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Introduction: Long-term exposure to air pollution (AP) has been shown to have an impact on mortality in numerous countries, but since 2005 no data exists for France., Objectives: We analyzed the association between long-term exposure to air pollution and mortality at the individual level in a large French cohort followed from 1989 to 2013., Methods: The study sample consisted of 20,327 adults working at the French national electricity and gas company EDF-GDF. Annual exposure to PM10, PM10–2.5, PM2.5, NO2, O3, SO2, and benzene was assessed for the place of residence of participants using a chemistry-transport model and taking residential history into account. Hazard ratios were estimated using a Cox proportional-hazards regression model, adjusted for selected individual and contextual risk factors. Hazard ratios were computed for an interquartile range (IQR) increase in air pollutant concentrations., Results: The cohort recorded 1967 non-accidental deaths. Long-term exposures to b aseline PM2.5, PM10-25, NO2 and benzene were associated with an increase in non-accidental mortality (Hazard Ratio, HR = 1.09; 95% CI: 0.99, 1.20 per 5.9 μg/m3, PM10-25; HR=1.09; 95% CI: 1.04, 1.15 per 2.2 μg/m3, NO2: HR=1.14; 95% CI: 0.99, 1.31 per 19.3 μg/m3 and benzene: HR=1.10; 95% CI: 1.00, 1.22 per 1.7 μg/m3).The strongest association was found for PM10: HR = 1.14; 95% CI: 1.05, 1.25 per 7.8 μg/m3. PM10, PM10-25 and SO2 were associated with non-accidental mortality when using time varying exposure. No significant associations were observed between air pollution and cardiovascular and respiratory mortality., Conclusion: Long-term exposure to fine particles, nitrogen dioxide, sulfur dioxide and benzene is associated with an increased risk of non-accidental mortality in France. Our results strengthen existing evidence that outdoor air pollution is a significant environmental risk factor for mortality. Due to the limited sample size and the nature of our study (occupational), further investigations are needed in France with a larger representative population sample.

Background: Epidemiological studies have investigated the health impacts of local sources of environmental pollution using as an outcome variable self-reported health, reflecting the overall perception interviewed people have of their own health. This work aims at analyzing the advantages and the results of this approach. A first step focused on describing the indicators., Methods: The literature on indicators of self-reported health was reviewed, leading to a discussion on data collection, selection of health effects, data processing, and construction of indicators., Results: The literature review concerned 51 articles. The use of self-reported health indicators allowed the studies to take into account the health concerns and complaints of populations exposed to environmental pollution. Various indicators of self-reported health were used in the studies. They measured physical, psychological and general dimensions of health. Standardized questionnaires were used less often than ad hoc questionnaires (78% of studies) developed to fit the needs of a given study. Three standardized questionnaires were used more frequently: the MOS Short-Form Health Survey (SF-36) to measure general health perceptions, the General Health Questionnaire (GHQ), and the Symptoms Checklist (SCL-90) to measure psychological distress., Conclusion: The choice of self-reported health indicators is a compromise between specificity of the studied health issues within a given environment and standardization of the questionnaires used to measure them. Such standardization is necessary to ensure the validity and the reliability of the information collected across time and situations. The psychometric properties of the measuring questionnaires are rarely estimated or verified when they are used., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: Epidemiological studies have investigated the health impacts of local sources of environmental pollution using as an outcome variable self-reported health, reflecting the overall perception interviewed people have of their own health. This work aims at analyzing the advantages and the results of this approach. This second part presents the results of the studies., Methods: Based on a literature review (51 papers), this article presents an analysis of the contribution of self-reported health to epidemiological studies investigating local sources of environmental pollution. It discusses the associations between self-reported health and exposure variables, and other risk factors that can influence health reporting., Results: Studies using self-reported health showed that local sources can be associated with a wide range of health outcomes, including an impact on mental health and well-being. The perception of pollution, especially sensory information such as odors, affects self-reported health. Attitudes referring to beliefs, worries and personal behaviors concerning the source of pollution have a striking influence on reported health. Attitudes can be used to estimate the reporting bias in a biomedical approach, and also constitute the main explanatory factors in biopsychosocial studies taking into account not only the biological, physical, and chemical factors but also the psychological and social factors at stake in a situation of environmental exposure., Conclusion: Studying self-reported health enables a multifactorial approach to health in a context of environmental exposure. This approach is most relevant when conducted within a multidisciplinary framework involving human and social sciences to better understand psychosocial factors. The relevance of this type of approach used as an epidemiological surveillance tool to monitor local situations should be assessed with regard to needs for public health management of these situations., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Estimates of mortality in future years are crucial for communication, prevention and anticipation related to the burden of diseases and for developing scenarios studying the effects of reducing environmental exposure. The aim of this study is to project observed trends of mortality in France for lung and breast cancer among females to 2021. Projections of mortality rates are based on a Bayesian age-period-cohort model and a Poisson distribution. We used cancer mortality data from the French mortality register (period 1977-2006) and population data from population registers (estimated for 1977-2006 and projected for period 2007-2021 using five scenarios: largest, smallest, youngest, older, average population). Alternative models were tested (generalized additive model, negative binomial distribution). For the average population scenario, lung and breast cancer mortality rates age-standardized to the world population, are respectively: 11.5 per 10(5) women (Credibility interval: 10.3-12.8) and 15.9 (14.4-17.6) in 2007-2011, 14.6 (11.7-18.1) and 14.5 (11.6-18.0) in 2012-2016, 18.2 (12.6-26.0) and 13.3 (9.1-18.9) in 2017-2021. Projections show an ongoing increase for lung cancer and decrease for breast cancer mortality rates, which are expected to be equal in 2012-2016. Compared projections of these two cancers using a similar method had not been done before. Aggressive prevention strategies targeting smoking among women are needed to control this fast growing epidemic of avoidable cancer. Planning of health care capacity for diagnosis and treatment of cancer among females is also necessary., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

