National Public Health Agencies Research Articles

Assessment of vaccination coverage of adolescents aged 16–18 years with an innovative electronic immunization record system

ObjectivesTo measure vaccine coverage among adolescents aged 16–18 years who participated in the National Defense Preparation Day in the Aquitaine region using the free electronic immunization record. Patients and methodsWe considered adolescents aged 16–18 years who participated in the National Defense Preparation Day in the Aquitaine region from April to October 2013. All participants received a letter explaining how to create an electronic immunization record. Those records were then validated by checking data against the copies of the vaccination cards brought by participants on the day they attended. Vaccination coverage was estimated for eight vaccinations according to the cumulative number of doses registered and vaccines recommended during childhood. ResultsAmong the 18,714 participants, 9636 agreed to create an electronic immunization record of which 2781 were validated. Vaccination coverage was˃90% for tuberculosis, diphtheria-tetanus-poliomyelitis, measles-mumps-rubella, and Haemophilus influenzae type B, and˂90% for pertussis, hepatitis B, meningococcal C disease, and human papillomavirus. These coverage rates were close to those reported in other available sources. ConclusionOur study calls attention to the insufficient vaccination of adolescents for pertussis, HBV, meningococcal C disease, and HPV. The absence of a system that routinely provides the vaccination status of this population is a major public health issue in France. The use of an electronic immunization record was innovative, but this tool is not extensively used in the general population and has been evaluated by Santé publique France (the French national public health agency).

Group B streptococcal disease in UK and Irish infants younger than 90 days, 2014–15: a prospective surveillance study

Group B streptococcus is a leading cause of serious infection in young infants in many countries worldwide. We aimed to define the burden and clinical features of invasive group B streptococcal disease in infants younger than 90 days in the UK and Ireland, together with the characteristics of disease-causing isolates. Prospective, active national surveillance of invasive group B streptococcal disease in infants younger than 90 days was done from April 1, 2014, to April 30, 2015, through the British Paediatric Surveillance Unit, microbiology reference laboratories, and national public health agencies in the UK and Ireland. Early onset was defined as disease in the first 6 days of life and late onset was defined as 7-89 days of life. Incidence was calculated using livebirths in 2014 (after adjustment for the 13-month surveillance period). Isolates were characterised by serotyping, multilocus sequence typing, and antimicrobial susceptibility testing. 856 cases of group B streptococcus were identified in 2014-15, an incidence of 0·94 per 1000 livebirths (95% CI 0·88-1·00). Incidence for early-onset disease (n=517) was 0·57 per 1000 livebirths (95% CI 0·52-0·62), and for late-onset disease (n=339) was 0·37 per 1000 livebirths (0·33-0·41). 53 infants died (case fatality rate 6·2%), of whom 27 had early-onset disease (case fatality rate 5·2%) and 26 had late-onset disease (case fatality rate 7·7%). The predominant serotypes were III (241 [60%] of 402 serotyped isolates) and Ia (69 [17%]); five serotypes (Ia, Ib, II, III, V) accounted for 377 (94%) of all serotyped isolates. The incidence of invasive infant group B streptococcal disease in the UK and Ireland has increased since a comparable study done in 2000-01. The burden of early-onset disease has not declined despite the introduction of national prevention guidelines. New strategies for prevention are required. Meningitis Now.

Genomic Analysis of Lassa Virus during an Increase in Cases in Nigeria in 2018

SummaryDuring 2018, an unusual increase in Lassa fever cases occurred in Nigeria, raising concern among national and international public health agencies. We analyzed 220 Lassa virus genomes from infected patients, including 129 from the 2017–2018 transmission season, to understand the viral populations underpinning the increase. A total of 14 initial genomes from 2018 samples were generated at Redeemer’s University in Nigeria, and the findings were shared with the Nigerian Center for Disease Control in real time. We found that the increase in cases was not attributable to a particular Lassa virus strain or sustained by human-to-human transmission. Instead, the data were consistent with ongoing cross-species transmission from local rodent populations. Phylogenetic analysis also revealed extensive viral diversity that was structured according to geography, with major rivers appearing to act as barriers to migration of the rodent reservoir.

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

BackgroundMaps 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.ObjectiveOur 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.MethodsWe 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.ResultsOver 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.ConclusionsOur 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.

