Excess mortality in Europe coincides with peaks of COVID-19, influenza and respiratory syncytial virus (RSV), November 2023 to February 2024

Since the end of November 2023, the European Mortality Monitoring Network (EuroMOMO) has observed excess mortality in Europe. During weeks 48 2023-6 2024, preliminary results show a substantially increased rate of 95.3 (95% CI:  91.7-98.9) excess all-cause deaths per 100,000 person-years for all ages. This excess mortality is seen in adults aged 45 years and older, and coincides with widespread presence of COVID-19, influenza and respiratory syncytial virus (RSV) observed in many European countries during the 2023/24 winter season.

Monitoring the reproductive number of COVID-19 in France: Comparative estimates from three datasets

BACKGROUND

The effective reproduction number (Rt) quantifies the average number of secondary cases caused by one person with an infectious disease. Near-real-time monitoring of Rt during an outbreak is a major indicator used to monitor changes in disease transmission and assess the effectiveness of interventions. The estimation of Rt usually requires the identification of infected cases in the population, which can prove challenging with the available data, especially when asymptomatic people or with mild symptoms are not usually screened. The purpose of this study was to perform sensitivity analysis of Rt estimates for COVID-19 surveillance in France based on three data sources with different sensitivities and specificities for identifying infected cases.

METHODS

We applied a statistical method developed by Cori et al. to estimate Rt using (1) confirmed cases identified from positive virological tests in the population, (2) suspected cases recorded by a national network of emergency departments, and (3) COVID-19 hospital admissions recorded by a national administrative system to manage hospital organization.

RESULTS

Rt estimates in France from May 27, 2020, to August 12, 2022, showed similar temporal trends regardless of the dataset. Estimates based on the daily number of confirmed cases provided an earlier signal than the two other sources, with an average lag of 3 and 6 days for estimates based on emergency department visits and hospital admissions, respectively.

CONCLUSION

The COVID-19 experience confirmed that monitoring temporal changes in Rt was a key indicator to help the public health authorities control the outbreak in real time. However, gaining access to data on all infected people in the population in order to estimate Rt is not straightforward in practice. As this analysis has shown, the opportunity to use more readily available data to estimate Rt trends, provided that it is highly correlated with the spread of infection, provides a practical solution for monitoring the COVID-19 pandemic and indeed any other epidemic.

Place of death in France: impact of the first wave (March-May 2020) of the Covid-19 epidemic

BACKGROUND

The Covid-19 epidemic entailed a major public health issue in France challenging the efficiency of the public health system. The distribution of deaths by place in France may have been affected by the epidemic and mitigation actions. This article presents mortality rate ratios by place of death in France during the first lockdown (17 March - 10 May, 2020) of the Covid-19 epidemic.

METHODS

We considered five places of death recorded in death certificates. Deaths in 2020 were compared to deaths from 2015 to 2019. We employed quasi-Poisson regressions in order to stablish mortality rate ratios (MRR) during the Covid-19 epidemic, for all-cause and non-Covid-19 deaths. Analysis was conducted in Metropolitan France, and for three groups of regions defined according to the intensity of the first COVID-19 epidemic wave.

RESULTS

A significant increase in all-cause and non-COVID-19 mortality at home was observed for all age groups. Also, an increase in mortality was observed in nursing homes, mostly due to Covid-19. Non-covid-19 mortality in public hospitals decreased significantly in all the country. These trends were mainly observed for cancers.

CONCLUSIONS

Overall mortality increased during the first wave of the Covid-19 epidemic. Most Covid-19 deaths took place in public hospitals and nursing homes at old ages. There was a displacement of non-Covid-19 mortality from public hospitals to home and nursing homes, particularly in the most highly exposed area. Among hypotheses to explain such a displacement, population avoidance of hospital care, or redeployment of hospital activity in this emergent context can be cited. Further analysis is needed to understand the reasons of the increase in non-Covid-19 mortality in nursing homes and at home.

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

AIMS

Mitigation actions during the COVID-19 pandemic may impact mental health and suicide in general populations. We aimed to analyse the evolution in suicide deaths from 2020 to March 2022 in France.

METHODS

Using free-text medical causes in death certificates, we built an algorithm, which aimed to identify suicide deaths. We measured its retrospective performances by comparing suicide deaths identified using the algorithm with deaths which had either a Tenth revision of the International Classification of Diseases (ICD-10) code for 'intentional self-harm' or for 'external cause of undetermined intent' as the underlying cause. The number of suicide deaths from January 2020 to March 2022 was then compared with the expected number estimated using a generalized additive model. The difference and the ratio between the observed and expected number of suicide deaths were calculated on the three lockdown periods and for periods between lockdowns and after the third one. The analysis was stratified by age group and gender.

RESULTS

The free-text algorithm demonstrated high performances. From January 2020 to mid-2021, suicide mortality declined during France's three lockdowns, particularly in men. During the periods between and after the two first lockdowns, suicide mortality remained comparable to the expected values, except for men over 85 years old and in 65-84 year-old age group, where a small number of excess deaths was observed in the weeks following the end of first lockdown, and for men aged 45-64 years old, where the decline continued after the second lockdown ended. After the third lockdown until March 2022, an increase in suicide mortality was observed in 18-24 year-old age group for both genders and in men aged 65-84 years old, while a decrease was observed in the 25-44 year-old age group.

CONCLUSIONS

This study highlighted the absence of an increase in suicide mortality during France's COVID-19 pandemic and a substantial decline during lockdown periods, something already observed in other countries. The increase in suicide mortality observed in 18-24 year-old age group and in men aged 65-84 years old from mid-2021 to March 2022 suggests a prolonged impact of COVID-19 on mental health, also described on self-harm hospitalizations and emergency department's attendances in France. Further studies are required to explain the factors for this change. Reactive monitoring of suicide mortality needs to be continued since mental health consequences and the increase in suicide mortality may be continued in the future with the international context.

