Health hazards: evolution and implication for public health surveillance by 2024 – French Institute for Public Health Surveillance / p. 1

Health hazards: evolution and implication for public health surveillance by 2024 An exercise of prospective monitoring conducted by the InVS,2014

The French Institute for Public Health Surveillance (InVS) has developed a set of methodological and organizational tools (monitoring, vigilance, science watch, and statistical methods) to fulfill its mission of surveillance and to contribute to decision-making. With these tools, the Institute can respond more effectively to the alerts it receives and to the questions it needs to address. Health crises in recent years have demonstrated the need to anticipate potentially hazardous situations. Accordingly, the Institute uses sources that enable it to identify future changes in its environment, in order to prepare for and prevent the health risks facing our society. The Institute has adopted a prospective monitoring approach, which allows it to take into account developments over the short, medium, and long terms, while regularly adjusting and redirecting (every three to five years) scenarios based on its analysis of current or recent changes in the social and economic environment and in the population’s health status. The Institute’s expertise is based on monitoring tools. It must be supplemented by other approaches specific to other organizations and disciplines (including sociology, economics, demography, and political science...).

Prospective monitoring at the Institute should apply a multidisciplinary and transdisciplinary approach aimed at identifying both (so-called dominant) trends over time, and (so-called weak) signals that may announce disruptions of these trends.

For InVS, the purpose of prospective monitoring is firstly to alert health authorities proactively and help them influence or shape public policies to optimize health and, secondly, to define the priorities that should be included in its planning, and to develop in-house individual and collective skills as well as the institutional ability to address unexpected changes.

The Institute works closely with other health safety agencies, as well as other institutes (the French Agency for Food, Environmental, and Occupational Health & Safety (Anses) conducts the same type of activity with partner institutes and agencies, (including InVS) to reach a common definition of and approach to prospective monitoring.

1/ French Institute for Public Health Surveillance (InVS), Office for science and quality management (DiSQ)2/ InVS, Library (SDOC)3/ InVS, Department of Coordination of Alerts and Regional Offices (DCAR)4/ InVS, Infectious Diseases Departement (DMI)5/ InVS, Environmental and Health Department (DSE)6/ InVS, Directorate General (DG)

7/ InVS, Chronic Diseases and Injuries Department (DMCT)8/ InVS, Occupational Health Department (DST)9/ InVS, Finance and Logistic Office (SFLE)10/ Regional office of InVS (Cire) Pays de la Loire11/ Cire Ile-de-France12/ Futuribles, Paris

The process was conducted internally, in 2014, with the help of a service provider specialized in prospective monitoring. Various steps were required: - identification of public health topics (diseases and their

determinants) important for InVS; - identification of variables, based on the determinants

identified in the first phase (figure 1). These variables were categorized into three themes: trigger factors for health events, spread factors, and response factors that can increase or decrease these events;

- the drafting of variable documents, by each of three working groups, one for each topic, proposing future

hypotheses of changes over time, one of the hypotheses must be trend-based;

- identification and then drafting by each of the three working groups of micro-scenarios based on the hypotheses made about the development of each variable (each micro-scenario must be derived from one of the hypotheses for each variable). One of these micro-scenarios must be trend-based (figure 2);

- identification and drafting of five macro-scenarios, each built from three micro-scenarios (one micro-scenario per group in each macro-scenario). One of these macro-scenarios must be trend-based;

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Daniel Eilstein1, Jerome Pozuelos1, Doriane Fuchs1, Maud Gorza1, Hélène Therre1, Bertrand Xerri1,Christine Aranda1, Edwige Bertrand2, Thierry Cardoso3, Didier Che5, Anne-Claire Colleville1, Henriette de Valk4, Adrien Debever6, Nicolas Duport7, Mounia El Yamani8, Pascal Empereur-Bissonnet5, Béatrice Escande9, Claire Fuhrman7, Isabelle Gremy7, Bruno Hubert3,10, Sophie Ioos3, Agnès Lefranc5, Alexandra Mailles4, Frédéric Moisan8, Mathilde Pascal5, Christophe Perrey5, Jocelyne Rajnchapel-Messai1, Benoît Salanave7, Véronique Vaillant4, Stéphanie Vandentorren3,11, Annie Velter4, Anne-Catherine Viso1, Cécile Wendling12

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November 2015An exercise of prospective monitoring conducted by the InVS,

7/ InVS, Chronic Diseases and Injuries Department (DMCT)

November 2015December 2015

ntroduction

ethod

p. 2 / French Institute for Public Health Surveillance – Health hazards: evolution and implication for public health surveillance by 2024

- identification of the issues and needs that these scenarios present for InVS;

- development of a list of recommendations for conducting sustainable prospective monitoring.