A reactive mortality surveillance system in France for alert and decision-making

Background In France, after the 2003 heat wave, a mortality syndromic surveillance system was set up by the National Public Health Agency, 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 the main excess mortality period detected by the system since 2011 that led to alert decision makers for actions. Methods Anonymized data from the administrative part of death certificate were daily collected from 3042 computerized city halls and were transmitted to the agency in routine. Representativeness was measured as the proportion of death registered by the system among the exhaustive number of deaths and analyzed by age, month and region. Deaths were described by gender, age group at national and regional levels using proportion. Mortality surveillance is performed routinely based on the comparison of the weekly observed and expected number of deaths estimated with the model developed by the European consortium EuroMomo between 2012 and 2016. Based on criteria, when an excess of death is observed, decision makers are alerted and an investigation is launched. Results The system recorded 77.5% of the national mortality covering the whole territory and varying from 67% to 96.8% in metropolitan regions and overseas. Three major excess deaths episodes occurred during winters 2011–12, 2012–13 and 2014–15 and were highly correlated with flu epidemics periods. Five punctual excess periods were identified during the summer months, among them 4 were concomitant with a heat wave or elevated temperature period. No particular event was found correlated to the fifth excess. The system was also able to detect events such as an increase in mortality in Guadeloupe in 2014 concomitant with chikungunya epidemics. National and regional epidemiological mortality reports were published weekly (daily if required) and transmitted to the Ministry of Health and regional health authorities with potential recommendations. Conclusion The effectiveness of the reactive mortality surveillance system to alert decision makers has been demonstrated. It is useful to adapt along the event recommendation for control measures as well as evaluation of impact of the event on mortality. However, the absence of medical causes of death may limit the ability to target recommendations. Facing the challenge of emergence of epidemics and climate changes, this reactive mortality system will be complementary for other surveillance systems for the future health crisis. The development of mortality surveillance with causes of death will ensure more information for interpretation of all-cause mortality changes.

Coberturas vacunales y farmacia comunitaria: ¿un binomio estratégicamente necesario y operativamente factible?

This article aims to analyze the existing information on the suitability and effectiveness of the community pharmacy in the shared management of vaccination strategies on population at risk, especially against seasonal influenza, which have developed in different countries around us.Although the real impact of this integration presents different results, mainly due to the fact that its implementation is carried out in health systems of different models and presents different approaches and designs that must be taken into account in its evaluation, the conclusion that can be reached is that the inclusion of the community pharmacist developing the functions of educator, facilitator or administrator of certain types of vaccines (anti-flu or pneumococcal, for example), increases vaccination coverage when compared to traditional models that integrate us. Being, in addition, highly positive the experience of the users of these services, integrated in a collaborative way with other centers or health actors.However, the integration of the community pharmacist in strategic and operational planning to increase vaccine coverage must clearly respond to specific needs based on local epidemiological data. And be closely coordinated with the Health Plans or the agendas of the National Public Health Agencies. This is the only way to take full advantage of the strengths and capabilities of community pharmacists in an approach that maximizes the effectiveness of their actions.

Big-data and occupational health surveillance: Screening of occupational determinants of health among French agricultural workers, through data mining of medico-administrative databases

Introduction Surveillance of diseases and associated exposures is a major issue in occupational health especially for identifying new work-related diseases. In addition to classical epidemiology (hypothesis-driven studies), complementary methods relying on data mining of health insurance data must be developed for early detection of work-related diseases, without any prior hypothesis. For this reason, the social security system of French agricultural workers “Mutualite sociale agricole” (MSA) emphasized the potential interest of a surveillance system through the exploitation of their up-to-date databases created for reimbursement of medical expenses. In partnership with the French Agency for Food, Environmental and Occupational Health and Safety (Anses), a pilot study has been set up in order to develop an innovative approach of data mining to look for associations between long-term diseases (LTD) and occupational activities. Methods The MSA was covering 3.2 million individuals in 2016, with about 1.2 million of active workers. Among them, the study population included all self-employed and steady employees, potentially including individuals who may have retired from 2007, that were registered at least once in MSA databases between 2006 and 2015. MSA holds administrative and medico-administrative databases which include occupational activities, socio-demographic variables (age, sex, incomes), as well as LTD, identified through ICD-10 codes. Following due authorizations especially of the French independent data protection authority (CNIL), MSA databases were cross-linked for the first time and restructured in order to apply logistic models and latent factor models. Obtained p-values and odds ratio (OR) were represented on graphics to highlight the key statistical signals of over-represented statistical associations between occupational activity and LTD. Results The population covered by this study accounted for about 2 million individuals (active workers or retirees), with about 900,000 self-employed and 1.2 million steady employees. In both databases, there was a majority of men (65.7%) and the average age was significantly different (P Conclusions This pilot study permitted to prove the feasibility and the relevance of using MSA data for health surveillance of occupational risks among agricultural workers. This approach has the following advantages: 1) enabling systematic evaluations of all disease–occupational activity associations, 2) high statistical power and 3) costless data acquisition. The main drawback is its lack of direct information regarding exposure. For this reason, in partnership with the French national public health agency “Sante publique France”, further work is currently performed to estimate retrospectively pesticides use relying on previous activities and crop-exposure matrices. This data mining approach will later be enriched by identifying diseases using the drugs consumption as a proxy via specific algorithms.

