[Surveillance of work-related suicide in France: An exploratory study]. / Surveillance des suicides liés au travail en France : une étude exploratoire.

BACKGROUND: Despite a large media coverage of the phenomenon, the number of work-related suicides is currently unknown in France. There are nevertheless some data available to document this important issue. The aim of this study was to explore the feasibility of an epidemiological surveillance system for work-related suicides designed to quantify and describe work-related suicides mainly according to economic sectors and occupational categories. METHODS: Existing data sources in France were identified and evaluated for their relevance and their potential use in a multi-sources surveillance system. A regional pilot study was performed using the main relevant sources identified to investigate different aspects of the system design. RESULTS: Four major data sources were identified to be used to describe work-related suicides: death certificates, social insurance funds, data collected by the officers of the labor inspectorate and data collected from autopsy reports in forensic departments. The regional pilot study gave an estimate of 28 cases of work-related suicide in two years. CONCLUSION: The findings point out the difficulties involved and the criteria for successful implement of such a system. The study provides some solutions for carrying out this system, the achievement of which will depend upon particular resources and partners' agreements. Recommendations for the next steps have been made based on this work, including possible collaboration with forensic departments, which collect essential data for surveillance.

Surveillance programme for uncompensated work-related diseases in France.

BACKGROUND: The surveillance programme for uncompensated work-related diseases (UWRDs) in France relies on a network of occupational physicians (OPs) who volunteer to report all UWRDs diagnosed during a biannual 2-week observation period. AIMS: To describe this programme and the usefulness of its results. METHODS: During the observation period, OPs record job title and employment sector for each worker. For each potential UWRD, they complete a one-page report form. RESULTS: Between 2007 and 2012, the number of reporting OPs ranged from 705 to 965 and they saw between 78884 and 114154 employees annually. The UWRD incidence rate reports varied from 5 to 5.3% for men and from 6.5 to 7.7% for women, with musculoskeletal disorders (MSDs) being most frequent, followed by mental ill-health. Incidence rates, except for hearing loss, were higher for women than men in all categories and, in 2012, were twice as high for women (3.1%) as for men (1.4%) for mental ill-health. Incidence rates in every category increased with age up to 54 years. The highest rates for MSDs were observed among blue-collar workers (6.9% in women and 4% in men in 2012) and the lowest rates in professionals/managers (1.1 and 0.4%, respectively). Conversely, the latter had the highest incidence of mental health disorders (5.9 and 3.3%). CONCLUSIONS: This 'Fortnight' protocol provides useful data on the frequency of diseases linked to employment and allows us to estimate the incidence of UWRDs, whether recognized as compensable or not, as well as their trends over time.

[The French mesothelioma network from 1998 to 2013]. / Mésothéliome: les dispositifs en place en France « le réseau mésothéliome ¼ 1998-2013.

Mesothelioma is a rare disease less than 0.3% of cancers in France, very aggressive and resistant to the majority of conventional therapies. Asbestos exposure is nearly the only recognized cause of mesothelioma in men observed in 80% of case. In 1990, the projections based on mortality predicted a raise of incidence in mesothelioma for the next three decades. Nowadays, the diagnosis of this cancer is based on pathology, but the histological presentation frequently heterogeneous, is responsible for numerous pitfalls and major problems of early detection toward effective therapy. Facing such a diagnostic, epidemiological and medico-legal context, a national and international multidisciplinary network has been progressively set up in order to answer to epidemiological survey, translational or academic research questions. Moreover, in response to the action of the French Cancer Program (action 23.1) a network of pathologists was organized for expert pathological second opinion using a standardized procedure of certification for mesothelioma diagnosis. We describe the network organization and show the results during this last 15years period of time from 1998-2013. These results show the major impact on patient's management, and confirm the interest of this second opinion to provide accuracy of epidemiological data, quality of medico-legal acknowledgement and accuracy of clinical diagnostic for the benefit of patients. We also show the impact of these collaborative efforts for creating a high quality clinicobiological, epidemiological and therapeutic data collection for improvement of the knowledge of this dramatic disease.

