the panel included 102 initial diagnostic codes and 73 additional codes for SOS Médecins, 272 initial diagnostic codes and 204 additional codes for OSCOUR®. At the end of the 3 rounds, 14 SOS Médecins (40%) and 11 OSCOUR® (28%) SGs achieved a consensus to maintain all of their diagnostic codes. Among these, indicators of winter seasonal surveillance (bronchiolitis and gastroenteritis) were included. CONCLUSION: This study involved a panel of national experts with international representation and a good level of involvement throughout the survey. In the absence of a standard definition, the Delphi method has been shown to be useful in defining and validating syndromic surveillance indicators.

Syndromic surveillance: A key component of population health monitoring during the first wave of the COVID-19 outbreak in France, February-June 2020.

BACKGROUND: The French syndromic surveillance (SyS) system, SurSaUD®, was one of the systems used to monitor the COVID-19 outbreak. AIM: This study described the epidemiological characteristics of COVID-19-related visits to both emergency departments (EDs) and the network of emergency general practitioners known as SOS Médecins (SOSMed) in France from 17 February to 28 June 2020. METHODS: Data on all visits to 634 EDs and 60 SOSMed associations were collected daily. COVID-19-related visits were identified using ICD-10 codes after coding recommendations were sent to all ED and SOSMed doctors. The time course of COVID-19-related visits was described by age group and region. During the lockdown period, the characteristics of ED and SOSMed visits and hospitalisations after visits were described by age group and gender. The most frequent diagnoses associated with COVID-19-related visits were analysed. RESULTS: COVID-19 SyS was implemented on 29 February and 4 March for EDs and SOSMed, respectively. A total of 170,113 ED and 59,087 SOSMed visits relating to COVID-19 were recorded, representing 4.0% and 5.6% of the overall coded activity with a peak in late March representing 22.5% and 25% of all ED and SOSMed visits, respectively. COVID-19-related visits were most frequently reported for women and those aged 15-64 years, although patients who were subsequently hospitalised were more often men and persons aged 65 years and older. CONCLUSION: SyS allowed for population health monitoring of the COVID-19 epidemic in France. As SyS has more than 15 years of historical data with high quality and reliability, it was considered sufficiently robust to contribute to defining the post-lockdown strategy.

Outpatient antibiotic use attributable to viral acute lower respiratory tract infections during the cold season in France, 2010-2017.

Antibiotic stewardship requires clear insight into antibiotic overuse and the syndromes that lead to prescription. The aim of this study was to estimate the proportion of antibiotic prescriptions attributable to acute lower respiratory tract infections (LRTIs) during the cold season. Using individual data from the French National Health Insurance (NHI) database, weekly time series were constructed of outpatient antibiotic (beta-lactams and macrolides) prescriptions between January 2010 and December 2017. Time series were also constructed of tenth edition of the International Classification of Diseases (ICD-10) discharge diagnoses from a national network of emergency departments (EDs), stratified by specific syndromes (pneumonia, bronchitis, bronchiolitis and influenza-like illness). The number of outpatient antibiotic prescriptions attributable to these syndromes during the cold season in France was modeled and estimated for the entire population, young children (≤5 years) and the elderly (≥75 years). LRTIs accounted for 40% (95% confidence interval [95% CI]: 29, 52) of outpatient antibiotic use during the cold season for the entire population, including 23% (95% CI: 13, 33) and 17% (95% CI: 13, 22) for bacterial and viral infections, respectively. In children and the elderly, viral LRTIs were the reason for 38% (95% CI: 31, 46) and 20% (95% CI: 16, 25) of outpatient antibiotic use, respectively (with bronchiolitis accountable for half of use in young children). In the entire population and in children, respectively, outpatient antibiotic overuse attributable to viral LRTIs was estimated to be 289 (95% CI: 221, 374) and 1588 (95% CI: 1295, 1922) prescriptions per 100 000 inhabitants per week. These results highlight the major role of viral infections in driving antibiotic prescriptions, particularly in young children.