Vaccination coverage and community pharmacy: A strategically necessary and operationally feasible binomial?

This article aims to analyse the existing information on the suitability and effectiveness of the community pharmacy in the shared management of vaccination strategies on population at risk, especially against seasonal influenza, which have developed in different countries around us.Although the real impact of this integration presents different results, mainly due to the fact that its implementation is carried out in health systems of different models and presents different approaches and designs that must be taken into account in its evaluation, the conclusion that can be reached is that the inclusion of the community pharmacist developing the functions of educator, facilitator or administrator of certain types of vaccines (anti-flu or pneumococcal, for example), increases vaccination coverage when compared to traditional models that integrate us. Being, in addition, highly positive the experience of the users of these services, integrated in a collaborative way with other centres or health actors.However, the integration of the community pharmacist in strategic and operational planning to increase vaccine coverage must clearly respond to specific needs based on local epidemiological data. And be closely coordinated with the Health Plans or the agendas of the National Public Health Agencies. This is the only way to take full advantage of the strengths and capabilities of community pharmacists in an approach that maximises the effectiveness of their actions.

Changes in work conditions and impact on workers’ health: The case of collective syndrome in workers of a French administration office in March 2017

Introduction In early 2017, the Regional Unit of Public Health France was solicited for recurring symptoms, mostly irritations and headaches, affecting employees of a 400 people administration office. These symptoms had emerged with the relocation in a new building completely renovated that was characterized by low consumption mode and cumulative new working conditions (open space, reorganization of services). These events led to the evacuation of the building because of non-compliant indoor air analyzes. In order to identify the origin of this episode, surveys were conducted by a multidisciplinary group (epidemiology, occupational health, environment, socio-anthropology) following the recommendations of the National Public Health Agency for the management of unexplained collective syndromes. Methods In this study, three health components were investigated: the environment, the epidemiological context and the psychosocial context. Environmental expertise was conducted on indoor air quality, ventilation, acoustics and lighting. A retrospective cohort epidemiological survey was set up among the employees to characterize the health events in terms of people's time and working conditions (noise, lighting, open space…). Finally, an assessment of the psychosocial context was carried out on the basis of interviews with volunteer employees and through the development of a chronogram of events that occurred in recent months. Results Environmental expertise has revealed a poor ventilation system that may have degraded the quality of indoor air, insufficient thermal comfort, acoustic discomfort and lighting problems. As a result, 78% of employees were symptomatic within 6 months (from October 2016 to April 2017), with a higher attack rate among women (85% vs. 68%, P =0.009) and 89% of people with multiple episodes of symptoms. Individuals presented a variety of symptoms with a higher incidence of headache (58%), asthenia (56%) and eye stinging (42%). For more than 70% of them, the symptoms disappeared when they left the building and for more than 30% when they opened the windows. The occupational doctor registered 28 recognitions of occupational accidents. Problems related to the building (light, noise, ventilation, odors) were more often felt by the symptomatic people. In total, 71% of people were dissatisfied with the work in open-space, the main inconveniences mentioned being: difficulty of concentration, noise and lack of confidentiality. The interviews of the psychosocial component put forward various elements that could have favored the epidemic phenomenon, such as the disruption of the organization of work, a damaged and impersonal work environment or communication problems with management. Conclusions The various investigations led to the identification of many symptomatic people, although we cannot exclude some biases of information and selection, and allowed us characterizing these events as sick building syndrome. The occurrence of various and non-specific symptoms having the particularity of disappearing at the exit of the building, the large number of recurrent cases and the higher attack rate in women are characteristic of these episodes. There are also triggers at the environmental level such as insufficient ventilation and noise- or lighting-related annoyances. The new organization of work in open-space was also a particularly contributory factor. Recommendations on the technical points but also on the working conditions were developed in consultation with the management and will require a mid-term evaluation.