Occupational and non-occupational attributable risk of asbestos exposure for malignant pleural mesothelioma.

OBJECTIVES: To estimate the proportion of pleural mesothelioma cases that can be attributed to asbestos exposure in France including non-occupational exposure. METHODS: A population-based case-control study including 437 incident cases and 874 controls was conducted from 1998 to 2002. Occupational and non-occupational asbestos exposure was assessed retrospectively by two expert hygienists. ORs of pleural mesothelioma for asbestos-exposed subjects compared to non-exposed subjects, and population-attributable risk (ARp) of asbestos exposure were estimated using a conditional logistic regression. RESULTS: A clear dose-response relationship was observed between occupational asbestos exposure and pleural mesothelioma (OR=4.0 (99% CI 1.9 to 8.3) for men exposed at less than 0.1 f/mL-year vs. 67.0 (99% CI 25.6 to 175.1) for men exposed at more than 10 f/mL-year). The occupational asbestos ARp was 83.1% (99% CI 74.5% to 91.7%) for men and 41.7% (99% CI 25.3% to 58.0%) for women. A higher risk of pleural mesothelioma was observed in subjects non-occupationally exposed to asbestos compared to those never exposed. The non-occupational asbestos ARp for these subjects was 20.0% (99% CI -33.5% to 73.5%) in men and 38.7% (99% CI 8.4% to 69.0%) in women. When considering all kinds of asbestos exposure, ARp was 87.3% (99% CI 78.9% to 95.7%) for men and 64.8% (99% CI 45.4% to 84.3%) for women. CONCLUSIONS: Our study suggests that the overall ARp in women is largely driven by non-occupational asbestos exposure arguing for the strong impact of such exposure in pleural mesothelioma occurrence. Considering the difficulty in assessing domestic or environmental asbestos exposure, this could explain the observed difference in ARp between men and women.

Prevalence of knee bursitis in the workforce.

BACKGROUND: Knee bursitis (KB) is a common disorder in specific occupations requiring frequent and/or sustained kneeling postures. AIMS: To assess the prevalence of KB in the general working population. METHODS: Between 2002 and 2005, a total of 3710 workers of a French region were randomly included in the study. A standardized physical examination of the knee was performed when knee pain was reported by the worker during the preceding 12 months. The criteria for diagnosis of KB were (i) the presence of pain and/or tenderness in the anterior face of the knee at the date of the examination (or for at least 4 days in the preceding week) and (ii) the presence of swelling and/or pressure-induced pain of the pre- or infra-patellar bursa. Occupational risk factors were assessed by a self-administered questionnaire. RESULTS: The prevalence of uni- or bilateral cases of knee bursitis was low: 0.6% [0.2-0.9] in men and 0.2% [0.0-0.6] in women. The highest prevalence was observed in the construction sector (2.3% [0.8-5.4]) and in the food and meat processing industries (1.4% [0.4-3.5)]. More blue-collar workers were affected than other occupation categories (0.8% [0.3-1.2] versus 0.1% [0.0-0.4]). CONCLUSIONS: The study showed a concentration of cases among male workers exposed to heavy workloads and frequent kneeling.

Working in temporary employment and exposure to musculoskeletal constraints.