Emergency department admissions for myocardial infarction and stroke in France during the first wave of the COVID-19 pandemic: National temporal trends and regional disparities.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic and the national lockdown have led to significant changes in the use of emergency care by the French population. AIMS: To describe the national and regional temporal trends in emergency department (ED) admissions for myocardial infarction (MI) and stroke, before, during and after the first national lockdown. METHODS: The weekly numbers of ED admissions for MI and stroke were collected from the OSCOUR® network, which covers 93.3% of all ED admissions in France. National and regional incidence rate ratios from 02 February until 31 May (2020 versus 2017-2019) were estimated using Poisson regression for MI and stroke, before, during and after lockdown. RESULTS: A decrease in ED admissions was observed for MI (-20% for ST-segment elevation MI and-25% for non-ST-segment elevation MI) and stroke (-18% for ischaemic and-22% for haemorrhagic) during the lockdown. The decrease became significant earlier for stroke than for MI. No compensatory increase in ED admissions was observed at the end of the lockdown for these diseases. Important regional disparities in ED admissions were observed, without correlation with the regional levels of COVID-19 cases. The impact of lockdown on ED admissions was particularly significant in six regions (Ile-de France, Occitanie, Provence-Alpes-Côte d'Azur, Nouvelle Aquitaine, Hauts-de-France and Bretagne). CONCLUSIONS: The decrease in ED admissions for MI and stroke observed during the lockdown was probably caused by fear of COVID-19 and augmented by the lockdown, and was heterogeneous across the French territory. ED admissions were slow to return to the usual levels from previous years, without a compensatory increase. These results underline the need to reinforce messages directed at the population to encourage them to seek care without delay in case of cardiovascular symptoms.

Real-time monitoring shows substantial excess all-cause mortality during second wave of COVID-19 in Europe, October to December 2020.

The European monitoring of excess mortality for public health action (EuroMOMO) network monitors weekly excess all-cause mortality in 27 European countries or subnational areas. During the first wave of the coronavirus disease (COVID-19) pandemic in Europe in spring 2020, several countries experienced extraordinarily high levels of excess mortality. Europe is currently seeing another upsurge in COVID-19 cases, and EuroMOMO is again witnessing a substantial excess all-cause mortality attributable to COVID-19.

Impact des deux confinements sur le recours aux soins d'urgence lors de l'épidémie de COVID-19 en Nouvelle-Aquitaine.

INTRODUCTION: Following the emergence of the COVID-19 epidemic in France, several preventive measures have been put in place, including a mandatory lockdown of the entire population. This measure was intended to slow down the viral circulation and protect the healthcare system, especially hospital departments. The aim of this study was to describe the activity of emergency department (ED) during the two lockdowns related to the COVID-19 epidemic in the Nouvelle-Aquitaine region. METHOD: A retrospective descriptive analysis of ED visits was performed for the period December 09, 2019 to December 20, 2020. The distribution of the number of ED visits was studied. RESULTS: ED visits decreased by 50% during the first lockdown in line with the COVID-19 epidemic and by 30% during the second. Hospitalization rate increased during the two lockdowns (+ 48% and + 20%, respectively). A differentiated use was observed during both lockdowns, with the emergence of the use of care for "coronavirus", "stroke" or "dyspnea / respiratory failure" while the typical pathologies "ENT infections" or "skin infections" were no more or less observed. CONCLUSION: Data from Oscour® allowed a real-time monitoring of the COVID-19 epidemic in France, and to assess the impact of lockdown on ED activity in the region. A decline in the use of healthcare services, the increase in hospitalization rate and the pathologies observed during the two lockdowns are in favour of a refocusing of the recourse for most serious pathologies.

Early assessment of the impact of mitigation measures to control COVID-19 in 22 French metropolitan areas, October to November 2020.

In France, measures including curfew and lockdown were implemented to control the COVID-19 pandemic second wave in 2020. This study descriptively assesses their possible effects, also relative to their timing. A considerable decrease in incidence of COVID-19 cases and hospital admissions was observed 7 to 10 days after mitigation measures were put in place, occurring earlier in metropolitan areas which had implemented these first. This temporal coincidence suggests the measures' positive impact, consistent with international experiences.

Epidemiological study of opioid use disorder in French emergency departments, 2010-2018 from OSCOUR database.

