Main outcomes from the first two years of France's screening programme for neonatal permanent hearing loss through a descriptive study

AIM

This study aimed to evaluate the implementation of France's neonatal hearing loss screening programme two years after its launch, and to estimate permanent bilateral neonatal hearing loss (PBNHL) prevalence and distribution by severity.

METHODS

This descriptive study used aggregated regional data on all births in France in 2015-2016. Screening coverage, refusal rate, positive predictive value (PPV), proportion of children with suspected PBNHL, PBNHL prevalence and distribution by severity were calculated.

RESULTS

800,000 neonates were eligible for the screening programme per year. Between 2015 and 2016, screening coverage increased (83.3 vs 93.8%; p<0.001), and the refusal rate remained stable (0.1%). In 2016, when considering the additional tests performed several weeks after birth, the proportion of suspected PBNHL neonates decreased (1.4 vs 0.9%) while the PPV increased (4.7 vs 7.6%). In 2015, the estimated prevalence of PBNHL (moderate to profound) was 0.09% (95% CI 0.08-0.10). Among neonates with >=41 decibels deficit, 56.8%, 16.6%, and 26.6% had moderate, severe and profound hearing loss, respectively.

CONCLUSION

The national target of 90% screening coverage was exceeded. The additional test could be useful to avoid overcrowding in diagnostic structures. Diagnostic data quality must be improved to confirm PBNHL prevalence and distribution by severity.

Maternal admissions to Intensive Care Units in France: trends in rates, causes and severity

Introduction

Maternal intensive care unit admission (ICU) is an indicator of severe maternal morbidity. This study aimed to estimate rates of maternal ICU admission during or following pregnancy in France, and to describe the characteristics of women admitted, the severity of their condition, associated diagnoses, regional disparities, and temporal trends between 2010 and 2014.

Methods

Women hospitalised in France in ICU during pregnancy or up to 42 days after pregnancy between 2010 and 2014 were identified using the national hospital discharge database (PMSI-MCO). The Simplified Acute Physiology Score (SAPS II) was used to estimate the severity. Trends in incidence rates were quantified using percentages of average annual variation based on a Poisson regression model.

Results

In total, 16,011 women were admitted to ICU, representing an overall rate of 3.97 ‰ deliveries. The average annual decrease in this rate between 2010 and 2014 was 1.7% (IC95%:-2, 00%; -1, 45%; p &lt; 0.0001) on average per year. The SAPS II score increased significantly from 18.4 in 2010 to 21.5 in 2014. Obstetrical hemorrhage (39.8%) and hypertensive complications during pregnancy (24.8%) were the most common reasons for admission. Within mainland France, we found notable disparities in maternal ICU admission rates between regions, from lowest in Pays-de-la-Loire region (2.69‰) to highest in Ile-de-France (5.05‰).

Conclusions

The rate of maternal ICU admission decreased from 2010 to 2014 in France, with a concomitant increase in case severity. Additional studies are needed to understand the territorial disparities identified in our study.

Key messages

The decreasing incidence of maternal ICU admission could be due to organisational changes with increased admission to intermediate care units. These changes have to be understood to accurately use maternal CU admission for maternal health surveillance.

Monitoring Fetal Alcohol Spectrum Disorder during the neonatal period in France

Background

Alcohol is a known teratogenic and foetotoxic agent. At birth, only the complete foetal alcohol syndrome (FAS) and at most a suspicion for some incomplete syndromic forms can be diagnosed. Yet, other Consequences of prenatal Alcohol Exposure (CAE) can also be observed and recorded in the neonatal period. Our goal was to describe the frequency of diagnosis codes for FAS and CAE at the national and regional level.

Methods

Between 2006 and 2013, we identified the ICM-10 codes Q860 (FAS) and P043 (CAE) in the hospital records for stays occurring in the 28 first days of life in the French national health insurance database (SNDS). Our “potential Foetal Alcohol Spectrum Disorders group” (pFASD), included the FAS and CAE subgroups. The pFASD prevalence was estimated per 1000 live births at the national and regional levels overall and then comparing: 2006-2009 and 2010-2013.

Results

From 2006 to 2013, 3207 neonates were diagnosed with pFASD during the neonatal period, i.e. 0.48 cases per 1,000 live births, including 0.07‰ of FAS. Between 2006-2009 and 2010-2013, pFASD remained stable (p = 0.6). At the regional level, the proportion of pFASD was the most frequent in one of the overseas territories (La Reunion Island, 1.22‰ births) and in the north-eastern part of mainland France (0.90 ‰ births to 1.02 ‰).

Conclusions

This study is the first to produce a national estimate of the frequency of neonatal diagnosis of FAS. It shows a stability of the frequency of pFASD cases recorded over the 2006-2013 period which is certainly underestimated but gives a first minimal estimate of the burden of alcohol use during pregnancy in France.

Key messages

Alcohol use during pregnancy remains a public health issue in France. Estimating the prevalence of FAS is of undeniable priority given the public health implications of these disorders that hinder the development of children exposed, and their avoidable nature.

First national results of the evaluation of the neonatal hearing loss screening programme in France

Background

The French newborn hearing screening programme set up in 2014 aims to identify affected children as early as possible to allow appropriate care. Our goal was to evaluate the implementation of this programme at the national level.

Methods

The programme consist in a screening using a test (T1) and a retest (T2) in the maternity hospital in all newborns. In some region, a delayed test (T3) is performed afterwards in children for whom it was not possible to confirm normal hearing. Children suspected of deafness subsequently enter the diagnosis phase. We defined evaluation indicators after stakeholders consultation. We developed a web application to collect aggregated data on live births. We estimated the rate of coverage, refusal, children suspected of hearing loss at the end of the screening phase and the prevalence of bilateral deafness.