BACKGROUND: In recent years, temporary work (TW) has increased in European countries due to the greater uncertainty in the economy. AIMS: To compare the prevalence of non-specific musculoskeletal symptoms of the upper extremities (UEMSDs) and their main risk factors in blue-collar workers employed through temporary agencies (TW) and in those in permanent employment (PE). METHODS: UEMSDs occurring during the preceding 7 days were assessed using a Nordic questionnaire completed by 1493 blue-collar workers randomly included in a surveillance programme for UEMSDs (171 in TW and 1322 in PE) in a large French region. Personal factors and work-related risk factors for UEMSDs were assessed by self-administered questionnaires. RESULTS: The prevalence of UEMSDs during the preceding 7 days did not significantly differ between workers in TW or PE. However, after adjustment for age and gender, TW had a higher risk of symptoms of the wrist/hand region (OR = 1.6, 95% CI 1.04-2.6). TW was characterized by higher exposure to paced work (OR = 2.0, 95% CI 1.4-3.0), repetitive work (OR = 2.3, 95% CI 1.6-3.4), awkward postures of the wrist (OR = 1.6, 95% CI 1.2-2.4) and intensive use of vibrating hand tools (OR = 1.7, 95% CI 1.1-2.3). Workers in TW suffered from a lack of autonomy (OR = 2.5, 95% CI 1.7-3.6) and skill discretion at work (OR = 2.0, 95% CI 1.3-3.1) more frequently, but there was no difference in relation to psychological demands of the task or social support. CONCLUSIONS: Temporary workers were more frequently exposed to working time constraints, repetitive work and biomechanical constraints of the wrist/hand region when compared to permanent workers and may represent a subpopulation at particularly high risk of UEMSDs.

[The determinants of under-reporting occupational diseases. The case of mesothelioma]. / Les déterminants de la sous-déclaration des maladies professionnelles. Le cas du mésothéliome.

BACKGROUND: Despite widespread press coverage of the harm caused by the asbestos, 40% of mesothelioma patients still do not file claims for compensation as an occupational disease. We aimed at studying elements that influence the administrative procedure of compensation, in particular social classes and instruction level. METHODS: This was a statistical analysis of data from the French national survey program of mesothelioma designed to understand social determinants of reporting occupational illness. Data from a give administrative district were then submitted to a qualitative study using in-depth interviews of patients with suspected mesothelioma. Discourse analysis was then applied to the corpus of information collected. Content analysis grouped the data into themes. RESULTS: The statistical analyses tended to show that the higher the educational level, the less often patients filed claims for their occupational disease. Manual workers asked for compensation for their disease more often than executives. The interviews conducted with suspected mesothelioma patients suggest several factors explaining these findings. The process of reporting an occupational disease is often initiated by the primary care physician who informs the patient about the possible link with a previous occupation, explains the procedure and motivate the patient whose main preoccupation is to fight against the illness, and less so to become recognized as a victim. In this context, the physician plays a fundamental role, independently of the patient's social status. CONCLUSION: Those results throw new light on the complexity of the administrative procedure for reporting occupational diseases in France and highlights possible causes of underdeclaration reporting. Physician awarness of these causes might improve identification of links between occupation and disease and the transmission of adapted information to all concerned patients in order to fight more effectively against the disparities resulting from underreporting.

[Suicide and occupation in France]. / Suicide et activité professionnelle en France.

BACKGROUND: Suicide is a complex and multifactorial phenomenon. The number of work-related suicides is difficult to assess in France. There are nevertheless some data available to document this problem. The aim of this study is to describe suicide attempts (SA) and suicide mortality according to occupation in France. METHODS: The description of SA relies on the "Baromètre Santé 2005", a cross-sectional representative survey conducted by the Inpes in France. The study population includes 6264 men and 7389 women in employment at the time of the survey. The prevalence of all life SA is described according to occupational category (one and two digits). Data on suicide mortality before the age of 65 comes from the Cosmop project, conducted by the Department of Occupational Health/InVS, and based on data from the "Echantillon démographique permanent"/Insee linked to medical causes of death from the French national death registry (CepiDc/Inserm). People included was born in France, employed at one of censuses (1968, 1975, 1982 and 1990, 187,938 men, 150,683 women). Relative risks for suicide mortality were estimated for the last known occupational category and economic sector. RESULTS: The prevalence of life course SA was higher among women than among men (6.6% vs 3.1%); an opposite situation was observed for mortality. Regarding salaried people, categories of manual workers and clerks are the most affected by SA and mortality from suicide whereas executives are the least concerned. Farmers were little affected by SA (0.4% men, 4.1% women) but experienced the highest rate of mortality by suicide (RR=3.1 men, RR=2.2 women). Among women, compared to non market sectors, the agricultural and equipment goods sectors exhibited an excessive risk of mortality from suicide. CONCLUSION: This study points out SA and mortality from suicide inequalities by occupational categories and to a lesser extent by economic sector. These results provide a first assessment on suicide according to occupation in France.