In France, the field of public health and public health training have developed over recent decades in parallel to the emergence of environmental health; however, these two fields are grounded in conceptual and methodological underpinnings that often differ. The authors of this article try to analyse the differences between these two approaches which both have prevention as their main purpose. Both approaches use epidemiology as a tool, but they are distinguished by their uniquely different definitions of environment. Unifying both approaches around a common basis is possible, but in order to do this, public health must evolve to expand and integrate new disciplines other than epidemiology. Supported by its close ties to societal issues of concern and recent scientific developments, the environmental health boom can and should revive public health values and contribute to the development of public health training in France.

Different designs can be used to analyze the relationships between respiratory mortality and long term exposure to atmospheric pollution: epidemiological studies (cohort, prevalence study) demonstrate the reality of the relationship and toxicological studies explain it. Cohort studies have the advantage of being able to take into account many confounding factors and thus avoid biases (which is not the case with prevalence studies), but require significant human and financial resources. They were first adopted in the US, but are now more often applied in Europe. The results are relatively consistent, as they all show a statistically significant association between an increase in particulate pollution and cardiopulmonary mortality. Mortality from lung cancer is also associated with long term exposition to particles and sometimes to ozone or nitrogen oxides. Cerebrovascular diseases and sudden death of young children have also been associated with particulate pollution. The relationships are more powerful for long term than short term exposure but are also linear and without threshold. In order to explain these effects (today the causality of the relationship is certain) there are many possible factors, particularly regarding particulate exposures: an increase in cardiovascular risk biomarkers (fibrinogen, white blood cells, and platelets), atherosclerosis, chronic inflammation of lung tissues increased by acute exposure, etc. More and more studies address the interaction between gene and environment and even epigenetic phenomena which could be responsible of these effects. Public Health impact could be quantified. The European E&H surveillance program Apheis, for example, estimated that if PM2.5 levels remained below 15 microg/m(3), a 30 year old person could see his life expectancy increased by 1 month to 2 years, depending on the studied city. Finally, mortality is not the only relevant indicator for health effects of air pollution. ISAAC studies address asthma, allergic rhinitis and eczema among children.