Results

In 2015, one year after the initiation of the programme, the coverage rate was already very high (88%) and even more so in 2016 (96%). Parental acceptance was very good (refusal: 0.1%). By the end of 2016, 19 out 27 regions had added a T3. The rate of suspicion of bilateral hearing loss was decreased by using a T3 (1.4% vs 0.9%). Bilateral deafness rate, estimated after a 2-years follow up, was 1.3‰ although it was estimated only on 51.5% of suspected children for whom diagnosis data had been transmitted.

Conclusions

The objective of a 90% coverage set by the French ministry of health has been met after 2 years of operation of the program. T3 appears useful in relieving diagnostic structures from false positives. Our estimated prevalence of bilateral deafness could be more accurate if data collection was improved but is consistent with prevalence reported in North America.

Key messages

The universal newborn hearing screening program has been successfully set up in France in terms of coverage. Future work should focus on improving the collection of follow up data to better characterise diagnosed children.

Pregnancy-related listeriosis in France, 1984 to 2011, with a focus on 606 cases from 1999 to 2011

Binary file ES_Abstracts_Final_ECDC.txt matches

Listeria monocytogenes encephalitis in France

PURPOSE

The authors had for aim to describe the characteristics of listeriosis encephalitis patients enrolled in a national study.

METHODS

Listeria monocytogenes was identified as the forth etiology of encephalitis, in a prospective study in France, in 2007. We analyzed 12 cases with confirmed listeriosis (seven with rhombencephalitis, five with encephalitis) and compared them with encephalitis of other etiologies and with listeriosis encephalitis, mandatorily notified during the same year.

RESULTS

L. monocytogenes strains were genoserotyped as IVb (n=6), IIa (n=3), and IIb (n=3). Cerebrospinal fluid (CSF) median protein level was 2.5g/L and the median WBC counts was 367cells/mm(3). Among twelve patients, seven patients had ongoing comorbidities. The case fatality rate during hospitalization was 50%. Patients presenting with listeriosis enrolled in the study did not differ from those reported to the mandatory surveillance system according to their demographical characteristics and comorbidities. They were older, presented more frequently with cancer, or were more often under corticosteroid treatment than patients presenting with encephalitis due to other etiologies.

CONCLUSIONS

Neurolisteriosis has a poor prognosis, thus it should be considered early in patients presenting with encephalitis to improve its management.

Prevalence of Chlamydia trachomatis: results from the first national population-based survey in France

BACKGROUND

Few studies have estimated Chlamydia trachomatis (CT) prevalence in the general population, most prevalence studies being based on people already attending healthcare settings.

OBJECTIVES

To estimate the prevalence of CT in France, assess the feasibility of home sampling without any face-to-face intervention and identify risk factors associated with CT infection using data from the Contexte de la Sexualité (CSF) survey on sexual behaviour; a national population-based survey, carried out by telephone in 2006.

METHODS

A random subsample of sexually experienced people aged 18-44 (N=4957) were invited to participate in a CT home-sampling study (NatChla study). Participants' samples were tested for CT by PCR. Percentages were weighted for unequal selection probabilities and post-stratified based on French population census data. Independent risk factors were identified by logistic regression.

RESULTS

CT prevalence in people aged 18-44 was estimated at 1.4% (95% CI 0.8% to 2.6%) for men, and 1.6% (95% CI 1.0% to 2.5%) for women. Increased rates were found in subjects aged 18-29: 2.5% (95% CI 1.2% to 5.0%) for men and 3.2% (95% CI 2.0% to 5.3%) for women. CT infection was associated, for both genders, with having their last sexual intercourse with a casual partner. Other risk factors were for men, having last intercourse with a new partner, living in the Paris area, and for women, multiple partners during the previous year, same sex partners and a low level of education.

CONCLUSIONS

CT prevalence in France is similar to that in other developed countries. Home sampling proved feasible and useful to reach members of the population with limited access to traditional care.

Congenital toxoplasmosis in France in 2007: first results from a national surveillance system

When immunocompetent people become infected with the parasite Toxoplasma gondii, the disease is generally asymptomatic. However, transplacental transmission of T. gondii may lead to severe congenital infection including in utero abortion, foetal death, or neurological or ocular damage of the foetus. France has had a national programme to prevent congenital toxoplasmosis since 1978. However, although estimated seroprevalence in pregnant women has fallen from 84% in the 1960s to 44% in 2003, no reliable data have been available on the annual number of cases of congenital toxoplasmosis or the severity of infection. In 2006, the French National Institute for Public Health Surveillance (Institut de Veille Sanitaire) and the National Reference Centre for Toxoplasmosis recommended that a national laboratory-based surveillance system be used for the surveillance of the disease. In 2007, 31 laboratories reported at least one congenital case through the surveillance system, giving a total of 272 cases. A total of 11 terminations of pregnancy were reported (six abortions and five foetal deaths). Of the live-born cases, 206 were asymptomatic, 28 were symptomatic and seven had a severe form of the disease. As there were 818,700 births in France and French overseas departments in 2007, the overall prevalence of congenital toxoplasmosis observed that year was 3.3 (95% confidence interval (CI): 2.9 to 3.7) per 10,000 live births and the incidence rate of the disease at birth was 2.9 (95% CI: 2.5 to 3.2) per 10,000 live births; the estimated incidence rate of symptomatic congenital toxoplasmosis was 0.34 (95% CI: 0.2 to 0.5) cases per 10,000 live births.

Changes in sexual behaviours: from secular trends to public health policies

OBJECTIVE

To explore the relative contribution of secular trends and public health policies to changes in sexual behaviour.

DESIGN

Three random probability surveys of the sexual behaviour of people aged 18-69 years were conducted in 1970, 1992 and 2006 in France.