Evolution of pleural cancers and malignant pleural mesothelioma incidence in France between 1980 and 2005.

The evolution of pleural cancers and malignant pleural mesothelioma incidence in France between 1980 and 2005 was analysed using data derived from the French network of cancer registries (FRANCIM) and the French National Mesothelioma Surveillance Program (PNSM). Mesothelioma proportions in pleural cancers were calculated by diagnosis year in the 1980-2000 period. Our results suggest that the incidences of pleural cancer and mesothelioma levelled off in French men since 2000 and continued to increase in French women. A decrease of the annual pleural cancer incidence average in men was noticed (-3.4% of annual rate of change) between 2000 and 2005. The proportion of pleural cancers that were mesothelioma was unchanged between 1980 and 2003 with an average of 86%. The age standardised incidence rate of pleural mesothelioma remained relatively stable between 1998 and 2005 with a slight falling trend. For women, the age standardised incidence rate of pleural cancers and mesothelioma increased during the period 1998-2005. Additionally, the proportion of pleural cancers that were mesothelioma increased during the same period of time. Finally, the increased trend observed in the incidence of pleural mesothelioma and cancers in women is credibly due to their under diagnosis in the 1980-1997 period. The comparison between the French incidence and the American and British ones shows that the decreasing trend in incidence of mesothelioma and pleural cancers in French men since 2000 is potentially associated with a lower amphibole consumption and by the implementation of safety regulations at work from 1977.

The French Musculoskeletal Disorders Surveillance Program: Pays de la Loire network.

OBJECTIVES: An epidemiological surveillance system for work-related musculoskeletal disorders (MSDs) was implemented in 2002 in France's Pays de la Loire region to assess the incidence and prevalence of MSDs in the general and working populations, identify levels of exposure to occupational risk factors and investigate the proportion of cases attributable to work exposure. METHODS: The program combines (1) surveillance of sentinel health events in the general population (carpal tunnel syndrome (CTS) was the sentinel event for upper limb MSDs), (2) assessment of the prevalence of the main upper limb MSDs and their risk factors in the workplace based on a network of occupational physicians and (3) registration of the notification of work-related diseases (WRDs). RESULTS: 1168 incident cases of CTS were included over a 3 year period. The estimated incidence of CTS was 1.00 per 1000 person-years in those aged 20-59 years (0.60 in men and 1.40 in women). The incidence rate was higher in employed than unemployed persons in the year of diagnosis (0.6 per 1000 vs 0.3 in men and 1.7 vs 0.8 in women). The occupational physician network noted high prevalence rates: 11% of men and 15% of women had at least one of the six main upper limb clinically-diagnosed MSDs. The WRD survey showed that MSDs represented 65% of notified WRDs. CONCLUSION: The Pays de la Loire program plays a significant role in informing the authorities and the public about the state of current MSDs. It is planned to extend it to a routine national surveillance program.

[Exposure to psychosocial stressors at work in the Pays de la Loire region in 2002]. / Exposition au stress psychosocial chez les salariés des Pays de la Loire en 2002.