2345 - Developing Conflict Analysis as a Surrogate Safety Measure Using an Expert Survey

Background Conflict analysis appears more important for pedestrian and bicyclist safety assessment than crashes alone because willingness to walk and bicycle depends significantly on perceptions of safety. Understanding and identifying the rate of conflicts on a segment of intersection also may provide a better source of data for local decision-makers because crash data due to its infrequent occurrence rate may not identify a location as dangerous until a fatality or injury occurs. Conflicts between vehicles, pedestrians and bicyclists occur at both intersections and street segments. The study seeks to develop a surrogate safety measure using conflict analysis, which considers conflict categories (severity of conflicts) and safety impact. Methods The research team identifies conflict characteristics that influence the potential seriousness of the conflict and five conflict types: Pedestrian – Vehicle Bicyclist – Vehicle Pedestrian – Bicyclist Vehicle – Bicyclist (Overtaking) Bicyclist – Pedestrian (Overtaking) The study surveys a panel of 132 experts from national transportation, planning, and public health agencies and advocacy organizations to calibrate the conflict safety and severity for each of these categories. The electronic survey uses a scenario approach to gather their feedback and obtains a response rate of 36% (n=47). The survey uses skip-logic, which allows respondents to self-identify their areas of expertise and directs them to the appropriate survey questions. Results The experts evaluate different levels of the conflict characteristics to grade the conflict severity based on the vulnerable road user and place it into one of four categories, A to D, and evaluate the likelihood the crash occurrence safe (no likelihood), moderately safe (low likelihood) or not safe (high likelihood). For pedestrian-vehicle conflicts, two findings stand out. Severity level increases even as the distance between pedestrian and vehicles decreases when emergency evasive actions must be taken. For short distances, irrespective of evasive action type, the survey respondents rated the conflict type as category A and labeled the situation not safe. The survey respondents give more weight to separation distance when rating a conflict situation for crash likelihood. The research team has developed a survey form and an Android app that can be used to collect conflict data in the field. Conclusions Coupled with crash data, understanding the conflict patterns and their possible causes can help transportation agencies make strategic decisions about active transportation investments. Moreover, conflict measures can act as a sketch planning level performance measure to understand potential safety issues related to transportation facilities.

Impact assessment of mass gatherings using labelling procedure in ED, Nouvelle-Aquitaine, 2016

ObjectiveTo access the potential health impact on the population during mass gathering over time using labelling procedure in emergency department (ED).IntroductionThe massive flow of people to mass gathering events, such as festivals or sports events like EURO 2016, may increase public health risks. In the particular context of several terrorist attacks that took place in France in 2015, the French national Public Health agency has decided to strengthen the population health surveillance systems using the mandatory notification disease system and the French national syndromic surveillance SurSaUD®.The objectives in terms of health surveillance of mass gathering are: 1/ the timely detection of a health event (infectious cluster, environmental exposure, collective foodborne disease…) 2/ the health impact assessment of an unexpected event such as a terrorist attack.In collaboration with the Regional Emergency Observatory (ORU), a procedure for the labeling of emergencies has been tested to identify the ED records that could be considered as linked to the event.MethodsDuring summer 2016, the procedure was tested on seven major festive events throughout the region. In addition to the main medical diagnosis, a specific ICD-10 code “Y3388” was chosen to be used in associated diagnosis for records that were supposed to linked to the event.Information on the labeling procedure was insured by the ORU to the emergency departments.All records with medical diagnoses or medical pattern beginning by Y33 have been analyzed.ResultsNo significant increase in the global indicator was observed in the ED impacted by mass gathering. The ED labelling procedure identified 260 records: two thirds corresponded to young men and 17% came from abroad. Among the 250 records labeled in associated diagnosis, 39% were associated to traumatisms and 31% corresponded to alcohol intake.ConclusionsThis study shows that a labelling procedure allows the identification, quantification and characterization of the population ED records associated with mass gathering. Additionally, a labelling procedure to assess a potential impact of an event as mass gathering can be implemented fairly rapidly.