Introduction: Lung cancer is currently the most common cancer in the world and as such is an important public health concern. One of the main challenges is to foresee the evolution of trends in lung cancer mortality rates in order to anticipate the future burden of this disease as well as to plan the supply of adequate health care. The aim of this study is to propose a quantification of future lung cancer mortality rates by gender in France until the year 2012., Methods: Lung cancer mortality data in France (1978-2002) were extracted from the National Statistics of Death and analyzed by 5-year age-groups and periods, using a Bayesian age-period-cohort model., Discussion: Between 1978 and 2002, female lung cancer mortality rate rises by 3.3%year(-1). For men, a slow increase is observed until 1988-1992 followed by a declining trend. In 1998-2002, age-standardized mortality rates were, respectively, 45.5 and 7.6 per 100000 for males and for females. By 2008-2012 these figures would reach 40.8 (95% credibility interval (CI): 32.7, 50.0) and 12.1 (CI: 11.7, 12.6) per 100000, respectively, which represents among women a 4.7% annual increase (CI: 4.5, 5.0)., Results: Our results highlight the relevance of pursuing public health measures in order to cope more actively with tobacco smoking in the prevention strategy against lung cancer specifically among women.

Introduction: Short term associations between air pollution indicators and hospitalizations for cardiovascular diseases have been suggested by epidemiological and clinical studies. The present study aims at estimating the association between particles with diameter <10 microm (PM(10)), nitrogen dioxide (NO(2)) and ozone and hospitalizations for cardiovascular diseases in eight French cities during the 1998-2003 period., Methods: The daily number of hospitalizations in each city was extracted from the French hospital information system (PMSI) for cardiovascular diseases, cardiac diseases, ischemic heart diseases and stroke. Excess relative risks (ERRs) of hospitalization associated with a 10 microg/m(3) increase in pollutant levels were estimated in each city by fitting a Poisson regression model, controlling for well-known confounding factors and temporal trends. City-specific results were then combined by inverse variance weighting., Results: Daily number of hospitalizations for cardiovascular diseases was associated with PM(10) levels (for a 10 microg/m(3) increase, ERR=0.8%, 95% CI: [0.2, 1.5]), with NO(2) (1.1%, [0.6, 1.6]) but not with ozone (0.1% [-0.2%, 0.5%]). Associations were stronger in people aged 65 years and over, and when only hospitalizations for ischemic heart diseases were considered. No association was found between strokes and air pollution levels., Discussion: Our study suggests that the ambient levels of air pollutants currently experienced in the eight French cities, which are close to European air quality guidelines, are yet linked to a short term increase of hospitalizations for cardiovascular diseases. These results are consistent with epidemiological and toxicological data on the cardiovascular effects of air pollution.

Background: During August 2003, record high temperatures were observed across Europe, and France was the country most affected. During this period, elevated ozone concentrations were measured all over the country. Questions were raised concerning the contribution of O3 to the health impact of the summer 2003 heat wave., Methods: We used a time-series design to analyze short-term effects of temperature and O3 pollution on mortality. Counts of deaths were regressed on temperatures and O3 levels, controlling for possible confounders: long-term trends, season, influenza outbreaks, day of the week, and bank holiday effects. For comparison with previous results of the nine cities, we calculated pooled excess risk using a random effect approach and an empirical Bayes approach., Findings: For the nine cities, the excess risk of death is significant (1.01% ; 95% confidence interval, 0.58-1.44) for an increase of 10 microg/m3 in O3 level. For the 3-17 August 2003 period, the excess risk of deaths linked to O3 and temperatures together ranged from 10.6% in Le Havre to 174.7% in Paris. When we compared the relative contributions of O3 and temperature to this joint excess risk, the contribution of O3 varied according to the city, ranging from 2.5% in Bordeaux to 85.3% in Toulouse., Interpretation: We observed heterogeneity among the nine cities not only for the joint effect of O3 and temperatures, but also for the relative contribution of each factor. These results confirmed that in urban areas O3 levels have a non-negligible impact in terms of public health.

The relationship between air pollution and mortality is now admissible with a sufficiently high level of causality proven. This link allows for health impact assessment to be carried out with a significant degree of accuracy, such as the case for the results which are presented here from the nine French cities involved in the Apheis programme. This health impact assessment is based on the methodology developed by the World Health Organization. The number of avoidable deaths is contained between categories ranging from 2.0 to 4.3, 4.0 to 8.9, and from 15.0 to 31.5 per 100,000 inhabitants according to very short term effects, short term effects and long term effects, respectively. There are two scenarios which can be envisioned for the reduction of fine particles levels which are capable of obtaining similar results for both very short term and short term effects. The first involves diminishing the daily concentrations which are above 20 microg/m3 until they reach this value, and the second entails systematically decreasing the daily levels by 5 microg/m3. The first strategy of reducing values to stabilize at 20 microg/m3 has been shown to be the one most favourable and promising for the long term effects. This strategy therefore confirms the reliability and strength of the recommendation formulated at the national level.