OBJECTIVE: An epidemiological surveillance system of work-related musculoskeletal disorders of the upper limb (MSDs) was implemented in 2002 in the Pays de la Loire region to assess the prevalence of the MSDs and their biomechanical and psychosocial risk factors in the working population. We will report here only the results concerning the exposure to psychosocial stress in the work environment. According to the Karasek "demand-autonomy" model, high psychological work demands may increase risk of ill health, particularly if there is a low level of decision latitude for the employees and low social support by the hierarchy or colleagues. METHODS: In 2002, 68 out a total of 400 occupational physicians volunteered to participate in the surveillance program and included 1 495 workers (895 men, 600 women) representative of the region's workforce. Work history and work environment were assessed by a self-administered questionnaire before the compulsory annual visit of occupational physicians. Exposure to psychosocial stress at work was assessed with the Job Content Questionnaire (JCQ) developed by Karasek. The three scales of decision latitude, social support and psychological demands were calculated using Karasek's recommendations. RESULTS: The mean scores of psychological demands, decision latitude and social support were 69.3 +/- 12.7; 22.3 +/- 3.2; 24.0 +/- 3.5, respectively. No differences were observed according to gender and age. A third of the workers were exposed to high psychological demands at work and most of them (61%) had little decision latitude to cope with work constraints. About 28% of workers suffered from a lack of social support from their colleagues or supervisors. Overall, about 17% of workers were exposed to a situation of "Job strain" (ie a combination of a high level of psychological demands and a low level of decision latitude) and 7% were exposed to a situation of "Job strain" with social isolation ("Job strain" with low social support). The situations of "Job strain", associated or not with a low level of social support, were particularly frequent in industries with taylorized work organisation, like the food industry and automobile industry, and in services characterised by strong merchant constrains, such as trade and cleaning services, for example. The frequency of "Job strain", with or without social isolation, was almost double in temporary workers. DISCUSSION: This study confirms that in a representative sample of workers, the exposure to occupational stress is not limited to managers and professionals, but concerns also a large number of employees and blue-collar workers of the public and private sectors. In general, the strongly qualified occupations are characterised by a high level of psychological demands, but individuals have large decision latitude to cope, which allows them to develop their capacities. The less qualified occupations are generally less confronted with a high level of mental demands than the managers and professionals. However, these individuals do not have enough decision latitude to cope with psychological demands which could lead to a high level of "Job strain", notably in the case of lack of social support from the supervisors and the colleagues. CONCLUSION: The study shows that the exposure to occupational stress is not limited to managers and professionals, but also concerns numerous employees and blue-collar workers. The determinants of work strain differ depending on occupations and this should be taken into consideration when implementing prevention programs for stress at work.

[Comparison of the French DRG based information system (PMSI) with the National Mesothelioma Surveillance Program database]. / Confrontation des données du Programme national de surveillance du mésothéliome (PNSM) et du Programme de médicalisation du système d'information (PMSI).

BACKGROUND: One of the main purposes of the French National Mesothelioma Surveillance Program is to estimate and follow the national incidence of pleural mesothelioma. We wanted to study the contribution of the French hospital national database as a valid source of mesothelioma incident cases. METHODS: From the 1998 and 1999 hospital national database, medical records with a diagnosis code of mesothelioma or pleural cancer where selected among patients who resided in one of the 17 administrative divisions covered by the National Mesothelioma Surveillance Program in 1998. From these records, 506 patients in 1998 and 474 patients in 1999 where identified and matched with the National Mesothelioma Surveillance Program cases over the same period using indirect criteria of identification (sex, age, place of residence). Medical records of cases unknown by the National Mesothelioma Surveillance Program where consulted in one of the administrative divisions. RESULTS: Only two-thirds of the registered cases of the National Mesothelioma Surveillance Program could be matched with a patient identified in the hospital national database with a diagnosis of mesothelioma registered during the same year. Consultation of the medical records showed that 1) certified cases registered in the National Mesothelioma Surveillance Program where often (83%) found in the hospital national database with a code of mesothelioma but 10 to 15% of the patients with a code of mesothelioma in the national hospital databases had a different diagnosis according to their medical records; 2) 65% of the patients with a code of mesothelioma in the national hospital databases that where unknown from the National Mesothelioma Surveillance Program in 1998 and 55% in 1999 where prevalent cases; 3) 3 suspected cases had not been reported to the National Mesothelioma Surveillance Program. CONCLUSION: Because of lack of diagnosis certification, mistakes in encoding diagnosis and the fact that incident and prevalent cases cannot be distinguished in the hospital national database make it impossible to estimate the mesothelioma incidence solely from this source of data. However, the hospital claim databases constitute a complementary source of information for the active search of incident cases performed by the National Mesothelioma Surveillance Program.