Outbreak of ED visits related to the use of synthetic cannabinoids, Mayotte Island

ObjectiveTo confirm and to characterize the increase in emergency department (ED) visits related to the use of synthetic cannabinoids (SC)IntroductionOn October 2016, the Indian Ocean Regional Health Agency was alerted about an increase in ED visits related to adverse reactions associated with use of SC on Mayotte Island. In this context, an investigation based on a syndromic surveillance system was implemented by the regional unit of the French national public health agency.MethodsAn extraction of anonymized records routinely collected by the syndromic surveillance system (1) was carried out from January 1st, 2012 to October 30, 2016. ED visits related to the consumption of SC were identified from ICD-10 codes of the principal diagnostic according to two levels of confidence:- a probable case was defined as ED visit coded X69 (Intentional self-poisoning by and exposure to other and unspecified chemicals and noxious substances). This code has been implemented specifically by ED physicians since august 2015;- a suspect case was defined as ED visit coded: F11 (Mental and behavioral disorders due to use of opioids), F12 (Mental and behavioral disorders due to use of cannabinoids), F16 (Mental and behavioral disorders due to use of hallucinogens), F18 (Mental and behavioral disorders due to use of volatile solvents), F19 (Mental and behavioral disorders due to multiple drug use and use of other psychoactive substances).Based on these data, an epidemic curve and a descriptive analysis of ED visits were carried out.ResultsIn total, 146 ED visits related to adverse events associated with use of SC were registered from January 1st, 2012 to October 30, 2016. The epidemic curve shows two waves between 2015 and 2016 with a particularly high peak in August 2015 (Figure 1). In total, 49% (n=72/146) of these ED visits were probably related to adverse reactions associated to use SC and 51% (n=74/146) meet to the suspect case definition. On the surveillance period, men represented 84% of the patients (n=122) and median age (min – max) was 23 (8-62) years old. When the severity score variable was filled (n = 138), a vital emergency was reported for 4% (n = 5) of patients and 19% of patients were hospitalized.ConclusionsData from syndromic surveillance system allowed to confirm an increase in ED visits related to adverse reactions associated with use of SC in Mayotte Island. To our knowledge, it’s the first time that an outbreak related to use SC is described in the Ocean Indian areaThis phenomenon was particularly marked in 2015 with a peak of ED visits on August 2016.After this outbreak, the regional unit of the French national public health agency recommended the pursuit of the coding X69 in principal diagnosis with the following case definition: any patient with an adverse reaction attributed to synthetic cannabinoid use whether suspected by the medical team or declared by the patient himself or if the patient is in possession of the substance; and to raise awareness ED physicians to the notification of these poisonings to the Regional Addictive Surveillance Center.In conclusion, the young population, weakened by a precarious socio-economic situation, is a target for new synthetic drugs and a threat to public health. This emerging risk in Mayotte must be taken into account and must be actively monitored. In this context, collaborative work with the emergency services must continue in parallel with targeted prevention measures.

Are the French SAMU data relevant for health surveillance?

ObjectiveTo evaluate whether SAMU data could be relevant for health surveillance and proposed to be integrated into the French national syndromic surveillance SurSaUD® system.IntroductionThe syndromic surveillance SurSaUD® system developed by Santé publique France, the French National Public Health Agency collects daily data from 4 data sources: emergency departments (OSCOUR® ED network) [1], emergency general practioners (SOS Médecins network), crude mortality (civil status data) and electronic death certification including causes of death [2]. The system aims to timely identify, follow and assess the health impact of unusual or seasonal events on emergency medical activity and mortality. However some information could be missed by the system especially for non-severe (absence of ED consultation) or, in contrast, highly severe purposes (direct access to intensive care units).The French pre-hospital emergency medical service (SAMU) [3] represents a potential valuable data source to complete the SurSaUD® surveillance system, thanks to reactive pre-hospital data collection and a large geographical coverage on the whole territory. Data are still not completely standardized and computerized but a governmental project to develop a national common IT system involving all French SAMU is in progress and will be experimented in the following years.MethodsA pilot study was performed in the South of France PACA region, where data from the six local SAMU structures are centralized into an interconnected database. A minimal set of variables required for health monitoring (administrative and medical items) and modalities for data extraction and transmission to Santé publique France were defined.SAMU data were transmitted daily to Santé Publique France and the PACA regional team developed a Microsoft Access® application to import decrypted data, request database and analyze indicators.Retrospective part of the study was performed over a 2-year period (2013-2014) and the prospective part during 2015 was based on daily data collection. Completeness and quality of variables were analyzed. SAMU indicators including several level of specificity were built and compared to existing SurSaUD® indicators in different situations (for detection, seasonal follow-up and health impact assessment) using Spearman coefficient correlation.ResultsDuring the pilot study, data from five of the six SAMU structures of PACA region were structured enough to be analyzed. On the study period, almost 2,400,000 files were recorded and 89% contain medical information. Data completeness was high (87%) and stable during the whole period. The annual rate of SAMU solicitation was 16 for 100 inhabitants at the regional scale. 15% of the records were opened only for medical advice. In contrast, patients were evacuated directly in intensive care unit in 9.5% of cases without ED admission. Coding quality depended on the existence and the use of official thesauri and varied widely among SAMU structures. Despite coding variations, SAMU indicators for winter epidemics were significantly correlated with ED and SOS Médecins indicators. Respectively with ED flu, bronchiolitis and gastroenteritis indicators, the strongest correlations were found for SAMU lower respiratory infection (0.74), SAMU bronchiolitis (0.72) and SAMU gastroenteritis / diarrhea / vomiting (0.81).ConclusionsThis pilot study demonstrated the feasibility to collect daily SAMU activity data. The key strengths of SAMU data were a large geographic coverage, the subsidiarity with SurSaUD® system data sources, the follow-up of prehospital activity and for patients directly admitted into an intensive care unit. Some limitations were highlighted related to differences in coding practices especially for medical diagnosis. The generalization of this study will require the standardization of coding practices and homogenization of thesaurus. The implementation of the national SAMU information system should allow in a very next future to widely progressing on these topics.