Direct impact of COVID-19 by estimating disability-adjusted life years at national level in France in 2020

BACKGROUND

The World Health Organization declared a pandemic of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), on March 11, 2020. The standardized approach of disability-adjusted life years (DALYs) allows for quantifying the combined impact of morbidity and mortality of diseases and injuries. The main objective of this study was to estimate the direct impact of COVID-19 in France in 2020, using DALYs to combine the population health impact of infection fatalities, acute symptomatic infections and their post-acute consequences, in 28 days (baseline) up to 140 days, following the initial infection.

METHODS

National mortality, COVID-19 screening, and hospital admission data were used to calculate DALYs based on the European Burden of Disease Network consensus disease model. Scenario analyses were performed by varying the number of symptomatic cases and duration of symptoms up to a maximum of 140 days, defining COVID-19 deaths using the underlying, and associated, cause of death.

RESULTS

In 2020, the estimated DALYs due to COVID-19 in France were 990 710 (1472 per 100 000), with 99% of burden due to mortality (982 531 years of life lost, YLL) and 1% due to morbidity (8179 years lived with disability, YLD), following the initial infection. The contribution of YLD reached 375%, assuming the duration of 140 days of post-acute consequences of COVID-19. Post-acute consequences contributed to 49% of the total morbidity burden. The contribution of YLD due to acute symptomatic infections among people younger than 70 years was higher (67%) than among people aged 70 years and above (33%). YLL among people aged 70 years and above, contributed to 74% of the total YLL.

CONCLUSIONS

COVID-19 had a substantial impact on population health in France in 2020. The majority of population health loss was due to mortality. Men had higher population health loss due to COVID-19 than women. Post-acute consequences of COVID-19 had a large contribution to the YLD component of the disease burden, even when we assume the shortest duration of 28 days, long COVID burden is large. Further research is recommended to assess the impact of health inequalities associated with these estimates.

Monitoring the reproduction number of COVID-19 in France: estimates compared from 3 datasets

Background

The effective reproduction number (Rt) represents the average number of secondary cases generated by an infected person. During an outbreak, near-real-time monitoring of Rt constitutes a key indicator for detecting changes in disease transmission and assessing the effectiveness of interventions. The estimation of Rt usually requires identifying infected cases in the population which is in practice challenging from available data. The purpose of this study was to compare Rt estimates for COVID-19 surveillance in France based on three data sources of different sensitivity and specificity for identifying infected cases.

Methods

By applying a statistical method developed by Cori et al., we estimated Rt using (1) confirmed cases identified from positive virological tests among the tested population (2) suspected cases recorded by a national network of emergency departments (3) hospital admissions for COVID-19 recorded by a national administrative system to manage hospital's organization.

Results

From June 2020 to March 2022, the estimates of Rt in France showed similar temporal trends regardless of the dataset. Estimates based on the daily number of confirmed cases provided an earlier signal that the two other sources, with a lag of 3 and 6 days compared to estimates based on emergency department visits and hospital admissions, respectively.

Conclusions

The COVID-19 experience has proven that monitoring temporal changes in Rt was a key indicator to help public health authorities controlling the outbreak in real time. Having data on infected people in the population to estimate the Rt is not straightforward in practice. As this study has shown, the opportunity of using more readily available data, provided that it is highly correlated with the spread of infection, gives a practical solution for monitoring the COVID-19 epidemic and any epidemic in general.

Key messages

• The effective reproduction number (Rt) is a key parameter to monitor transmission during epidemics but its estimation from available data is often a critical issue.

• Based on COVID-19 experience, data sufficiently correlated with the spread of infection may be appropriate to estimate Rt and monitor its temporal trend.

Non-COVID activity in French emergency department during COVID-19 pandemic (March 2020 to March 2022)

Background

The COVID-19 epidemic and mitigation actions had major impacts on health and healthcare use by the French population. Since 2004, the French public health agency daily collects individual data of visits in the emergency departments (ED) OSCOUR® network (94% of national visits in 2022). We aimed to analyse the evolution of non-Covid ED visits from 2020 to March 2022, in order to identify potential indirect impact of the epidemic.

Methods

The main medical diagnosis (MD) coded in ICD-10 from each ED visit from 2017 to March 2022 was classified into 17 ICD-10 chapters and in 95 disjoint subgroups of pathologies. The observed numbers of ED visits by age group and by chapters/subgroups were compared to expected numbers, estimated using an overdispersed Poisson regression model based on 2017-2019 data.

Results

The observed numbers of ED visits for all chapters and for a large part of subgroups were significantly lower than the expected numbers during the three lockdowns in all age groups and progressively returned to the expected level in 2021. A change in the pattern of a limited list of subgroups was observed: ED visits for purpura, chronic blood diseases and neurologic disorders in children decreased during the first lockdown and remained under the expected level until March 2022. Inversely the number of ED visits for mental health and wheezing in children, for pulmonary embolism in adults and for neoplams in the elderly increased and remained over the expected values until 2022.

Conclusions

Syndromic ED system was a pillar of the French reactive surveillance of direct and indirect impacts of COVID-19 epidemic. The changes observed for different subgroups of pathologies may reflect a negative impact of the epidemic, a positive effect of protective measures on the spread of other infectious diseases, a modification in the organization or in the use of health care in specific domains. Further studies using hospitalization data could explore these hypotheses.

Key messages

• Existing syndromic surveillance system implemented before the emergence of SARS-COV2 enabled to monitor non-Covid-19 visits to emergency departments and assess changes in patterns of pathologies.