METHODS

Data of the 2006 survey (n = 12,364) were compared with those from two surveys carried out in 1970 (n = 2625) and 1992 (n = 20,055).

RESULTS

Over the last decades, median age at first intercourse has decreased by 4 years for women (22.0 in the 1930s vs. 17.6 in the 2000s) and 1 year for men (18.1 vs. 17.2). Lifetime number of sexual partners increased for women (1.8 in 1970 vs. 4.4 in 2006), but not for men (11.8 vs. 11.6). At the same time, the proportion of respondents, especially women, who reported nonpenetrative sexual practices and considered sexual intercourse essential to well being was on the increase. These changes are mainly attributed to an increase in women's social status. A marked increase in condom use was observed following the first AIDS/HIV prevention campaigns in the 1980s.

CONCLUSION

Public health interventions that are synergistic with trends in social norms are likely to be more effective than those that run counter to them. In France, sexual health and HIV prevention policies aimed at harm limitation appear to have chimed with secular trends. The evidence of greater diversification of sexual practices offers potential to increase the range of safer sex messages used in public health interventions.

Toxoplasmosis among pregnant women in France: risk factors and change of prevalence between 1995 and 2003

BACKGROUND

Congenital toxoplasmosis may affect any organ, produce severe complications such as hydrocephalus and lead to ocular lesions which can appear late after birth. Fetal outcome can be fatal. During pregnancy, the mother can become infected, particularly by eating undercooked meat or poorly washed raw fruits and vegetables. In France, prevention of congenital toxoplasmosis is based on serial serology tests, performed repeatedly until delivery for pregnant women who remain negative then at the first prenatal visit.

METHODS

We used toxoplasmosis serology data collected during national perinatal surveys conducted in 1995 and 2003 to estimate toxoplasmosis prevalence, assess risk factors and ascertain time trends in prevalence. In each survey, socioeconomic variables as well as the serological status for toxoplasmosis were collected for all pregnant women who had terminated a pregnancy during a given week period.

RESULTS

In 2003, 15,108 pregnant women were included; the prevalence of Toxoplasma infection was 43.8% (95% CI: 43.0-44.6). Prevalence increased with age and was greater for those who lived in the Southwest of France, the greater Paris area and in overseas districts. In 2003, as in 1995, prevalence increased with education level, occupational status of the household and number of pregnancies. Prevalence decreased 19% between 1995 and 2003. The decrease was significantly greater for pregnant women aged less than 30 years than for those aged more or equal to 30 years.

CONCLUSION

Although it decreased over time, toxoplasmosis prevalence remained higher in France than in other European countries. With more than one out of two women in France susceptible of having Toxoplasma infection, it is important to promote preventive measures to avoid infection during pregnancy.

French situation concerning the Swedish Chlamydia trachomatis variant

In 2006, a plasmid deletion mutant of Chlamydia trachomatis was identified in Sweden that can not be detected with those commercial tests targeting the deleted area. In order to study the spread of this strain in France, a laboratory-based surveillance system was set up by the National Reference Centre for Chlamydiae and the Institut de Veille Sanitaire. Among 1,141 C. trachomatis-positive specimens from all over France, the new variant was only detected in one case. This case was a non-French resident consulting a sexually transmitted infections clinic. Although the new variant does not seem to be established in France as yet, surveillance based on the testing of C. trachomatis-positive samples from all over France continues.

Rectal lymphogranuloma venereum surveillance in France 2004-2005

Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by Chlamydia trachomatis strains belonging to the L1, L2 or L3 genotype. An alert about an outbreak of LGV among MSM in the Netherlands was published in January 2004. The first cases of rectal LGV in France were retrospectively diagnosed in March 2004 and sentinel surveillance for LGV was implemented in April 2004. Most of the participating centres were located in the cities of Paris and Bordeaux. Only confirmed rectal LGV cases were included in the surveillance. Rectal specimens from men that were found to be positive for C trachomatis by PCR were sent to the National Reference Centre for Chlamydia infection for genotyping. Simple epidemiological data provided by clinicians and genotyping results were sent to the Institut de Veille Sanitaire (InVS) where data were anonymously recorded. A total of 328 C. trachomatis rectal strains isolated in men were genotyped by the end of December 2005. Of these, 244 (74%) were LGV strains belonging to the L2 genotype. No L1 or L3 C. trachomatis genotype was found. Diagnosis was made retrospectively for 46 cases. The median age of patients with LGV was 39 years. HIV status was known for 96 patients: 82/96 (85%) were HIV-infected. Most LGV cases were diagnosed in the Paris area (92%). Among the remaining 26% C. trachomatis strains, genotypes Da and G were the most frequent. As with syphilis in recent years, the emergence of LGV in Europe is mainly affecting HIV-infected MSM. The screening and treatment of STIs should be included in the clinical follow-up of all HIV-infected MSM.

Rectal lymphogranuloma venereum surveillance in France 2004-2005

Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI) caused by Chlamydia trachomatis strains belonging to the L1, L2 or L3 genotype. An alert about an outbreak of LGV among MSM in the Netherlands was published in January 2004. The first cases of rectal LGV in France were retrospectively diagnosed in March 2004 and sentinel surveillance for LGV was implemented in April 2004. Most of the participating centres were located in the cities of Paris and Bordeaux. Only confirmed rectal LGV cases were included in the surveillance. Rectal specimens from men that were found to be positive for C trachomatis by PCR were sent to the National Reference Centre for Chlamydia infection for genotyping. Simple epidemiological data provided by clinicians and genotyping results were sent to the Institut de Veille Sanitaire (InVS) where data were anonymously recorded. A total of 328 C. trachomatis rectal strains isolated in men were genotyped by the end of December 2005. Of these, 244 (74%) were LGV strains belonging to the L2 genotype. No L1 or L3 C. trachomatis genotype was found. Diagnosis was made retrospectively for 46 cases. The median age of patients with LGV was 39 years. HIV status was known for 96 patients: 82/96 (85%) were HIV-infected. Most LGV cases were diagnosed in the Paris area (92%). Among the remaining 26% C. trachomatis strains, genotypes Da and G were the most frequent. As with syphilis in recent years, the emergence of LGV in Europe is mainly affecting HIV-infected MSM. The screening and treatment of STIs should be included in the clinical follow-up of all HIV-infected MSM.