Impact de la diffusion d’un guide sur la nutrition et l’activité physique aux élèves de 5 e de France métropolitaine

"J'aime manger, j'aime bouger, le guide nutrition pour les adolescents", ("I love to eat and move, the nutrition pamphlet for teenagers"), which is one of the eight information guides of the French Nutritional and Health Programme, is distributed annually by Santé publique France, the national public health agency, to 8th grade students by their biology teachers. The aim of this study was to assess the impact of this dissemination plan and the way 8th grade students and biology teachers perceive the pamphlet. Teenagers' knowledge of the French Nutritional and Health Programme's recommendations was also assessed. This study was based on a mixed method and was conducted in 2015 on 432 8th grade students by face-to-face interviews at home and 20 8th grade biology teachers interviewed individually or during focus groups. The pamphlet obtained a recognition score of 40% among young people, who mostly saw it during a course at high school. 30% of teenagers reported having read or only skimmed through it and more than three-quarters reported that they liked the pamphlet. Teenagers and teachers found the pamphlet clear and accessible and globally appreciated the content, but they considered that it could be modernized. Systematic distribution of the guide to students of a specific school grade is an efficient strategy to reach a maximum number of young people. It should be continued in the future. Modernization of the guide and improved support to teachers to distribute the guide could improve the performance of the programme.

Prevalence and circumstances of forced sex and post-migration HIV acquisition in sub-Saharan African migrant women in France: an analysis of the ANRS-PARCOURS retrospective population-based study

Sub-Saharan African migrant women are a key population at risk of HIV infection in Europe. Using data from the ANRS-PARCOURS study, we aimed to assess the prevalence of forced sex after migration and its association with post-migration acquisition of HIV as well as the circumstances of forced sex after migration, including housing and administrative insecurity, among sub-Saharan African migrant women living in the Paris Region, France. The ANRS-PARCOURS study was a retrospective life-event survey done between February, 2012, and May, 2013, in health-care facilities in the Paris region of France. Women were eligible if they were born in sub-Saharan Africa, aged between 18 and 59 years, and had been diagnosed with HIV infection at least 3 months earlier for women receiving HIV care or not diagnosed with HIV. In this analysis, we used ANRS-PARCOURS study data to compare the incidence of forced sex after migration in three groups of sub-Saharan African migrant women: those who acquired HIV after migrating, those who acquired HIV before migrating, and those without HIV. We assessed the associations between forced sex, sexual partnerships, and living conditions after migration with mixed-effects logistic regression and generalised structural equation models. The study is registered with ClinicalTrials.gov, number NCT02566148. We obtained data from 980 eligible individuals who participated in the ANRS-PARCOURS study (407 without HIV and 573 HIV-positive) from 54 randomly selected health-care facilities. We excluded 20 women whose HIV infection could not be dated and eight women with missing data from the analyses, for a total of 405 women in the reference group (without HIV) and 547 women in the HIV group (156 with post-migration HIV acquisition, 391 with pre-migration HIV). Women who acquired HIV after migration experienced forced sex after migration more frequently than women without HIV (24 [15%] vs 18 [4%]; p=0·001). Forced sex after migration was associated with being hosted by family or friends (β=0·95, 95% CI 0·19-1·72) and lack of stable housing (β=1·10, 0·17-2·03). Lack of a residence permit was also associated with forced sex after migration. The social hardships faced by sub-Saharan African migrant women after migration, especially a lack of housing or lack of a residence permit, increases their exposure to sexual violence and to HIV infection. The French National Agency for Research on AIDS and Viral Hepatitis, Santé publique France, the national public health agency.