Background: A heatwave occurred in France in August 2003, with an accompanying excess of all-cause mortality. This study quantifies this excess mortality and investigates a possible harvesting effect in the few weeks after the heatwave., Methods: A time-series study using a Poisson regression model with regression splines to control for nonlinear confounders was used to analyze the correlation between heatwave variable and mortality in 9 French cities., Results: After controlling for long-term and seasonal time trends and the usual effects of temperature and air pollution, we estimated that 3,096 extra deaths resulted from the heatwave. The maximum daily relative risk of mortality during the heatwave (compared with expected deaths at that time of year) ranged from 1.16 in Le Havre to 5.00 in Paris. There was little evidence of mortality displacement in the few weeks after the heatwave, with an estimated deficit of 253 deaths at the end of the period., Conclusions: The heatwave in France during August 2003 was associated with a large increase in the number of deaths. The impact estimated using a time-series design was consistent with crude previous estimates of the impact of the heatwave. This finding suggests that neither air pollution nor long-term and seasonal trends confounded previous estimates. There was no evidence to suggest that the extras deaths associated with the heatwave were simply brought forward in time.

Background: With 4,500 deaths in year 2000, female lung cancer mortality rates increased by 3% every year over the last two decades in France. This trend, not observed among males, is attributed to the regular increase of female smoking. In order to answer French Health decider's concerns, we estimated the future female lung cancer mortality rates and numbers of deaths for the next fifteen years, in France and its regions., Methods: Analyses were based on numbers of female deaths from lung cancer observed between 1975 and 1999, and on past and future population estimates for 1975-2014, at national and regional levels. Mortality rates and numbers of deaths in France and its regions by 5-year periods and 5-year age groups were given in the 1975-1999 death certificate data base, and were projected for 2000-2014. The analysis used a bayesian approach of the age-cohort model with auto-regressive constraints on parameters. Estimated mortality rates were standardized on truncated 20-85 + world population., Results: French female lung cancer mortality increased by 3% every year between 1975 and 1999. In period 1995-1999, truncated 20-85 + mortality rates, and number of deaths per year were respectively 11.4 per 100,000 and 4,000. Mortality rates increased in all regions but variations were maximum in Corsica (+ 314%) and minimum in Auvergne (+ 37%). For the whole of France, the estimated truncated 20-85 + standardized rate, was respectively, 14.1 and 22.5 per 100,000 in period 2000-04 and period 2010-14, which represents a 60% increase between these two time periods. At the regional level, the maximum variation was found in Languedoc-Roussillon (107%), the minimum in Nord-Pas-de-Calais (40%)., Conclusions: The bayesian approach of the age-cohort model is increasingly used because it produces stable projections, without having to include other cancer parameters. Nevertheless, it would be interesting to extend this model by incorporating a tobacco consumption component, in order to assess scenarios based on consumption decreases.

Objectives: To quantify the short term effects of air pollution on mortality and hospitalisation for cardiovascular or respiratory disorders in the nine French cities (Bordeaux, Le Havre, Lille, Lyon, Marseille, Paris, Rouen, Strasbourg and Toulouse) of the Surveillance Air et Santé program., Methods: Data were available on mortality and hospitalisation were available, respectively, from 1990 to 1997 and 1995 to 1999. Exposure data were the concentrations of sulphur dioxide, particles with a diameter of less than or equal to 10 mm, black smoke, nitrogen dioxide, ozone, and carbon monoxide. The analysis assessed the relationships, in each of the cities, between the daily numbers of deaths and hospitalisations and the daily levels of polluting agents, taking into account confounding factors. A combined relative risk was calculated for all the cities. The number of deaths and hospitalisations attributable to air pollution was then estimated for each of the cities, based on the relative risk., Results: Significant relationships were found for mortality, from whatever cause, and for hospitalisations for respiratory disorders in children aged under 15. If the levels of air pollution were reduced to 10 microg/m3 in the nine cities, 2800 premature deaths and 750 hospitalisations for respiratory disorders in children would be avoided, every year., Conclusion: Today, it is possible to assess the benefits of reducing air pollution in terms of health in the short term. These analyses would provide a sanitary dimension to the strategies for the reduction of urban pollution on local and European level.