OBJECTIVES: Opioid consumption in France has remained stable over the last 15 years, with much lower levels than in the USA. However, few data are available on patients who consume opioids and their use of the health system. Emergency department (ED) data has never been used as a source to investigate opioid use disorder (OUD) in France. DESIGN/SETTINGS/PARTICIPANTS: We used the OSCOUR national surveillance network, collecting daily ED data from 93% of French ED, to select and describe visits and hospitalisations after an OUD-related ED visit between 2010 and 2018 using International Classification of Diseases, version 10 (ICD10) codes. We described the population of interest and used binomial negative regressions to identify factors significantly associated with OUD such as gender, age, administrative region, year of admission and ICD10 codes. We also analysed the related diagnoses. PRIMARY OUTCOME MEASURE: Trend in ED visits for an OUD-related ED visit. RESULTS: We recorded 34 362 OUD-related visits out of 97 892 863 ED visits (36.1/100 000 visits). OUD-related visits decreased from 39.2/100 000 visits in 2010 to 32.9/100 000 visits in 2018, resulting in an average yearly decrease of 2.1% (95% CI 1.5% to 2.7%) after multivariate analysis. We recorded 15 966 OUD-related hospitalisations out of 20 359 574 hospitalisations after ED visits (78.4/100 000 hospitalisations) with an increase from 74.0/100 000 hospitalisations in 2010 to 81.4/100 000 hospitalisations in 2018. The analysis of related diagnoses demonstrated mostly polydrug abuse in this population. CONCLUSIONS: While the proportion of OUD visits decreased in the time frame, the hospitalisation proportion increased. The implementation of a nationwide surveillance system for OUD in France using ED visits would provide prompt detection of changes over time.

Excess all-cause mortality during the first wave of the COVID-19 epidemic in France, March to May 2020.

Through a weekly all-cause mortality surveillance system, we observed in France a major all-cause excess mortality from March to May 2020, concomitant with the coronavirus disease (COVID-19) epidemic. The excess mortality was 25,030 deaths, mainly among elderly people. Five metropolitan regions were the most affected, particularly Île-de-France and the Grand-Est regions. Assessing the excess mortality related to COVID-19 is complex because of the potential protective effect of the lockdown period on other causes of mortality.

Excess all-cause mortality during the COVID-19 pandemic in Europe - preliminary pooled estimates from the EuroMOMO network, March to April 2020.

A remarkable excess mortality has coincided with the COVID-19 pandemic in Europe. We present preliminary pooled estimates of all-cause mortality for 24 European countries/federal states participating in the European monitoring of excess mortality for public health action (EuroMOMO) network, for the period March-April 2020. Excess mortality particularly affected ≥ 65 year olds (91% of all excess deaths), but also 45-64 (8%) and 15-44 year olds (1%). No excess mortality was observed in 0-14 year olds.

Large concomitant outbreaks of acute gastroenteritis emergency visits in adults and food-borne events suspected to be linked to raw shellfish, France, December 2019 to January 2020.

On 27 December 2019, the French Public Health Agency identified a large increase in the number of acute gastroenteritis and vomiting visits, both in emergency departments and in emergency general practitioners' associations providing house-calls. In parallel, on 26 and 27 December, an unusual number of food-borne events suspected to be linked to the consumption of raw shellfish were reported through the mandatory reporting surveillance system. This paper describes these concomitant outbreaks and the investigations' results.

Evaluation of the French reactive mortality surveillance system supporting decision making.

BACKGROUND: In France, a mortality syndromic surveillance system was set up with objectives of early detection and reactive evaluation of the impact of expected and unexpected events to support decision makers. This study aims to describe the characteristics of the system and its usefulness for decision makers. METHODS: Anonymized data from the administrative part of death certificates were daily collected from 3062 computerized city halls and were transmitted to Santé publique France in routine. Coverage of the system was measured as the proportion of deaths registered by the system among the complete number of deaths and analyzed by age, month and region. Deaths were described by gender, age and geographical level using proportion. The excess periods of deaths were described based on the comparison of the weekly observed and expected numbers of deaths between 2012 and 2016. RESULTS: The system recorded 77.5% of the national mortality covering the whole territory. About 81% of deaths were aged 65 years old and more. The surveillance system identified mortality variations mainly during winter and summer, for some concomitant with influenza epidemic or heatwave period, and thus provided information for decision makers. CONCLUSION: The ability of the system to detect and follow mortality outbreaks in routine in the whole territory has been demonstrated. It is a useful tool to provide early evaluation of the impact of threats on mortality and alert decision makers to adapt control measures. However, the absence of information on medical causes of death may limit the ability to target recommendations.

Mapping influenza activity in emergency departments in France using Bayesian model-based geostatistics.