Surveillance of human listeriosis in France, 2001-2003

Mandatory notification of listeriosis began in France in 1999. Enhanced public health surveillance, including routine molecular characterisation of Listeria monocytogenes strains, epidemiologic follow up of cases, and collection of food samples, has improved the sensitivity of outbreak detection and response.

[An outbreak of appendectomies in La Désirade, Guadeloupe, August 1995-July 1996]

BACKGROUND

In October 1995, over 50 cases of appendectomies among the 1.605 residents of the island La Désirade (Guadeloupe) were reported by the only island clinician to the local health authority. We describe the outbreak investigations which were implemented in order to describe the phenomenon and generate hypotheses on its cause.

METHODS

An exhaustive case finding of residents having undergone appendectomy between 10 August 1995 and 22 July 1996 was conducted. We reviewed the medical charts of the cases; read pathology slides; interviewed cases and their families to retrieve detailed clinical history; studied the prevalence of markers of infection and of stool pathogens and analysed water supply quality data.

RESULTS

We identified 226 cases of appendectomy (14% of the island population), 40% in May-June 1996, 46% in males and 40% under 15 years of age. Clinical, biological and pathological findings were heterogeneous and did not support the hypothesis of an outbreak of appendicitis. The study of abdominal symptoms in the families of the cases did not support person to person transmission but revealed frequent, subacute or chronic abdominal complaints. The analysis of markers of infection or of stool bacteria and parasites in a self selected sample of the island population was not suggestive. Water supply did not show any bacterial or chemical contamination.

CONCLUSION

The investigation of a large outbreak of appendectomies was unable to find a single infectious or toxic origin to a high prevalence of chronic abdominal symptoms in an isolated population. An inappropriate medical answer in an isolated population probably turned heterogeneous complaints into an outbreak with major public health consequences.

Surveillance of human listeriosis in France, 2001-2003

Mandatory notification of listeriosis began in France in 1999. Enhanced public health surveillance, including routine molecular characterisation of Listeria monocytogenes strains, epidemiologic follow up of cases, and collection of food samples, has improved the sensitivity of outbreak detection and response. The incidence of listeriosis declined from 4.5 cases/million in 1999-2000 to approximately 3.5 cases/million during the period 2001-2003. Clinical, demographic and microbiological characteristics of listeriosis in France remained stable during this time period. Maternal-fetal infections accounted for 24% of all cases. Serovar 4b accounted for 49% of cases and 60% of case clusters. The incidence of listeriosis in France has declined and is now lower than in several other European countries.

Surveillance of listeria infections in Europe

In addition to the economic consequences and threats associated with outbreaks, listeriosis remains of great public health concern, as it has one of the highest case fatality rates of all the foodborne infections (20%-30%), and has common source epidemic potential. Changes in the way food is produced, distributed and stored have created the potential for diffuse and widespread outbreaks involving many countries. In 2002, a survey was carried out to assess the need for and the feasibility of a European network on listeria infections in humans. Data on surveillance systems and laboratory methods were collected through two postal surveys sent to the national Centres for communicable disease surveillance and to the listeria reference laboratories. Surveillance systems for listeria infections were in operation in 16 out of the 17 countries surveyed, and 16 countries had a national reference laboratory (NRL). All countries based their case definition of listeriosis on the isolation of Listeria monocytogenes. Fourteen NRLs performed at least one typing method on human strains. At least 13 countries already carried out or expressed willingness to carry out characterisation of isolates by pulsed field gel electrophoresis (PFGE) of L. monocytogenes strains isolated from human cases following a standard protocol. The participants concluded that there was a clear added value to having a European surveillance network for listeria infections, particularly for outbreak detection and investigation, and that a surveillance network based on the existing national surveillance systems was feasible.

Surveillance of listeria infections in Europe

In addition to the economic consequences and threats associated with outbreaks, listeriosis remains of great public health concern, as it has one of the highest case fatality rates of all the foodborne infections (20%-30%), and has common source epidemic potential. Changes in the way food is produced, distributed and stored have created the potential for diffuse and widespread outbreaks involving many countries. In 2002, a survey was carried out to assess the need for and the feasibility of a European network on listeria infections in humans. Data on surveillance systems and laboratory methods were collected through two postal surveys sent to the national Centres for communicable disease surveillance and to the listeria reference laboratories. Surveillance systems for listeria infections were in operation in 16 out of the 17 countries surveyed, and 16 countries had a national reference laboratory (NRL). All countries based their case definition of listeriosis on the isolation of Listeria monocytogenes. Fourteen NRLs performed at least one typing method on human strains. At least 13 countries already carried out or expressed willingness to carry out characterisation of isolates by pulsed field gel electrophoresis (PFGE) of L. monocytogenes strains isolated from human cases following a standard protocol. The participants concluded that there was a clear added value to having a European surveillance network for listeria infections, particularly for outbreak detection and investigation, and that a surveillance network based on the existing national surveillance systems was feasible.

L'épidémiologie des infections sexuellement transmissibles en France

BACKGROUND

Sexually transmitted infections (STI) in France are reported on a voluntary basis through several sentinel surveillance systems.