The set of variables, micro-scenarios, and macro-scenarios begins with an two-part introduction. The first contains the prospective hypotheses about determinants and the second the expected consequences on individual and public health.

The following variables were selected: - trigger factors: "smoking", "nutrition, alcohol, sedentary

lifestyle", "psychosocial risks in the workplace, economic and social pressure, insecurity, changing

work environment", "economic situation", "aging", "exposure of workers and consumers", "geopolitical conflicts and tensions throughout the world";

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▪ Figure 1 - Creation process of prospective scenarios

▪ Figure 2 - Example of a morphological table

Variable sheet 1 Hyp 1 (trend based) Hyp 2 Hyp 3 Variable sheet 2

Hyp 1 (trend based) Hyp 2 Hyp 3 Variable sheet 3

Hyp 1 (trend based) Hyp 2 Hyp 3

Variable sheet 1 Hyp 1 (trend based) Hyp 2 Hyp 3 Variable sheet 2

Hyp 1 (trend based) Hyp 2 Hyp 3

Variable sheet 1 Hyp 1 (trend basedl) Hyp 2 Hyp 3 Variable sheet 2

Hyp 1 (trend based) Hyp 2 Hyp 3 Variable sheet 3

Hyp 1 (trend based) Hyp 2 Hyp 3

Micro-scénario 1 (trend based)

Micro-scénario 1 (trend based)

Micro-scénario 1 (trend based)

Macro-scénario 1 (trend based)

Micro-scénario 2

Micro-scénario 2

Micro-scénario 3

Micro-scénario 2

Micro-scénario 3

Micro-scénario 4

Macro-scénario 2

Macro-scénario 3

Triggering

Diffusion

Responses

H2 H3

H2

H2 H3

H2 H3

H4

Micro-scénarios Sc 1 Micro-sc 1 Micro-sc 2 …

H2

H2 H3

H3

H4

H2 H3 H4

1. Variable 01

2. Variable 02

Key variables

3. Variable 03

4. Variable 04

5. Variable 05

6. Variable 06

7. …

Hypotheses on variables

H1

H1

H1

H1

H1

H1

esults of the exercise

Health hazards: evolution and implication for public health surveillance by 2024 – French Institute for Public Health Surveillance / p. 3

- spread factors: "urbanization in France", "urbanization in the world", "risk behaviors", "trust in experts", "human-animal proximity and its health effects", "family and social links", "mobility of people and goods (trade, migration, tourism)", "trends in treatment and health care practices (antibiotic resistance)";

- response factors that may increase or decrease the events: "adaptation to the health impacts of extreme weather events", "big data", "organization of the agency system", "geographic inequalities", "perception of health risks", "prevention", "solidarity".

The micro-scenarios are: - trigger factors: "economic stagnation and social

inequalities due to health events (trend-based)", "economic recession and State disengagement", "technological innovation", "major disaster", "an active and protective State that does whatever is possible to prevent the outbreak of new diseases or health events", "State disengagement as a trigger factor of health events among the most vulnerable", "social solidarity: the ecological transition as a trigger factor?";

- spread factors: "urban concentration, uncontrolled movement of goods and people, social atomization (trend-based)", "law enforcement officials as public health actors who limit the diffusion of risks", "deregulation", "emergency scenario", "ecology", "digital";

- response factors that may increase or decrease the events: "the State manages the emergency (trend-based)", "economic ultraliberalism, State disengagement", "health at the heart of public policies", "serious economic and energy crises".

The five macro-scenarios are (table 1): - "inequalities and fragmentation: increasingly obvious

and hard to manage (trend-based)"; - "ecological transition and health promotion"; - "controlled technology development to the extent

possible"; - "global technological explosion"; - "disasters and disorganization".