• An increase in the number of emergency department visits during the COVID-19 epidemic was observed for mental health in children, for pulmonary embolism in adults and for neoplams in the elderly.

Reactive surveillance of suicides during the COVID-19 epidemic in France, 2020- March 2022

Background

Mitigation actions during the COVID-19 pandemic, in particular lockdowns and curfews, may impact mental health and suicide in general populations. We aimed to analyse the evolution in suicide deaths from January 2020 to March 2022 in France.

Methods

Using free-text medical causes in death certificates, we built an algorithm, which aimed to identify suicide deaths. We measured its retrospective performances by comparing suicide deaths identified using the algorithm with deaths which had either an ICD10 code for ‘intentional self-harm’ or for ‘external cause of undetermined intent’ as underlying cause. The number of suicide deaths from January 2020 to November 2021 was then compared with the expected number estimated using a generalized additive model. The analysis was stratified by age group and gender. Analysis from December 2021 to March 2022 was conducted using electronic death certificates only.

Results

The free-text algorithm demonstrated high performances. From January 2020 to November 2021, suicide mortality declined during France's three lockdowns, particularly in men, and remained quite comparable with expected values between and after both of the country's lockdowns. Provisional results based on electronic death certificates suggest that suicide mortality remained stable until March 2022.

Conclusions

Monitoring suicide mortality is possible in France with a 4-month delay; this will be reduced to two days when electronic death certification is fully deployed. This study highlighted the absence of an increase in suicide mortality during France's COVID-19 pandemic, and a substantial decline during lockdowns periods, something already observed in other countries. Further studies are required to explain the factors for this decline.

Key messages

• In the absence of reactive coding of medical causes of deaths, the study proposed an approach to reactively identify suicide based on free-text medical causes from death certificates.

• Our findings provide reassurance that the COVID-19 pandemic has not had a negative impact on the general population in terms of suicide in France from March 2020 to September 2021.

107 - La surveillance syndromique de l’épidémie de COVID-19 en France de mars 2020 à octobre 2021

Contexte

Depuis l’émergence de la COVID-19 en France, quatre vagues épidémiques ont été observées entre fin janvier 2020 et octobre 2021. Crée en 2004, le système de surveillance syndromique SurSaUD® a été l'un des premiers utilisés pour la surveillance populationnelle de la COVID-19 en France. Il collecte quotidiennement les données de morbidité (SOS Médecins et Oscour®) et de mortalité. Cette étude présente les principaux résultats de cette surveillance au cours des quatre vagues épidémiques en France (mars 2020 et octobre 2021).

Méthodes

En 2021, 62 sur 63 associations SOS Médecins et près de 700 services d'urgences du réseau Oscour® (93 % au niveau national) transmettaient quotidiennement leurs données d'activité à Santé publique France. Les recours pour COVID-19 ont été identifiés avec les codes diagnostiques suivants: U07.1 et U07.1.0 chez SOS Médecins; U07.1, U07.10, U07.11, U07.12, U07.14, B342, B97.2 et U04.9 chez Oscour®. Le nombre hebdomadaire de recours et leur proportion dans l'activité totale des différents réseaux ainsi que la proportion d'hospitalisation après passage aux urgences ont été analysés par âge et sexe.

Résultats

Au total, 253 803 actes SOS Médecins et 571 294 passages aux urgences pour suspicion de COVID-19 ont été enregistrés sur la période d’étude. La première vague était la plus intense et la plus brève avec le pic le plus élevé pour les deux réseaux en S13-2020 (12 177 actes et 23,2 % d'activité chez SOS Médecins; 34 085 passages et 20,3 % de part d’’activité aux urgences). Près d'un passage pour COVID-19 sur deux a été suivi d'une hospitalisation (271 730 hospitalisations). On observait également un impact de l’épidémie différent selon l’âge et le sexe.

Discussion/Conclusion

Les données issues de SurSaUD® sont analysées quotidiennement pour apprécier l’évolution de l’épidémie. Les indicateurs produits sont communiqués chaque jour aux autorités sanitaires et au grand public.

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

108 - Surveillance nationale des conduites suicidaires et autres troubles de santé mentale pendant la crise de la COVID-19

Contexte

L'impact de l’épidémie de COVID-19 sur la santé mentale de la population a rapidement été mis en évidence dans la littérature scientifique internationale. A partir de novembre 2020, des signaux émanant des professionnels de la psychiatrie ont alerté sur une possible hausse des conduites suicidaires, notamment chez les enfants.

Méthodes

A partir des résumés de passages aux urgences (RPU) du réseau OSCOUR® (93 % des passages nationaux), disponibles quotidiennement et sur plusieurs années d'historique, les passages en lien avec la santé mentale, dont les conduites suicidaires et les troubles dépressifs ont été étudiés. Les analyses ont été réalisées sur la période 2020-2021 en comparaison aux années 2018-2019, pour six classes d’âges dont les 11-14 ans, les 15-17 ans et les 18-24 ans.

Résultats

L'analyse des passages aux urgences en 2020, ne montrait aucune augmentation des passages pour geste suicidaire. En revanche, on observait chez les enfants de 11-17 ans, une augmentation des tableaux dépressifs à partir de mi-septembre 2020 qui s'intensifiait dès 2021 (+60 % entre S01 et S47-2021 par rapport à 2018-2019). Dès janvier 2021, une hausse des passages pour idées et gestes suicidaires était également observée, chez les 11-17 ans (respectivement +126 % et +35 % entre S01 et S47-2021) et les 18-24 ans (+95 % et +22 % resp.). Parmi les 11-17 ans, les 11-14 ans étaient les plus impactés sur l'ensemble de ces indicateurs. Aucune augmentation marquée n’était observée chez les adultes.