METHODS

To monitor STI, sentinel laboratory- or clinician-based surveillance systems were set up by the Institut de Veille Sanitaire: gonorrhea surveillance (Renago) in 1986, Chlamydia infections surveillance (Renachla) in 1989, and more recently, syphilis surveillance in 2000 and rectal lymphogranuloma venereum (LGV) in 2004.

RESULTS

From 2000 to 2003, 1,089 syphilis infections were reported. Most of the cases were diagnosed in men having sex with men (MSM) and were mainly reported by STI clinics located in the Paris area. From 1997 to 2000, an increase of gonorrhea was observed each year. After two years of stable trend, the prevalence of gonorrhea increased again in 2003. From 2002 to 2004, 123 LGV cases were diagnosed in France and were observed only in MSM. Since 2001, Chlamydia infections have steadily increased, particularly in women.

COMMENTS

Because STI surveillance is based on a voluntary basis, the number of reported cases is probably lower than the number of STI diagnosed in France. However, the data provided by the different surveillance systems reveals that STI have been increasing in France since 1997. Moreover, the resurgence of syphilis in 2000 and the emergence of rectal LGV in 2004 indicate that these STI occur mainly in MSM. Trends on incidence and patients characteristics observed in France are similar to those of several Europeans countries. European Public Health interventions are becoming necessary to prevent and control STI.

Gonorrhoea surveillance system in France: 1986-2000

OBJECTIVE

The objectives of this study were to monitor epidemiologic trends in Neisseria gonorrhoeae (NG) infections and to assess antimicrobial resistance patterns of NG.

METHODS

RENAGO, a voluntary-based laboratory surveillance system, including private and public laboratories, was set up in France in 1986. Every NG strain isolated by the participating laboratories was sent to the National Reference Center, Institut Alfred Fournier, Paris, where susceptibility to 6 antibiotics was tested. These laboratories reported monthly numbers of positive NG isolates and associated epidemiologic data. Because the number of laboratories varied every year, the average number of NG isolates per laboratory per year was computed to monitor annual trends in gonorrhea incidence.

RESULTS

The average number of NG isolated per laboratory per year decreased steadily from 10.6 in 1986 to 0.6 in 1997 but then yearly increased and reached 1.9 in 2000. Increasing gonorrhea was observed mostly in men and in the Paris area. The proportion of rectal strains increased significantly from 0.9% in 1986 to 9.2% in 2000. From 1998 to 2000, 5.3% of the isolates had reduced susceptibility or were resistant to ciprofloxacin, 7.3% were PPNG strains and 27.4% were resistant to tetracycline, 18.5% had a reduced susceptibility to thiamphenicol, and 1 strain was resistant to the latter. Neither strain was resistant to ceftriaxone or to spectinomycin.

CONCLUSION

From 1998 to 2000, gonorrhea markedly increased in France and seemed to affect mainly gay men in Paris, which suggests relapses to risky sexual behaviors and highlights the need for strengthening prevention. During the same period, NG ciprofloxacin resistance has sharply increased and should be carefully monitored because of the wide use of ciprofloxacin single-dose treatment.

Two consecutive nationwide outbreaks of Listeriosis in France, October 1999-February 2000

In France, listeriosis surveillance is based on mandatory notification of all culture-confirmed cases, with systematic typing of isolates and routine collection of the patient's food history. From October 1999 to March 2000, two outbreaks of listeriosis were detected through this enhanced surveillance system. In outbreak 1, analysis of the food histories of cases suggested brand X "rillettes," a pâté-like meat product, as the vehicle of infection, and the outbreak strain of Listeria monocytogenes was subsequently isolated from the incriminated rillettes. In outbreak 2, a case-control study showed that consumption of jellied pork tongue was strongly associated with infection with the outbreak strain (odds ratio = 75.5, 95% confidence interval: 4.7, 1,216.0). However, trace-back results did not permit incrimination of any particular manufacturer of jellied pork tongue, and the outbreak strain was not isolated from the incriminated food or from any production sites. Consumption of jellied pork tongue was discouraged on epidemiologic evidence alone. The consecutive occurrence of these two outbreaks confirms the epidemic potential of listeriosis, even in a context of decreasing incidence, and underlines the importance of timely case-reporting and systematic typing of human L. monocytogenes strains to allow early detection and separate investigation of different clusters.

The capacity of Porphyromonas gingivalis to multiply under iron-limiting conditions correlates with its pathogenicity in an animal model

Isolates of Porphyromonas gingivalis have various abilities to induce infections in an animal model. The hypothesis of this study was that pathogenic strains of P. gingivalis could multiply under iron-limiting conditions, while non-pathogenic strains could not. Three pathogenic strains (W50, W83, and ATCC 49417) grew to a final optical density (660 nm) > 2 in horse serum, while the growth of the 3 non-pathogenic strains (ATCC 33277, LB13D-2, and HW24D-1) was negligible. When an excess of hemin or ferric chloride was added to the serum, significant growth of the non-pathogenic strains occurred. Under iron-limiting conditions, the pathogenic strains of P. gingivalis had a much lower requirement for human iron-loaded transferrin and hemin than the non-pathogenic strains. Proteolytic degradation of transferrin, which may be associated with the release of iron, was not markedly different for pathogenic and non-pathogenic strains. In addition, no relationship could be established between the level of 55Fe uptake from 55Fe-transferrin and the pathogenicity of strains. Our study provided evidence that the ability of P. gingivalis to multiply in vitro under iron-limiting conditions may be correlated with its ability to induce infections in an animal model. Isolates of P. gingivalis possessing a low requirement for iron are likely to have a higher potential for initiating periodontal infections.