Why are manual workers at high risk of upper limb disorders? The role of physical work factors in a random sample of workers in France (the Pays de la Loire study).

OBJECTIVE: To investigate the reasons for the excess risk of upper limb musculoskeletal disorders among manual workers compared with other workers in a random sample of 2656 French men and women (20-59 years old) participating in a study on the prevalence of work related upper limb disorders conducted by France's National Institute of Health Surveillance. METHODS: Prevalence ratios (PR) of physician-diagnosed musculoskeletal disorders of the shoulder, elbow, wrist, and hand (any of six leading disorders, rotator cuff syndrome, carpal tunnel syndrome) in manual versus non-manual workers were calculated using Cox regression models with a constant time of follow up and robust variance. RESULTS: 11.3% of men and 15.1% of women were diagnosed with an upper limb disorder. The risk was especially high in manual workers (PRs: 1.40 to 2.10). Physical work factors accounted for over 50% of occupational disparities overall, 62% (men) to 67% (women) for rotator cuff syndrome, and 96% (women) for carpal tunnel syndrome. The authors calculated that under lower levels of physical work exposures, up to 31% of cases among manual workers could have been prevented. CONCLUSIONS: In working men and women, upper limb musculoskeletal disorders are frequent. Physical work exposures, such as repetitive and forceful movements, are an important source of risk and in particular account for a large proportion of excess morbidity among manual workers.

The French National Mesothelioma Surveillance Program.

OBJECTIVES: The French National Mesothelioma Surveillance Program (NMSP) was established in 1998 by the National Institute for Health Surveillance (InVS). Its objectives are to estimate the trends in mesothelioma incidence and the proportion attributable to occupational asbestos exposure, to help improve its pathology diagnosis, to assess its compensation as an occupational disease, and to contribute to research. METHODS: The NMSP records incident pleural tumours in 21 French districts that cover a population of approximately 16 million people (a quarter of the French population). A standardised procedure of pathological and clinical diagnosis ascertainment is used. Lifetime exposure to asbestos and to other factors (man made mineral fibres, ionising radiation, SV40 virus) is reconstructed, and a case-control study was also conducted. The proportion of mesothelioma compensated as an occupational disease was assessed. RESULTS: Depending on the hypothesis, the estimated number of incident cases in 1998 ranged from 660 to 761 (women: 127 to 146; men: 533 to 615). Among men, the industries with the highest risks of mesothelioma are construction and ship repair, asbestos industry, and manufacture of metal construction materials; the occupations at highest risk are plumbers, pipe-fitters, and sheet-metal workers. The attributable risk fraction for occupational asbestos exposure in men was 83.2% (95% CI 76.8 to 89.6). The initial pathologist's diagnosis was confirmed in 67% of cases, ruled out in 13%, and left uncertain in the others; for half of the latter, the clinical findings supported a mesothelioma diagnosis. In all, 62% applied for designation of an occupational disease, and 91% of these were receiving workers' compensation. CONCLUSIONS: The NMSP is a large scale epidemiological surveillance system with several original aspects, providing important information to improve the knowledge of malignant pleural mesothelioma, such as monitoring the evolution of its incidence, of high risk occupations and economic sectors, and improving pathology techniques.

[Quantitative assessment of the risk of lung cancer and pleural mesothelioma among automobile mechanics]. / Evaluation quantitative du risque de cancer du poumon et de mésothéliome pleural chez les mécaniciens de véhicules automobiles.