Discussion/Conclusion

La surveillance mise en place dès début 2020 montre un impact majeur de la crise sanitaire sur la santé mentale de la population, en particulier chez les adolescents. Ces résultats ont conduit Santé publique France et ses partenaires à lancer une campagne nationale d'information sur la santé mentale à destination de ce public « En parler c'est déjà se soigner » et à renforcer la surveillance mise en place.

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

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

Background

The French syndromic surveillance (SyS) system, SurSaUD^®, was one of the systems used to monitor the COVID-19 outbreak.

Aim

This study described the epidemiological characteristics of COVID-19-related visits to both emergency departments (EDs) and the network of emergency general practitioners known as SOS Médecins (SOSMed) in France from 17 February to 28 June 2020.

Methods

Data on all visits to 634 EDs and 60 SOSMed associations were collected daily. COVID-19-related visits were identified using ICD-10 codes after coding recommendations were sent to all ED and SOSMed doctors. The time course of COVID-19-related visits was described by age group and region. During the lockdown period, the characteristics of ED and SOSMed visits and hospitalisations after visits were described by age group and gender. The most frequent diagnoses associated with COVID-19-related visits were analysed.

Results

COVID-19 SyS was implemented on 29 February and 4 March for EDs and SOSMed, respectively. A total of 170,113 ED and 59,087 SOSMed visits relating to COVID-19 were recorded, representing 4.0% and 5.6% of the overall coded activity with a peak in late March representing 22.5% and 25% of all ED and SOSMed visits, respectively. COVID-19-related visits were most frequently reported for women and those aged 15–64 years, although patients who were subsequently hospitalised were more often men and persons aged 65 years and older.

Conclusion

SyS allowed for population health monitoring of the COVID-19 epidemic in France. As SyS has more than 15 years of historical data with high quality and reliability, it was considered sufficiently robust to contribute to defining the post-lockdown strategy.

Did the COVID-19 pandemic impact population’s mental health?

Background

Sanitary, societal and economic effects due to the COVID-19 pandemic could lead to an impact on population's mental health. Santé publique France (SpF), the French public health agency set up a specific monitoring based on emergency department (ED) and GP's associations (GPs) SOS Médecins (SOSMed) data to early assess the impact of COVID-19 pandemic on mental health.

Methods

Since 2004, SpF daily collects data from ED participating to the OSCOUR® network (93% of French emergency attendances) and from SOSMed network. For both data sources, visits for several mental health disorders were analyzed for different age groups in 2020 and 2021 (until Week 16) and compared to years 2018 and 2019 (mean) with a focus on the two lockdown periods (resp W11 to W19-2020 and W45 to W51-2020)

Results

During the first lockdown period, while a major decrease of all-cause activity was observed in both networks, the number of SOSMed visits for anxiety increased in adults with a peak of + 115% in W13-2020 compared to 2018-19 and remained higher than the 2 previous years until W12-2021. An increase in ED visits for mood disorders (including depression) for children (especially 11-17yo) were also observed from W36 (back to school) and reinforced at the beginning of the 2nd lockdown period to reach +111% in W12-2021 compared to 2018-19. 11-17yo children were also concerned by an increase in ED visits for suicide ideation since W36 (peak of + 170% in W12-2021) and suicide attempt from W04-2021 to W12-2021 (peaks of + 45% and +41% in W05 and W10-2021).

Discussion

ED and SOSMed visits are the most reactive data sources to assess the impact of COVID-19 pandemic on the mental health of French population. These results confirm that the impact concerns all age groups. For children, the condition seems to worsen in 2021 and highlight the need of a close follow-up of the situation and the reinforcement of preventive measures in order to prevent long-term impacts.

Key messages

Results confirm an impact of COVID-19 pandemic on populations mental health.

Impact of COVID-19 on mental health: a long-term issue for children?

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

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

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

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

Evaluation of the French reactive mortality surveillance system supporting decision making

BACKGROUND

In France, a mortality syndromic surveillance system was set up with objectives of early detection and reactive evaluation of the impact of expected and unexpected events to support decision makers. This study aims to describe the characteristics of the system and its usefulness for decision makers.

METHODS

Anonymized data from the administrative part of death certificates were daily collected from 3062 computerized city halls and were transmitted to Santé publique France in routine. Coverage of the system was measured as the proportion of deaths registered by the system among the complete number of deaths and analyzed by age, month and region. Deaths were described by gender, age and geographical level using proportion. The excess periods of deaths were described based on the comparison of the weekly observed and expected numbers of deaths between 2012 and 2016.

RESULTS

The system recorded 77.5% of the national mortality covering the whole territory. About 81% of deaths were aged 65 years old and more. The surveillance system identified mortality variations mainly during winter and summer, for some concomitant with influenza epidemic or heatwave period, and thus provided information for decision makers.

CONCLUSION

The ability of the system to detect and follow mortality outbreaks in routine in the whole territory has been demonstrated. It is a useful tool to provide early evaluation of the impact of threats on mortality and alert decision makers to adapt control measures. However, the absence of information on medical causes of death may limit the ability to target recommendations.

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

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

Public Health Tracking to address the complexity of environmental health: The case of France

To address the complex relationship between environment and health, public-health professionals have recognized the benefits of building enduring interdisciplinary partnerships and of developing innovative Environmental and Public Health Tracking (EPHT) systems. In specific, EPHT can increase understanding of environmental health threats; improve comparability of risks between different areas of the world; enable transparency and trust among citizens and institutions; and inform preventive decision making. EPHT does so by sharing data and knowledge; and by identifying and supporting best practices.