[Epidemiology of human Listeria infections in France]

Human listeriosis is a relatively rare but serious disease with case fatality rates between 20 and 30%. The majority of patients who have listeriosis present with meningitis or septicaemia. Listeriosis during pregnancy can lead to a congenital infection, neonatal sepsis and meningitis or foetal death. The main mode of transmission is through contaminated foods. The infection usually occurs sporadically but small outbreaks and even large epidemics have occurred in a large number of industrialised countries. During the last 10 years several Listeria monocytogenes control measures have been introduced and implemented at the retail level and in production for plants or foods potentially contaminated with Listeria monocytogenes. During this period the incidence of listeriosis decreased substantially and is at present estimated at 300-400 cases annually.

Effect of prevention measures on incidence of human listeriosis, France, 1987-1997

To assess the impact of preventive measures by the food industry, we analyzed food monitoring data as well as trends in the incidence of listeriosis estimated through three independent sources: the National Reference Center of Listeriosis; a laboratory-based active surveillance network; and two consecutive nationwide surveys of public hospital laboratories. From 1987 to 1997, the incidence of listeriosis decreased by an estimated 68%. A substantial reduction in the proportion of Listeria monocytogenes-contaminated products was observed at the retail level. The temporal relationship between prevention measures by the food industry, reduction in L. monocytogenes-contaminated foodstuffs, and reduction in listeriosis incidence suggests a causal relationship and indicates that a substantial part of the reduction in illness is related to prevention efforts.

The number of gonococcal infections identified by the RENAGO network is increasing

Surveillance of sexually transmitted infections (STIs) in France is based mainly on laboratory reporting, as STIs are not among the diseases notified by physicians. The network RENAGO (Reseau National du Gonocoque) was set up in 1986 to monitor national t

Risk factors for Toxoplasma infection in pregnancy: a case-control study in France

Each year an estimated 4900 cases of primary Toxoplasma infection occur in pregnant women in France, a country with a high prevalence. Since 1992 all pregnant women at risk of Toxoplasma infection have been required to undergo monthly serological testing. This case-control study, the first of its kind in France, was undertaken to identify risk factors for Toxoplasma infection during pregnancy, with a view to improving primary prevention among non-immune pregnant women. A total of 80 pregnant women who seroconverted to Toxoplasma were matched with 80 pregnant women who had repeatedly negative tests. The women were interviewed by telephone, using a standardized questionnaire, to determine socio-demographic characteristics, exposure to possible risk factors and the type of information on prevention received during pregnancy. The risk factors for Toxoplasma infection included in a multivariate analysis were poor hand hygiene (OR = 9.9; 95%CI: 0.8-125), consumption of undercooked beef (OR = 5.5; 95%CI: 1.1-27), having a pet cat (OR =4.5; 95%CI: 1.0-19.9), frequent consumption of raw vegetables outside the home (OR = 3.1; 95%,CI: 1.2-7.7) and consumption of undercooked lamb (OR = 3.1; 95%CI: 0.85-14). Receipt of documentary advice on prevention was associated with a lower risk of infection. Prevention campaigns among pregnant women in France could be improved and should focus on eating habits, hand hygiene and cats.

Surveillance of sexually transmitted diseases by laboratory networks in France

In France, most of sexually transmitted diseases (STDs) are diagnosed by clinicians in the private sector (general practitioners, gynaecologists, dermatologists who specialise in venereal disease, and urologists) but genitourinary medicine (GUM) clinics a

[Epidemiology of infectious endocarditis]

The incidence of infective endocarditis (20 to 160 cases per million inhabitants yearly) increases with age; it does not seem to be decreasing over time. There is no previously known heart disease in 30% of the patients, a native valve disease in 30 to 60%, a prosthetic valve in 15-20%. Streptococci remain the leading microorganisms. Digestive streptococci and staphylococci are increasing. Iatrogenic portals of entry are in progression. During the hospital stay, case fatality ratio varies from 13 to 20%. After endocarditis, the patient remains at risk of late cardiac surgery and of recurrence. Survival after 5 years is approximately 85%.

Listeriosis outbreak associated with the consumption of rillettes in France in 1993

An outbreak of listeriosis involving 38 patients occurred in France between 18 June and 5 October 1993. The epidemic clone was characterized by serovar 4b, phagovar 2671:108:312, and DNA macrorestriction patterns 12 and 13. Thirty-one case-patients were materno-neonatal patients and 7 patients were nonpregnant adults. Preliminary analysis of a case-control study implicated a pork product, rillettes, of a particular brand (odds ratio, 18; 95% confidence interval, 2.2-208) as the vehicle of infection. Rillettes is a ready-to-eat food prepared with ham meat cooked with grease. The implicated lots of rillettes were recalled in mid-August, and the French authorities issued a warning to the general public. Microbiologic analysis of unopened plastic cans of rillettes confirmed the results of the case-control study 3 weeks after the recall. Final analysis showed that the rillettes was the major vehicle of the outbreak but suggested that other brand A meat products could also have been involved.

Surveillance of meningococcal disease in France, 1990-1997

The surveillance of meningococcal disease in France is based on four complementary sources of data. 1. Meningococcal disease has been a notifiable disease since 1902. A case definition for surveillance was introduced in 1985, based on the isolation of Ne

Comparison of infective endocarditis in patients with and without previously recognized heart disease

In a consecutive series of patients with infective endocarditis, we compared the charts of 123 nonaddicted patients without previously known heart disease with those of 174 patients with native valve disease. The 2 groups were similar in age, sex, clinical findings, and mortality rates, but infective endocarditis was more often located on the aortic valve, more often due to Streptococcus bovis and enterococci in patients without previously known heart disease.