BACKGROUND: Maps of influenza activity are important tools to monitor influenza epidemics and inform policymakers. In France, the availability of a high-quality data set from the Oscour® surveillance network, covering 92% of hospital emergency department (ED) visits, offers new opportunities for disease mapping. Traditional geostatistical mapping methods such as Kriging ignore underlying population sizes, are not suited to non-Gaussian data and do not account for uncertainty in parameter estimates. OBJECTIVE: Our objective was to create reliable weekly interpolated maps of influenza activity in the ED setting, to inform Santé publique France (the French national public health agency) and local healthcare authorities. METHODS: We used Oscour® data of ED visits covering the 2016-2017 influenza season. We developed a Bayesian model-based geostatistical approach, a class of generalized linear mixed models, with a multivariate normal random field as a spatially autocorrelated random effect. Using R-INLA, we developed an algorithm to create maps of the proportion of influenza-coded cases among all coded visits. We compared our results with maps obtained by Kriging. RESULTS: Over the study period, 45 565 (0.82%) visits were coded as influenza cases. Maps resulting from the model are presented for each week, displaying the posterior mean of the influenza proportion and its associated uncertainty. Our model performed better than Kriging. CONCLUSIONS: Our model allows producing smoothed maps where the random noise has been properly removed to reveal the spatial risk surface. The algorithm was incorporated into the national surveillance system to produce maps in real time and could be applied to other diseases.

The influence of a major sporting event upon emergency department attendances; A retrospective cross-national European study.

Major sporting events may influence attendance levels at hospital emergency departments (ED). Previous research has focussed on the impact of single games, or wins/losses for specific teams/countries, limiting wider generalisations. Here we explore the impact of the Euro 2016 football championships on ED attendances across four participating nations (England, France, Northern Ireland, Wales), using a single methodology. Match days were found to have no significant impact upon daily ED attendances levels. Focussing upon hourly attendances, ED attendances across all countries in the four hour pre-match period were statistically significantly lower than would be expected (OR 0.97, 95% CI 0.94-0.99) and further reduced during matches (OR 0.94, 95% CI 0.91-0.97). In the 4 hour post-match period there was no significant increase in attendances (OR 1.01, 95% CI 0.99-1.04). However, these impacts were highly variable between individual matches: for example in the 4 hour period following the final, involving France, the number of ED attendances in France increased significantly (OR 1.27, 95% CI 1.13-1.42). Overall our results indicate relatively small impacts of major sporting events upon ED attendances. The heterogeneity observed makes it difficult for health providers to predict how major sporting events may affect ED attendances but supports the future development of compatible systems in different countries to support cross-border public health surveillance.

Retrospective observational study of emergency department syndromic surveillance data during air pollution episodes across London and Paris in 2014.

INTRODUCTION: Poor air quality (AQ) is a global public health issue and AQ events can span across countries. Using emergency department (ED) syndromic surveillance from England and France, we describe changes in human health indicators during periods of particularly poor AQ in London and Paris during 2014. METHODS: Using daily AQ data for 2014, we identified three periods of poor AQ affecting both London and Paris. Anonymised near real-time ED attendance syndromic surveillance data from EDs across England and France were used to monitor the health impact of poor AQ.Using the routine English syndromic surveillance detection methods, increases in selected ED syndromic indicators (asthma, difficulty breathing and myocardial ischaemia), in total and by age, were identified and compared with periods of poor AQ in each city. Retrospective Wilcoxon-Mann-Whitney tests were used to identify significant increases in ED attendance data on days with (and up to 3 days following) poor AQ. RESULTS: Almost 1.5 million ED attendances were recorded during the study period (27 February 2014 to 1 October 2014). Significant increases in ED attendances for asthma were identified around periods of poor AQ in both cities, especially in children (aged 0-14 years). Some variation was seen in Paris with a rapid increase during the first AQ period in asthma attendances among children (aged 0-14 years), whereas during the second period the increase was greater in adults. DISCUSSION: This work demonstrates the public health value of syndromic surveillance during air pollution incidents. There is potential for further cross-border harmonisation to provide Europe-wide early alerting to health impacts and improve future public health messaging to healthcare services to provide warning of increases in demand.

Improving regional influenza surveillance through a combination of automated outbreak detection methods: the 2015/16 season in France.

The 2014/15 influenza epidemic caused a work overload for healthcare facilities in France. The French national public health agency announced the start of the epidemic - based on indicators aggregated at the national level - too late for many hospitals to prepare. It was therefore decided to improve the influenza alert procedure through (i) the introduction of a pre-epidemic alert level to better anticipate future outbreaks, (ii) the regionalisation of surveillance so that healthcare structures can be informed of the arrival of epidemics in their region, (iii) the standardised use of data sources and statistical methods across regions. A web application was developed to deliver statistical results of three outbreak detection methods applied to three surveillance data sources: emergency departments, emergency general practitioners and sentinel general practitioners. This application was used throughout the 2015/16 influenza season by the epidemiologists of the headquarters and regional units of the French national public health agency. It allowed them to signal the first influenza epidemic alert in week 2016-W03, in Brittany, with 11 other regions in pre-epidemic alert. This application received positive feedback from users and was pivotal for coordinating surveillance across the agency's regional units.