In France, the concept of EPHT builds on the observation that our changing environment creates new risks that require both specific surveillance of the link between exposure and health indicators, and syndromic surveillance (SyS) of sentinel health indicators. A specific surveillance of air pollution and health has been informing French policies on air pollution for 23 years. France has also coordinated the European Apheis and Aphekom specific-surveillance projects. Using routine pollution and health data, these projects succeeded by being built on a Europe-wide collaborative network that facilitates decision-making on local and national levels.

In addition, since the 2003 heat wave France has developed syndromic surveillance for detecting the health impacts of new threats as diverse as environmental phenomena and emerging infectious diseases. France also coordinated the Triple-S project, which inventoried SyS activities in Europe; and produced guidelines for human and veterinary SyS in Member States and a proposal for a European SyS strategy. Examples of the complementarity between specific and SyS in environmental health in France include: heat and cold waves, air pollution, flooding, storms and industrial accidents. In today's world of open data, EPHT shows great promise for contributing to better informing decision makers and the population on environmental-health risks.

Key messages

Environmental and Public Health Tracking (EPHT) systems and enduring interdisciplinary partnerships provide an innovative way to address the complex relationship between environment and health. France has been in the forefront of applying innovative EPHT (Environmental and Public Health Tracking) by using complementary specific and syndromic (SyS) surveillance systems.

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

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

Description of low back pain attendances in French ED

Background

Low back pain (LBP) is one of the leading contributors to disease burden worldwide [1]. In 2018, French health care insurance launched a population awareness campaign in order to promote effective behaviour change in France. Because LBP acute episodes often lead to emergency visits, Santé publique France, the French Public Health Agency and the Federation of Observatories for Emergency Medecine, performed a pre-campaign situational analysis of LBP in the French emergency department (ED) involved in the OSCOUR® network.

Methods

The OSCOUR network is part of the French syndromic surveillance system SurSaUD® [2] coordinated by Santé publique France since 2004. In 2017, the system collects daily individual data from about 700 ED representing 92% of the French ED attendances. Those data contain demographic, administrative and medical information including discharge diagnosis coded according ICD-10. ED attendances with a diagnosis related to LBP were analyzed from 2014 to 2017. Temporal distribution of LBP attendances, hospitalizations after discharge and stay duration in ED services were also analyzed.

Results

From 2014 to 2017, 504 ED were included in the analysis and LBP represented 1.12% (N = 481,291) of ED all visits. This proportion remained stable over the period. 60% of LBP attendances concerned 18 to 50 years old adults and almost 10% were hospitalized after discharge. This proportion increased with age to reach 43% for the 85 years old and more. LBP attendances were more frequent on Monday. Median stay duration were almost 3 hours but increased with age and for hospitalized patients.

Conclusions

The broad coverage of the ED OSCOUR® network on the whole territory and the strong partnership between epidemiologists and clinicians enable Santé publique France to produce reliable results which are also consistent with ED physician’s perception. Finally those results can be used as a reference contributing to evaluate potential benefits of this campaign.

Key messages

This description of low back pain ED attendances is consistent with emergency physicians perception on field and can be used as a reference to evaluate potential benefits of the prevention campaign. The national coverage of the ED OSCOUR® network and the strong partnership with emergency physicians enable Santé publique France to produce relevant description on the main causes of ED attendances.

Alcohol-related attendances in French emergency departments in 2017

Background

France is one of the leading countries in terms of daily alcohol consumption per inhabitant. Alcohol is a major concern for emergency department (ED) since it accounts for a large part of their resources and increases behavior problems resulting in violence against staff. Individual information of French ED attendances registered in OSCOUR network are daily collected by Santé publique France, the French Public Health Agency. This study aims at describing alcohol-related ED attendances (ARA) in 2017 in France.

Methods

The OSCOUR network included 677 ED in 2017 recording 92% of national attendances. ARA were identified through the main and associated medical diagnoses coded by physicians using ICD10. The study considered acute alcohol intoxication, dependence syndrome/withdrawal state, other mental disorders and intoxications due to alcohol, chronic complications and intentional self-poisoning by alcohol. The number of ARA was analyzed by age group, gender and region.

Results

1.4% of total attendances were associated to alcohol consumption (202,184 attendances) in 2017. 68% of ARA were due to acute alcohol intoxication and 14% for dependence syndrome/withdrawal state. The highest proportions of ARA were observed for people aged 40-59 yo and 18-24 yo, particularly for women. Regions of North and West metropolitan France and La Réunion Island had the highest proportion of ARA among the total number of attendances.

Conclusions

The part of ARA in France is consistent with figures provided in international studies using similar data. This proportion is similar with proportion of major public health issues like influenza, that represented 1% of the total ED attendances from November 2016 to February 2017 and reached 1.8% in January (month of the epidemic peak). Consequences of alcohol use represent a heavy burden for ED and the health system in France. This is all the more true as ARA are underestimated due to the low coding rate of associated medical diagnosis in ED.

Key messages

1.4% of total French ED attendances were associated to alcohol consumption in 2017. This proportion is close to the proportion of influenza attendances in ED.

A New Approach to Compare the Performance of Two Classification Methods of Causes of Death for Timely Surveillance in France

Timely mortality surveillance in France is based on the monitoring of electronic death certificates to provide information to health authorities. This study aims to analyze the performance of a rule-based and a supervised machine learning method to classify medical causes of death into 60 mortality syndromic groups (MSGs). Performance was first measured on a test set. Then we compared the trends of the monthly numbers of deaths classified into MSGs from 2012 to 2016 using both methods. Among the 60 MSGs, 31 achieved recall and precision over 0.95 for either one or the other method on the test set. On the whole dataset, the correlation coefficient of the monthly numbers of deaths obtained by the two methods were close to 1 for 21 of the 31 MSGs. This approach is useful for analyzing a large number of categories or when annotated resources are limited.