BACKGROUND: A quantitative assessment of the risk of lung cancer and pleural mesothelioma among mechanics exposed to dust released from automobile asbestos-containing parts was performed. METHODS: The population of automobile mechanics in France, according to profession and industrial sectors codes, was estimated from the data of the 1999 census. Risks were computed for a total male population of 242,360 automobile mechanics aged 16 to 60 years. Exposure to asbestos among these workers comes from maintenance tasks involving asbestos-containing parts produced before 1997 (date of the asbestos ban in France). Airborne asbestos concentration data available from the literature were highly variable. No data reporting the distribution of time spent for such tasks over a typical week of work were available. Therefore, different weekly exposure profiles were simulated, based on data from the 1994 SUMER survey. Risk models were those used for assessing asbestos health effects by all national and international agencies. Exposure scenarios mixed different levels of exposure, periods of time, proportions of exposed workers and dates of the "natural" disappearance of the automobile fleet built before asbestos was banned in brakes and other parts. The most realistic scenario hypothesizes that all automobile mechanics were exposed to asbestos, that the exposure levels ranged from 0.06 and 0.25 fibers/liter per week for the period before 1997, and between 0.01 and 0.06 fibers/liter per week afterwards until 2010. RESULTS: According to this scenario, the number of lifelong cancer deaths (lung and pleura) induced by asbestos exposure in this population is estimated at 602 "unavoidable" cases, due to exposure experienced before 2003; 43 other cases will occur if asbestos is not removed from existing automobiles.

[Use of a job-exposure matrix for the screening of occupational exposure to asbestos]. / Utilisation d'une matrice emplois-exposition pour l'identification des expositions professionnelles à l'amiante.

BACKGROUND: According to a recent French legislation (1995), retired people who have been exposed to an occupational carcinogen can benefit from a specific post-occupational medical follow-up program, supported by the "Caisse Primaire d'Assurance-Maladie" (CPAM), the French health insurance system. However, only very few people presently take access to this social measure. The ESPACES project developed and evaluated a procedure to identify retirees who have been exposed to asbestos during their career, and to inform them about the post-occupational medical follow-up program. METHODS: This pilot study was performed within the health centers ("Centres d'examens de santé" (CES)) of the health insurance system in a random sample of men who have retired from the six main French administrative divisions between 1994 to 1996. A probability of exposure to asbestos was attributed through a job exposure matrix. Subjects were interviewed in the CES to validate their exposure data. Retired subjects with confirmed exposure to asbestos were referred to their CPAM, to apply for the medical follow-up. The whole process was evaluated through a comparison with control CPAMs, and simulations were performed to assess its sensitivity and specificity, as well as the total number of persons in France who could potentially benefit. RESULTS: Among the 737 persons classified as exposed by the matrix who came to the CES, the exposure was confirmed for 53.8%, and 143 benefited from the medical follow-up, 17 times more than in a sample of control CPAMs. Based on an annual number of about 250,000 new retirees, simulations showed that a low detection threshold, taking into account the probability and duration of exposure, would yield approximately 25,000 persons coming to the CES, more 6,000 of them benefiting from the follow-up. CONCLUSION: The proposed detection threshold would allow for a feasible and ethically acceptable generalization, due to the optimization of the false negative and false positive rate.

[Causes of death in a cohort of EDF-GDF employees: comparison between occupational medicine and official statistics data]. / Causes de décès dans une cohorte de travailleurs EDF-GDF: comparaison des données de la médecine du travail et de la statistique nationale.