Between 1990 and 1995, 9 French cities provided data on daily air pollution, total mortality, cardiovascular mortality, and respiratory mortality. Personnel in individual cities performed Poisson regressions, controlling for trends in seasons, calendar effects, influenza epidemics, temperature, and humidity, to assess the short-term effects of air pollution. The authors describe results obtained from the quantitative pooling of these local analyses. When no heterogeneity could be detected, a fixed-effect model was used; otherwise, a random-effect model was used. Significant and positive associations were found between total daily deaths in these cities and the 4 air pollution indicators studied: (1) Black Smoke, (2) sulfur dioxide, (3) nitrogen dioxide, and (4) ozone. A 50-microg/m3 increase in Black Smoke (24 hr), sulfur dioxide (24 hr), nitrogen dioxide (24 hr), or ozone (8 hr) was associated with increases in total mortality of 2.9% (95% confidence interval [CI]) = 1.3, 4.4), 3.6% (95% CI = 2.1, 5.2), 3.8% (95% CI = 2.0, 5.5), and 2.7% (95% CI = 1.3, 4.1), respectively. Similar results were obtained for cardiovascular mortality. Except for sulfur dioxide, positive--but not significant--associations were found with respiratory mortality. The internal consistency among the cities studied, as well as consistency with previously published results, favors a causal interpretation of these associations.

Background: In the world, the cervix cancer is the second commonest cancer in women. Its incidence is decreasing but it is still too frequent. The aim of this study was to predict the incidence of cervix cancer among women in the Department of Bas-Rhin., Methods: Incidence data were provided by the Bas-Rhin Tumor Registry. The incidence of in situ tumors and invasive cancers was predicted in 2010-2014 by using an age - period - cohort model and a Bayesian approach., Results: The incidence rates predicted by the model, standardized to the European population, were 99.7 per 10(5)population in 2000-2004 (CI 95%: [82.7-118.5]) and 177.1 per 10(5) population in 2010-2014 (CI 95%: [103.7-288.5]) for in situ and 13.0 per 10(5) population (CI 95%: [9.5-17.2]) in 2000-2004 and 11.1 per 10(5)population (CI 95%: [4.5-22.7]) in 2010-2014 for invasive tumors., Conclusions: The decrease of invasive tumors is due to screening. The improvement of the quality of the screening and treatment of in situ tumors would allow the number of incident cases of cervix cancer to decrease.

Time series studies conducted in the field of air pollution aim at testing and quantifying short-term relations which can exist between daily air pollution levels and daily health effects. The method used for this type of survey has sometimes been misunderstood mainly because individual factors and indoor exposure to air pollutants were not taken into account. The adjustment on these individual confounding factors commonly used in classic epidemiologic studies (case-control studies, cohort studies) is not adequate to times series studies which are based on aggregate data. This is different for those factors that change over time according to the levels of air pollution (meteorological conditions, influenza epidemics, trend of health cases) which, when being analysed, must be taken into account either indirectly through time modelling or directly through non-linear modelling processes. During this last decade, numerous studies using the time series method have been published and have found short-term associations between daily levels of air pollution commonly observed and daily respiratory mortality. The consistency of the numerous results published in the international literature are more arguments in favour of non-confounding short-term relations between air pollution and respiratory mortality.