Automatic classification of free-text medical causes from death certificates for reactive mortality surveillance in France

BACKGROUND

Mortality surveillance is of fundamental importance to public health surveillance. The real-time recording of death certificates, thanks to Electronic Death Registration System (EDRS), provides valuable data for reactive mortality surveillance based on medical causes of death in free-text format. Reactive mortality surveillance is based on the monitoring of mortality syndromic groups (MSGs). An MSG is a cluster of medical causes of death (pathologies, syndromes or symptoms) that meets the objectives of early detection and impact assessment of public health events. The aim of this study is to implement and measure the performance of a rule-based method and two supervised models for automatic free-text cause of death classification from death certificates in order to implement them for routine surveillance.

METHOD

A rule-based method was implemented using four processing steps: standardization rules, splitting causes of death using delimiters, spelling corrections and dictionary projection. A supervised machine learning method using a linear Support Vector Machine (SVM) classifier was also implemented. Two models were produced using different features (SVM1 based solely on surface features and SVM2 combining surface features and MSGs classified by the rule-based method as feature vectors). The evaluation was conducted using an annotated subset of electronic death certificates received between 2012 and 2016. Classification performance was evaluated on seven MSGs (Influenza, Low respiratory diseases, Asphyxia/abnormal respiration, Acute respiratory disease, Sepsis, Chronic digestive diseases, and Chronic endocrine diseases).

RESULTS

The rule-based method and the SVM2 model displayed a high performance with F-measures over 0.94 for all MSGs. Precision and recall were slightly higher for the rule-based method and the SVM2 model. An error-analysis shows that errors were not specific to an MSG.

CONCLUSION

The high performance of the rule-based method and SVM2 model will allow us to set-up a reactive mortality surveillance system based on free-text death certificates. This surveillance will be an added-value for public health decision making.

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

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

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

INTRODUCTION

Poor air quality (AQ) is a global public health issue and AQ events can span across countries. Using emergency department (ED) syndromic surveillance from England and France, we describe changes in human health indicators during periods of particularly poor AQ in London and Paris during 2014.

METHODS

Using daily AQ data for 2014, we identified three periods of poor AQ affecting both London and Paris. Anonymised near real-time ED attendance syndromic surveillance data from EDs across England and France were used to monitor the health impact of poor AQ.Using the routine English syndromic surveillance detection methods, increases in selected ED syndromic indicators (asthma, difficulty breathing and myocardial ischaemia), in total and by age, were identified and compared with periods of poor AQ in each city. Retrospective Wilcoxon-Mann-Whitney tests were used to identify significant increases in ED attendance data on days with (and up to 3 days following) poor AQ.

RESULTS

Almost 1.5 million ED attendances were recorded during the study period (27 February 2014 to 1 October 2014). Significant increases in ED attendances for asthma were identified around periods of poor AQ in both cities, especially in children (aged 0-14 years). Some variation was seen in Paris with a rapid increase during the first AQ period in asthma attendances among children (aged 0-14 years), whereas during the second period the increase was greater in adults.

DISCUSSION

This work demonstrates the public health value of syndromic surveillance during air pollution incidents. There is potential for further cross-border harmonisation to provide Europe-wide early alerting to health impacts and improve future public health messaging to healthcare services to provide warning of increases in demand.

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

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

Excess all-cause and influenza-attributable mortality in Europe, December 2016 to February 2017

Since December 2016, excess all-cause mortality was observed in many European countries, especially among people aged ≥ 65 years. We estimated all-cause and influenza-attributable mortality in 19 European countries/regions. Excess mortality was primarily explained by circulation of influenza virus A(H3N2). Cold weather snaps contributed in some countries. The pattern was similar to the last major influenza A(H3N2) season in 2014/15 in Europe, although starting earlier in line with the early influenza season start.

Success Factors of European Syndromic Surveillance Systems: A Worked Example of Applying Qualitative Comparative Analysis

INTRODUCTION

Syndromic surveillance aims at augmenting traditional public health surveillance with timely information. To gain a head start, it mainly analyses existing data such as from web searches or patient records. Despite the setup of many syndromic surveillance systems, there is still much doubt about the benefit of the approach. There are diverse interactions between performance indicators such as timeliness and various system characteristics. This makes the performance assessment of syndromic surveillance systems a complex endeavour. We assessed if the comparison of several syndromic surveillance systems through Qualitative Comparative Analysis helps to evaluate performance and identify key success factors.

MATERIALS AND METHODS

We compiled case-based, mixed data on performance and characteristics of 19 syndromic surveillance systems in Europe from scientific and grey literature and from site visits. We identified success factors by applying crisp-set Qualitative Comparative Analysis. We focused on two main areas of syndromic surveillance application: seasonal influenza surveillance and situational awareness during different types of potentially health threatening events.

RESULTS

We found that syndromic surveillance systems might detect the onset or peak of seasonal influenza earlier if they analyse non-clinical data sources. Timely situational awareness during different types of events is supported by an automated syndromic surveillance system capable of analysing multiple syndromes. To our surprise, the analysis of multiple data sources was no key success factor for situational awareness.

CONCLUSIONS

We suggest to consider these key success factors when designing or further developing syndromic surveillance systems. Qualitative Comparative Analysis helped interpreting complex, mixed data on small-N cases and resulted in concrete and practically relevant findings.