Time out: NFL conflicts of interest with public health efforts to prevent TBI

A long-standing ethical challenge for public health organisations is how to manage conflicts of interest (COI) in partnerships with industry. This has been a particular concern with industries such as...

Public health agencies' obligations and the case of Zika.

This article focuses on the initial reactions to the Zika epidemic by national and international public health agencies. It presents and analyzes some responses public officials made about sexual and reproductive health at the inception of the epidemic. It also describes the different challenges and obligations faced by local and international public health agencies, as these have not been clearly outlined. The article argues that these agencies have different obligations and should fulfill them despite existing obstacles. While international agencies should honor their leadership role and make recommendations at a meta-level, local agencies should provide, in the case of Zika, a framework for empowerment and grant women the freedom to achieve sexual and reproductive health so that they can avoid the consequences of this epidemic.

Support for healthy eating at schools according to the comprehensive school health framework: evaluation during the early years of the Ontario School Food and Beverage Policy implementation.

Provincial, national and international public health agencies recognize the importance of school nutrition policies that help create healthful environments aligned with healthy eating recommendations for youth. School-wide support for healthy living within the pillars of the comprehensive school health (CSH) framework (social and physical environments; teaching and learning; healthy school policy; and partnerships and services) has been positively associated with fostering improvements to student health behaviours. This study used the CSH framework to classify, compare and describe school support for healthy eating during the implementation of the Ontario School Food and Beverage Policy (P/PM 150). We collected data from consenting elementary and secondary schools in a populous region of Ontario in Time I (2012/13) and Time II (2014). Representatives from the schools completed the Healthy School Planner survey and a food environmental scan (FES), which underwent scoring and content analyses. Each school's support for healthy eating was classified as either "initiation," "action" or "maintenance" along the Healthy School Continuum in both time periods, and as "high/increased," "moderate" or "low/decreased" within individual CSH pillars from Time I to Time II. Twenty-five school representatives (8 elementary, 17 secondary) participated. Most schools remained in the "action" category (n = 20) across both time periods, with varying levels of support in the CSH pillars. The physical environment was best supported (100% high/increased support) and the social environment was the least (68% low/decreased support). Only two schools achieved the highest rating (maintenance) in Time II. Supports aligned with P/PM 150 were reportedly influenced by administration buy-in, stakeholder support and relevancy to local context. Further assistance is required to sustain comprehensive support for healthy eating in Ontario school food environments.

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.

Outbreaks of health care–associated influenza-like illness in France: Impact of electronic notification

Mandatory notification of health care-associated (HA) infections, including influenza-like illness (ILI) outbreaks, has been implemented in France since 2001. In 2012, the system moved to online electronic notification of HA infections (e-SIN). The objectives of this study are to describe ILI outbreak notifications to Santé publique France (SPF), the French national public health agency, and to evaluate the impact of notification dematerialization. All notifications of HA ILI outbreaks between July 2001 and June 2015 were included. Notifications before and after e-SIN implementation were compared regarding notification delay and information exhaustiveness. Overall, 506 HA ILI outbreaks were reported, accounting for 7,861 patients and health care professionals. Median delay between occurrence of the first case and notification was, respectively, 32 and 13 days before and after e-SIN utilization (P < .001). Information exhaustiveness was improved by electronic notification regarding HA status (8.5% of missing data before and 2.3% after e-SIN, P = .003), hypotheses of cause (25.4% of missing data before vs 8.0% after e-SIN, P < .001), and level of event control (23.7% of missing data before vs 7.5% after e-SIN, P < .001). HA influenza notifications, including HA ILI or influenza, to health authorities are essential to guide decisional instances and health care practices. Electronic notifications have improved the timeliness and quality of information transmitted.