Listeriosis in 225 non-pregnant patients in 1992: clinical aspects and outcome in relation to predisposing conditions

Clinical information was collected on 225 cases of Listeria monocytogenes (LM) infection not associated with pregnancy occurring in France in 1992. Infections affected primarily men (62%) and persons over 65 years of age. Of the cases found, 81% occurred in persons with some underlying condition: 34% involved patients with severe immunosuppression; 37% were on dialysis or had diabetes mellitus, alcoholism, hepatic failure or malignancies without immunosuppressive therapy; and 10% had other underlying conditions not clearly associated with immunosuppression. The clinical presentation of listeriosis depended on the predisposing factors: in previously healthy adults central nervous system infection was the most frequent clinical form (80%), whereas the group characterized by severe immunosuppression or other immunosuppressive conditions tended to develop bacteraemia (52%). The rate of hospital-associated cases (11%) was lower than that reported in other countries. Mortality directly related to LM infection was 24%. Predisposing disease was the major prognostic factor. No fatal outcome was observed in the group of adults < 65 years old without underlying conditions. In summary, although classification based on the degree of alteration of T-cell-mediated immunity enables determination of the role of predisposing conditions in cases of listeriosis outside of pregnancy, clinical aspects and outcome of listeriosis vary within these groups and depend on the severity of each underlying disease.

Procedures associated with infective endocarditis in adults. A case control study

OBJECT

To assess the relative risk of infective endocarditis associated with various procedures and the protective efficacy of antibiotic prophylaxis by a case-control study.

BACKGROUND

Recommendations for the prevention of infective endocarditis are based on the hypothesis of a relationship between procedures and infective endocarditis which is supported by anecdotal reports and data from experimental models.

METHODS

Cases met the Von Reyn's diagnostic criteria modified with echocardiographic and macroscopic findings Controls were recruited from cardiology or medicinal wards. Cases (n = 171) and controls were matched as regards sex, age and underlying cardiac condition. They were requested to indicate all the medical, surgical or dental procedures within the previous 3 months. Among potential confounding factors, infectious episodes and skin wounds in the previous 3 months were reported. Antibiotic prophylaxis administration was documented for type, dosage, duration and administration schedule.

RESULTS

Cases significantly more frequently than controls had undergone at least one procedure (matched odds ratio, 1.6; 95% confidence interval, 1.01 to 2.53). Dental procedures considered as a whole were not associated with an increased risk, although scaling and root canal treatment showed a trend towards a higher risk of infective endocarditis (P = 0.065). Among non-dental procedures, only surgery appeared to be at risk (matched odds ratio, 4.7; 95% confidence interval, 1.02 to 22). Considering all procedures, the risk of infective endocarditis increased significantly with the number of procedures. While general co-morbid conditions did not differ between the two groups, cases significantly more frequently than controls had experienced an infectious episode or a skin wound. In multivariate analysis, only infectious episodes and skin wounds significantly increased the risk of infective endocarditis. Scaling was the only independent risk factor for viridans streptococcal infective endocarditis. The 46% protective efficacy of antibiotic prophylaxis was not significant.

CONCLUSIONS

Procedures do increase the risk of infective endocarditis. The interpretation of the apparent low risk associated with dental procedures may be as a result of the current practice of antibiotic prophylaxis. Our data suggest that surgery should be more clearly mentioned in future guidelines, and reemphasize that a rigorous treatment of any focal infection in cardiac patients is mandatory. From the efficacy rate of antibiotic prophylaxis,it can be estimated that the overall incidence of infective endocarditis might be reduced by 5 to 10% in France by appropriate use of antibiotic prophylaxis in cardiac patients.

[Invasive group A streptococcal infections in France]

OBJECTIVES

Following the recent report of necrosing fasciitis cases in Great Britain, we conducted a study of group A streptococci infections in France to evaluate the frequency and severity of the different clinical presentations, particularly necrosing fasciitis.

METHODS

Thirteen hospital laboratories were selected because of the large number of group A streptococci blood cultures they observed in 1993. The microbiologists in these hospitals, in relation with clinicians, identified 83 patients with a group A streptococci bacteraemia between January 1, 1993 and June 30, 1994.

RESULTS

Sixty-three percent of the patients had an underlying condition: 39% had a chronic general or local disease and 24% had severe immunodepression. The skin portal of entry was found for 70% of the cases. Patients were divided into 4 groups according to the clinical picture: there were 16 cases of streptococci shock syndrome, 13 with deep infections, 25 infections of soft tissue (including 3 cases of fasciitis) and 29 cases of isolated bacteraemia.

CONCLUSION

Overall, one-fourth of the patients died due to the streptococci infection, one-half of whom had a toxic shock syndrome. Mortality was correlated with age and health status, but also with the clinical presentation of the disease. Compared with former years, there was no increase in the number of group A streptococci infections, nor in the number of necrotizing fasciitis in France in 1993. However, streptococci shock syndrome is of particular importance because of its frequency and poor outcome.

Investigations related to the epidemic strain involved in the French listeriosis outbreak in 1992

Two hundred seventy-nine cases of human listeriosis (92 pregnancy-related cases and 187 non-pregnancy-related cases) caused by a serovar 4b and phagovar 2389:2425:3274:2671:47:108:340 strain were identified in France between March and December 1992. Epidemiological investigations included a case-control study (not described here) and microbiological analyses of foods. Results of the case-control study and characterization of food isolates identified pork tongue in jelly, a ready-to-eat meat product, as the major vehicle of this outbreak, and to a lesser extent, delicatessen products contaminated secondarily during handling in food stores. As far as serotyping, phage typing, DNA macrorestriction pattern analysis (obtained by pulsed-field gel electrophoresis [PFGE]), and ribotyping are concerned, this epidemic strain is phenotypically and genomically closely related to strains responsible for major outbreaks of listeriosis previously observed in Europe and North America. The epidemic strain sensu stricto as defined by PFGE (2/1/3) displayed the same serovar, phagovar, ribovar, and ApaI and NotI PFGE patterns as the epidemic strains from outbreaks in Switzerland, California, and Denmark, but it consistently showed differences in the SmaI PFGE profile. This information greatly contributed to the identification of the major food vehicle (pork tongue in jelly) and further allowed exclusion of other foods (cheese) as possible sources of this major listeriosis epidemic.