Excess mortality among the elderly in European countries, December 2014 to February 2015

Since December 2014 and up to February 2015, the weekly number of excess deaths from all-causes among individuals?≥?65 years of age in 14 European countries have been significantly higher than in the four previous winter seasons. The rise in unspecified excess mortality coincides with increased proportion of influenza detection in the European influenza surveillance schemes with a main predominance of influenza A(H3N2) viruses seen throughout Europe in the current season, though cold snaps and other respiratory infections may also have had an effect.

Quality comparison of electronic versus paper death certificates in France, 2010

Background

Electronic death certification was established in France in 2007. A methodology based on intrinsic characteristics of death certificates was designed to compare the quality of electronic versus paper death certificates.

Methods

All death certificates from the 2010 French mortality database were included. Three specific quality indicators were considered: (i) amount of information, measured by the number of causes of death coded on the death certificate; (ii) intrinsic consistency, explored by application of the International Classification of Disease (ICD) General Principle, using an international automatic coding system (Iris); (iii) imprecision, measured by proportion of death certificates where the selected underlying cause of death was imprecise. Multivariate models were considered: a truncated Poisson model for indicator (i) and binomial models for indicators (ii) and (iii). Adjustment variables were age, gender, and cause, place, and region of death.

Results

533,977death certificates were analyzed. After adjustment, electronic death certificates contained 19% [17%-20%] more codes than paper death certificates for people deceased under 65 years, and 12% [11%-13%] more codes for people deceased over 65 years. Regarding deceased under and over 65 respectively, the ICD General Principle could be applied 2% [0%-4%] and 6% [5%-7%] more to electronic than to paper death certificates. The proportion of imprecise death certificates was 51% [46%-56%] lower for electronic than for paper death certificates.

Conclusion

The method proposed to evaluate the quality of death certificates is easily reproducible in countries using an automatic coding system. According to our criteria, electronic death certificates are better completed than paper death certificates. The transition to electronic death certificates is positive in many aspects and should be promoted.

SurSaUD® Software: A Tool to Support the Data Management, the Analysis and the Dissemination of Results from the French Syndromic Surveillance System

Objective

The presentation describes the design and the main functionalities of the software developed to support the data management and data analysis of the French syndromic surveillance system.

Introduction

The French syndromic surveillance system SurSaUD® was set up by the French institute for public health surveillance (InVS) in 2004. The system is based on three main data sources: 1/the attendances in the Emergency departments (ED), 2/the consultations to emergency General Practitioners’ associations SOS Médecins 3/the mortality data from civil status offices and e-certificates.

In 2012, 400 of the 710 ED and 59 of the 62 GP’s associations are involved in the system. 80% of the national mortality is also collected. Given this large database and the need to analyze data in a short delay to reach the early warning objective of the system, a specific software has been developed.

Methods

The application has been designed in order to support the users with automatised process of the three main following steps:

Data integration in a database, data management and the control of data quality transmitted by the providers

The statistical analysis of the data, according to different demographic, geographic and syndromic criteria. Individual and aggregated data are consultated using reporting tools (graphs and tables).

The output and reporting for decision makers and feedback for data providers through epidemiological bulletins and dashboards.

Each night, XML files containing data recorded during the previous day are sent from the ED and GP’s association SOS Médecins to InVS. All files are automatically integrated in the national database. A data quality process is done to check the completeness and the validity of the transmitted data. The data are managed by aggregating by age groups, syndromes, by day and ED or association.

After the data management, bulletins and dashboards are automatically generated. Those Word® documents contain graphs, tables or maps with the most recent data. This functionality allows producing already formatted documents, including an updated overview of the health situation of the previous days. Through those documents available at 10:30 AM every day, the epidemiologists can analyse, add comments of the results and publish their bulletins in a short delay.

The users can also consult aggregated data through a BI tool to have a more in-depth analysis of the public health. Such tool can also support the investigation of abnormal signals.

Results

Sursaud software is a login and password-protected and secured internet web site. Since its deployment in 2010, about 300 users have had an access to the software and 25% are data providers.

In August 2012, almost 35,000 new patients are daily caught by the system and nearly 50 millions of patients are recorded in the database since 2004.

To analyse data, the diagnosis coded either in ICD10 for ED visits or with specific thesaurus for GP’s calls are pre-aggregated in about 200 syndromes covering a large part of the medical diagnosis and call reasons collected in the system. 22 age groups are also available with a focus on the most frailty population, like the youngest and the elderly. Finally, various geographic levels can be chosen, from the local ED or association to the national level.

An average of 25 bulletins or dashboards is daily produced by the software and about 10,000 documents have been produced since the deployment. They support the analysis of general overviews of population health or are focused on the surveillance of specific health situations, such as epidemics, emergent pathologies or exceptional events (disasters, mass gatherings,…)

Conclusions

The software is a fundamental support for the French syndromic surveillance system. A new version is being developed in order to add improvements and integrate the mortality data. The deployment of this second version is expected in 2013.

Synergies Between Human and Animal Health Syndromic Surveillance: Triple-S Outputs

Objective

The objective of this study, based on the Triple-S project outputs, was to present the existing synergies between human and animal health syndromic surveillance (SyS) systems in Europe and a proposal to enhance this kind of collaboration.

Introduction

The Triple-S project (Syndromic Surveillance Systems in Europe, www.syndromicsurveillance.eu), co-financed by the European Commission and involving twenty four organizations from fourteen countries was launched in September 2010 with the following objectives 1) performing an inventory of existing or planned SyS systems in Europe both in animal and public health, 2) building a network of experts involved in SyS 3) producing guidelines to implement SyS systems, 4) developing synergies between human and animal health SyS systems. The project is based on a cooperation between human and animal health experts, as supported by the One Health initiative [1].