Background: Many studies have shown positive associations between urban air pollution, mortality and hospitalizations for cardiovascular diseases. This study tried to estimate short term effects of ambient air pollution on myocardial infarction on the basis of data collected in a morbidity registry., Methods: The daily number of myocardial infarctions between 1984 and 1989 was supplied by the Monica registry (Bas-Rhin). The pollution variables were daily mean and maximum of hourly measures of carbon monoxyde (CO), sulfur dioxide (SO(2)), particles (PM13), nitrogen monoxyde (NO) and nitrogen dioxide (NO(2)), mean and maximum of hourly measures of ozone (O(3)) between 10 a.m. and 6 p.m. Other data were influenza epidemics, daily temperature and humidity. The analysis was a Poisson regression controlling for trend, season, meteorological factors and pollutant, using non parametric smoothing. Influence of day of week and influenza were controlled through dummy variables., Results: For the hourly maximum of NO with a 5 day lag the association was statistically significant (square root relation): for an increase from percentile 25 (63 microg/m(3)) to percentile 75 (189 microg/m(3)), the RR was 1.087 (95% CI: 1.014-1.166). The association was significant during winter with a RR of 1.129 (95% CI: 1.028-1.241) for a percentile 25 (101 microg/m(3)) to percentile 75 (265 microg/m(3)) increase. A positive linear association was found with daily maximum of NO(2) during winter with a 5 day lag: the RR, for an increase from percentile 25 (59 microg/m(3)) to percentile 75 (107 microg/m(3)) was 1.095 (95% CI: 1.015-1.181). For the daily mean and maximum of O(3), a positive association was found but it was not robust. For other pollutants, no association was found., Conclusions: The association between NO(2) and coronary events, hospitalizations and mortality, has been shown in several studies but not in all. This secondary pollutant could be a proxy for small particles.

Background: This study aims at quantifying air pollution effects on mortality and at evaluating the feasibility of a standardized epidemiological surveillance system of air pollution in 9 French cities., Methods: Data collection and analysis followed a standardized protocol. Data pollution depended on the development of local air quality surveillance networks (number of indicators, number of stations.). The Generalised Additive Models (GAM) were used to quantify the association between air pollution and mortality., Results: In the 9 studied areas, associations between all causes, cardiovascular and respiratory mortality, and air pollution indicators were observed. These associations were linear without threshold. Depending on the pollutants, excess in mortality related to an interquartile increase in acid-particulate pollution varied between 0.3 and 3.5% for total mortality, 0.5 and 6.3% for cardiovascular mortality, and between 0.1 and 12% for respiratory mortality. Photochemical air pollution varied between 0.4 and 7.3% for total mortality, 1.4 and 6.7% for cardiovascular mortality, and between 1.7 and 30.4% for respiratory mortality., Conclusion: In spite of a standardized common protocol, some disparities, inherent to the local characteristics, were noted (length of time series, numbers of ambient urban stations selected and pollutants available.). Nevertheless, this pilot study showed that multicentric epidemiological monitoring of air pollution effects on health was feasible. Yet, this requires to validate the results obtained through a re-analysis of the mortality data on a longer period of study. It also requires to study the feasibility and the relevance of the use of other health indicators, such as hospital admissions.

New regulations on the quality of air together with the epidemiological results obtained in the last 10 years on the short-term effects of air pollution on health have led the InVS to set up a program of epidemiological surveillance in 9 French cities. The first phase of this program was dedicated to the study of feasibility of such a surveillance system. Metrological and health data collection was conducted at both local and national levels in order to obtain significant data in close collaboration with experts of each field. The analysis of the relationship between temporal variations of daily series of the two types of indicators have allowed to obtain dose-response relationships between air pollution and mortality. The organisational and technical feasibility of such a surveillance system was confirmed in the first phase of the program.

The colorectal cancer is one of the three most frequent cancers. It concerns more and more men and women and is a of heavy consequence for mortality and treatment. This study attempted to predict the incidence and the number of incident cases of colorectal cancer. The analysis is a Poisson regression based on an age-period-cohort model. The predicted value of the incidence of colon cancer, standardized on the world population (25-89 years old), is increasing with time: it is, in 2005-2009, 41.5 for 100,000 for the women and 104.9 for 100,000 for the men. For rectum cancer, the predicted value of incidence is, in 2005-2009, 22.9 for 100,000 for the women and 37.2 for 100, 000 for the men. During the period 2005-2009, the number of incident cases is, for colon, 1,195 women (the mean increase, every ten years, is 31%) and 2,254 men (the mean increase, every ten years, is 65%). During the same period, the number of incident cases is, for rectum, 640 women (the mean increase, every ten years, is 24%) and 807 men (the mean increase every ten years is 14%). These results are similar to those of other studies in Europe and in the World.