BACKGROUND: In an epidemiological study, medical causes of death may be obtained from different sources. In a study on French gas and electricity company (EDF-GDF) workers, they were obtained from the national INSERM database. Additionally, the causes collected by the EDF-GDF occupational physicians were available for a subset of 1,330 deaths, which occurred between 1989 and 1994. The data from the two sources were compared with each other, in order to assess whether they were globally equivalent, and the potential impact of their differences on the results of epidemiological analyses. METHODS: Concordance rates between causes of death in the INSERM and EDF-GDF physicians databases were calculated according to the International Classification of Diseases (ICD) ninth revision codes and for various causes groups. Causes of death records were also examined in order to clarify the observed divergences. SMRs were computed in order to evaluate the consequences of using each database in epidemiological analyses. Finally, some SMRs were computed with the two sources and compared with each other. RESULTS: INSERM and EDF-GDF physicians causes belonged to the same causes group in 81% of cases, but the exact cause was different for more than half of them. The concordance rate was high for the deaths by AIDS and by cancer, and low for deaths by respiratory system and digestive system diseases. More causes of death were coded as "unknown" in EDF-GDF physicians data than in INSERM data. The SMRs varied widely depending on whether the INSERM or EDF-GDF physicians causes of death databases were used. CONCLUSIONS: Causes of death recorded in the INSERM and EDF-GDF physicians databases are very different. Therefore, using the national mortality rates computed by INSERM with the EDF-GDF physicians causes of death to calculate SMRs is not valid, and it is observed that they may be very different from those computed with INSERM data. In a general way, it should be better to use the INSERM database, which is a common source, in order to generate results comparable with other studies. However, this database has its own limitations, and it may be better, in particular situations and for internal analyses, to use another source if it seems to be a better one.

Evaluation of the quality of coding of job episodes collected by self questionnaires among French retired men for use in a job-exposure matrix.

BACKGROUND: and AIMS: The ESPACES study was intended to identify retirees who may have been, according to their job descriptions, exposed to asbestos during their working lives. As part of this study, we analysed the quality of the occupation and activity sector coding as well as its effect on the subjects' exposure status. METHODS: The occupation and activity sector for a sample of 450 retired men were coded twice (with the second coder blinded to the first result), according to the international codes for industries (ISIC-1975) and occupations (ISCO-1968). For each series, linking the information about a job episode (dates, ISIC code, ISCO code) with the matrix allowed attribution of a probability of asbestos exposure to each episode and each subject. The asbestos exposure in the two series was compared by the kappa reproducibility coefficient. RESULTS: The analysis concerned 425 questionnaires. There was at least one difference in the code for either activity sector (ISIC) or occupation (ISCO) in half the episodes (50.2%). The exposure status estimated by the job-exposure matrix did not change between the series for 84.7% of the subjects. The kappa coefficient was 0.64 for all questionnaires, 0.70 when the questionnaire was coded twice by the same coder, and 0.62 when coded by two different coders. CONCLUSIONS: Despite intra- and inter-differences between coders, the coding of job episodes for the ESPACES study appears satisfactory and hence indicates that the assessment of the subjects' asbestos exposure was assessed without major distortions. This study underlines the usefulness of employing coders specifically trained for this technique.

Socioeconomic, demographic, occupational, and health factors associated with participation in a long-term epidemiologic survey: a prospective study of the French GAZEL cohort and its target population.

The purpose of this paper is to examine personal and health factors, both at the beginning of the study and thereafter, associated with participation in the GAZEL cohort, set up in 1989 in a large French company. The authors used logistic regression to analyze the associations between participation and data available for both participants (n = 20,093) and nonparticipants (n = 24,829). Higher participation was associated with male sex, marriage, children, managerial status, and residence in particular regions. Among men, lower participation was associated with sick leave in the year before recruitment and afterwards. During follow-up, participation was negatively associated with several groups of diseases, especially those associated with alcohol consumption. The risk of upper respiratory and digestive tract and lung cancer during follow-up was higher among nonparticipants. The same phenomenon occurred among women, but less markedly, for cancers of the breast and genital organs. During follow-up, mortality among men was higher among nonparticipants, especially for alcohol-related diseases. The association among women was less strong. Among men, but not among women, diseases caused by alcohol, smoking, or dangerous behavior were the primary reason for the health differences observed between participants and nonparticipants. Overall, the most important determinants of participation were cultural factors and lifestyle behaviors.