Methods

A network of European experts involved in SyS was identified through the Triple-S inventory of SyS systems. A meeting of human health experts was organized back to back with a similar meeting with animal health experts in Paris, September 12–14, 2011. A joint session human/animal health allowed experts to discuss the interest of synergies between both sides. The objectives were to 1) encourage experience and knowledge transfer, 2) discuss what and how information should be shared between both sides to improve respective performances.

Results

The results of the inventory of veterinary SyS systems showed that 40% of identified systems already shared or had planned to share information with human health sector. For these systems the collaboration between human and animal health sectors consisted in meetings on a regular basis to discuss the surveillance results.

Discussions during the Triple-S meeting highlighted two reasons for enhancing synergies between both sides. First human health and animal health epidemiologists face common statistical and epidemiological issues when dealing with SyS, i.e. use of data collected for other purpose than surveillance; standardization of clinical observations; syndrome definition; anomaly detection; interpretation of unspecific signals; response to alerts. Both sides have thus interest in sharing their experiences and knowledge to improve their respective systems.

Second, systems on both sides have similar objectives and target health events potentially threatening both animal and human populations: zoonoses, extreme weather events, environmental / food contamination, bioterrorist attack... For those events, animal population can play the role of sentinel for human population. Regular information flow between human and animal SyS could thus enhance the timeliness and sensitivity of SyS systems for detecting unexpected health events. Moreover, sharing information could help animal and human health experts to interpret and confirm unspecific signals, and confirm the impact of common health threats.

All participants of the meeting agreed on the idea to routinely share outputs of the systems but were sceptical about sharing raw data to perform global analysis.

Conclusions

Each aspect of the Triple-S project includes both human and animal health and will thus contribute to build natural collaboration between both sides. Such a project has demonstrated that scientific community is more and more willing to collaborate beyond the boundaries of these two health fields.

Synergies between human and animal health seem as necessary for syndromic surveillance as it is for traditional surveillance, if not more. They seem especially important for the detection of emerging zoonotic threats but not only. Sharing surveillance outputs from both sides would be the first step of collaboration but deeper synergy, e.g. sharing data and analyse them globally, could also be considered. Triple-S guidelines for implementation of SyS systems in Europe will take into account and promote synergies between human and animal health.

How to use near real-time health indicators to support decision-making during a heat wave: the example of the French heat wave warning system

Introduction The French warning system for heat waves is based on meteorological forecasts. Near real-time health indicators are used to support decision-making, e.g. to extend the warning period, or to choose the most appropriate preventive measures. They must be analysed rapidly to provide decision-makers useful and in-time information. The objective of the study was to evaluate such health indicators. Methods A literature review identified a range of possible mortality and morbidity indicators. A reduced number were selected, based on several criteria including sensitivity to heat, reactivity, representativity and data quality. Two methods were proposed to identify indicator-based statistical alarms: historical limits or control charts, depending on data availability. The use of the indicators was examined using the 2006 and 2009 heat waves. Results Out of 25 possible indicators, 5 were selected: total mortality, total emergency calls, total emergency visits, emergency visits for people aged 75 and over and emergency visits for causes linked to heat. In 2006 and 2009, no clear increases were observed during the heat waves. The analyses of real-time health indicators showed there was no need to modify warning proposals based on meteorological parameters. Discussion These findings suggest that forecasted temperatures can be used to anticipate heat waves and promote preventive actions. Health indicators may not be needed to issue a heat wave alert, but daily surveillance of health indicators may be useful for decision-makers to adapt prevention measures.

Excess mortality among the elderly in 12 European countries, February and March 2012

In February and March 2012, excess deaths among the elderly have been observed in 12 European countries that carry out weekly monitoring of all-cause mortality. These preliminary data indicate that the impact of influenza in Europe differs from the recent pandemic and post-pandemic seasons. The current excess mortality among the elderly may be related to the return of influenza A(H3N2) virus, potentially with added effects of a cold snap.

Excess mortality among the elderly in 12 European countries, February and March 2012

In February and March 2012, excess deaths among the elderly have been observed in 12 European countries that carry out weekly monitoring of all-cause mortality. These preliminary data indicate that the impact of influenza in Europe differs from the recent pandemic and post-pandemic seasons. The current excess mortality among the elderly may be related to the return of influenza A(H3N2) virus, potentially with added effects of a cold snap.

CCL2 binding is CCR2 independent in primary adult human astrocytes

Chemokines are low relative molecular mass proteins, which have chemoattractant actions on many cell types. The chemokine, CCL2, has been shown to play a major role in the recruitment of monocytes in central nervous system (CNS) lesions in multiple sclerosis (MS). Since resident astrocytes constitute a major source of chemokine synthesis including CCL2, we were interested to assess the regulation of CCL2 by astrocytes. We showed that CCL2 bound to the cell surface of astrocytes and binding was not modulated by inflammatory conditions. However, CCR2 protein was not detected nor was activation of the classical CCR2 downstream signaling pathways. Recent studies have shown that non-signaling decoy chemokine receptors bind and modulate the expression of chemokines at site of inflammation. Here, we show that the D6 chemokine decoy receptor is constitutively expressed by primary human adult astrocytes at both mRNA and protein level. In addition, CCL3, which binds to D6, but not CCL19, which does not bind to D6, displaced CCL2 binding to astrocytes; indicating that CCL2 may bind to this cell type via the D6 receptor. Our results suggest that CCL2 binding to primary adult human astrocytes is CCR2-independent and is likely to be mediated via the D6 decoy chemokine receptor. Therefore we propose that astrocytes are implicated in both the establishment of chemokine gradients for the migration of leukocytes into and within the CNS and in the regulation of CCL2 levels at inflammatory sites in the CNS.