Characteristics of infective endocarditis in France in 1991. A 1-year survey

OBJECTIVE

To update data on incidence and characteristics of infective endocarditis in France.

BACKGROUND

Numerous studies have shown that the incidence and course of infective endocarditis remain stable in spite of advances in treatment and of prophylactic recommendations.

METHODS

A survey of all consecutive cases of infective endocarditis was conducted over 12 months in all the institutions of three French regions.

RESULTS

Data were collected from 415 cases of definite (32%), probable (53%), and possible (15%) infective endocarditis. The adjusted annual incidence was 24.3 cases per million inhabitants. Thirty-four percent of the patients had no previously known heart disease, 33% had native valve disease, 22% had a prosthetic valve, and 11% had miscellaneous underlying conditions. Infective endocarditis was located solely on the mitral valve in 39%, solely on the aortic valve in 36%, and on the tricuspid valve in 6%. Echocardiography showed a vegetation on the mitral valve in 39%, on the aortic valve in 29%, and on the tricuspid valve in 8%. The causal microorganism was identified in 92%; it was a Streptococcus in 58%, and a Staphylococcus in 23%. Twenty patients were intravenous drug users, and 45 had had a medical or a surgical procedure, which might be associated with the occurrence of infective endocarditis. During the first 2 months after admission, 24% of the patients underwent surgery, and 17% of all patients died.

CONCLUSIONS

Despite medical and surgical advances, infective endocarditis remains frequent and severe in France.

Surveillance of sexually transmitted diseases in France: recent trends and incidence

OBJECTIVE

To present recent trends in sexually transmitted diseases (STDs) in France and to estimate the gonorrhoea incidence in 1990.

METHODS

Trends were analysed from data of three surveillance systems: (1) STD clinics: number of diagnoses, (2) a sentinel voluntary General Practitioner (GP) network: mean number of acute male urethritis/week/GP, characteristics of the notified urethritis (age, presence of discharge, sexual orientation), (3) a sentinel voluntary laboratory network: mean number of gonorrhoea isolates/month/laboratory, characteristics of patients with positive isolates (sex, age, site of sampling) and of strains (PPNG and TRNG rates). To estimate the gonorrhoea incidence in France in 1990, results of a study held among a national sample of laboratories were used, combined with data from surveillance systems and specific studies.

RESULTS

Decreasing trends in gonorrhoea in STD clinics and in the laboratory network as well as in acute male urethritis in the GP network have been observed since implementation of the networks in 1985. The rate of PPNG strains has regularly increased in the laboratory network to reach 14% in 1991. Data suggest that the incidence in some acute non recurrent STDs could have increased among homo/bisexual men since 1988. Chlamydia trachomatis is now the most frequent diagnosis in STD clinics. Estimation of male gonorrhoea incidence rate in France in 1990 of 74/100,000 inhabitants (15-59 years) is consistent with figures observed in England and Wales, where the age distribution is very similar. On the other hand, the estimated female gonorrhoea incidence rate of 14/100,000, which concerns only microbiologically ascertained cases, is one third in France than that observed in England and Wales.

CONCLUSION

The consistency of the decreasing trends in gonorrhoea and acute male urethritis observed from the different networks reduces the possibility of a bias due to any change in notification or in prescription. Trends in Chlamydia trachomatis will be better appraised in the near future with the recent implementation of new systems. The French STD surveillance appears quite satisfactory for male infections and has been able to show a marked decrease in the incidence of some STDs in the last years. Surveillance of female STDs is to be improved, in terms of monitored diagnoses and selected health care facilities. Differences between the female gonorrhoea incidence rate observed in England and Wales and the one computed for France could be attributed to differences in contact tracing policies between the two countries or to differences in sexual lifestyles.

[Epidemiology of bacterial endocarditis in France in 1991]

In order to update our information about the incidence and demographic, microbiological and clinical characteristics of infective endocarditis (IE) in France, a 12 month long study was carried out in three regions: Ile de France, Rhône-Alpes and Lorraine. Four hundred and fifteen cases of IE were recensed: certain (32%), probable (53%) or possible (15%). The annual incidence was 24.3 per million. The average age was 56 +/- 19 years. There was no past history of cardiac disease in 34% of cases; 33% had native valvular heart disease and 22% had one or more valvular prostheses. The site of IE was mitral in 39%, aortic in 36%, tricuspid in 6% and other or multivalvular in 19% of cases. The causal microorganism was isolated in 92% of cases. It was a streptococcus in 58% of cases (S. viridans in 27%; group D streptococcus + enterococcus in 23%); a staphylococcus was isolated in 23% of cases (Staphylococcus Aureus in 18%) and another microorganism in 11% of cases. The presumed portal of entry was dental in 24%, gastro-intestinal in 13%, cutaneous in 6% and urinary in 4% of cases. Twenty patients were intravenous drug addicts. Forty-five patients had medical or surgical procedure. Twenty-four per cent of patients were operated during the first two months, 17% died during this period (15% of operated and 18% of non-operated patients). Despite the advances in antibiotic therapy and in cardiac surgical techniques, IE seems to be as common and as severe as ten years ago.(ABSTRACT TRUNCATED AT 250 WORDS)