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▪ Table 1 - Macro-scenarios and micro-scenarios on which they are based

Macro-scenarios Micro-scenarios constituting macro-scenarios

Triggering factor Diffusion Response

Inequalities and fragmentation: increasingly obvious and hard to

manage (trend-based)

Economic stagnation and social inequalities due to health

events (trend-based)

Urban concentration, uncontrolled movement of

goods and people, social atomization (trend-based)

The State manages the crisis (trend-based)

Ecological transition and health promotion

Social and solidarity economy and ecological transition

Diffusion controlled by the law, regulations and public policies

Health at the heart of French and European public policies

Controlled technology development... to the extent

possibleTechnological innovations

Diffusion contrôlée par le droit, la réglementation et les politiques publiques

By the private sector

Global technological explosion Technological innovationsAverage dissemination:

unregulated private initiatives as diffusion factors

By the private sector

Disasters and disorganization Great disasterExtreme diffusion due to the

disaster

The disaster that disrupts responses, breaks the trust and

aggravates inequalities

The selected issues are: - health inequalities (social and geographical), especially

for poverty-related illnesses (cancer, respiratory, cardiovascular, and nutrition diseases), access to care; identification of vulnerable populations;

- the frequency and the development of diseases and health disorders, as well as determinants with a substantial (economic and social) burden (such as neurodegenerative diseases, cancer, nutrition, and extreme weather events);

- consideration of health in both its individual (citizens responsible for their own health) and collective (vaccination, prevention) dimensions;

- using big data for health purposes; - acquisition of new technologies (measures) and follow-

up on their development; - anticipation and identification of emerging trends,

technologies, and events (environmental, infectious, behavioral, etc.): nanomaterials, new infectious risks, new behaviors, etc.;

- the combination of different geographical scales (world, Europe, France, region, city, citizen);

- integration of ethical dimensions in our work (individual and collective approaches).

ssues and needs

French Institute for Public Health Surveillance (Institut de veille sanitaire), 12 rue du Val d’Osne 94415 Saint-Maurice Cedex France – Tel.: 33 (0)1 41 79 67 00 – Fax: 33 (0)1 41 79 67 67 – www.invs.sante.fr – ISBN-NET : 979-10-289-0163-9 – Design/Production: Communication department – InVS – Legal deposit: december 2015

Suggested citation: Eilstein D, Pozuelos J, Fuchs D, Gorza M, Therre H, Xerri B, et al. Health hazards: evolution and implication for public health surveillanceby 2024. An exercise of prospective monitoring conducted by the InVS, 2014. Synthesis. Saint-Maurice : Institut de veille sanitaire ; 2015. 4 p.Available at the following URL: http://www.invs.sante.fr

To learn more

You can consult the full report (in French) from which this brochure: Eilstein D, Pozuelos J, Fuchs D, Gorza M, Therre H, Xerri B, et al. Risques pour la santé : évolution et conséquences pour la veille sanitaire à l’horizon 2024. Exercice de veille prospective InVS, 2014. Saint-Maurice : Institut de veille sanitaire ; 2015. 60 p. Available at the following URL: http://www.invs.sante.fr

Key words: prospective monitoring, epidemiologic surveillance, epidemic intelligence, public health, issues, anticipation, trends, signal, planning

The analysis of the contribution of this exercise (acquisition of new knowledge, methods, and information sources, multidisciplinary group exercise, detachment from emergencies and everyday life), and the pitfalls (difficulty in understanding the purpose and the challenges of prospective monitoring at the beginning of the process, technical difficulties linked to the lack of specific knowledge about prospective monitoring, difficulty of assessing the reliability of assumptions) has made it possible to make some recommendations about the conditions necessary for sustainable prospective monitoring at the Institute: - redefine the issues, the objectives and the purpose of

the process (including planning assistance); - strengthen and develop collaborations as part of the

merger with the Health Emergency Preparedness and Response Establishment (Eprus) and the National Institute for Prevention and Health Education (Inpes) (other health and safety agencies, research organizations, social scientists, media, social networks);

- learn the process and tools, help from an external consultant who is an expert in prospective monitoring;

- organize (identify and reserve specific time to facilitate the process, integrate it into the InVS planning process, and into the future institute);

- deliver (develop the protocol for the process, ensure that identified issues become discussion topics internally, update the variable documents);

- assess the quality of the process (inputs, time spent, etc.);

- assess the usefulness of the process.

If prospective monitoring is to remain a priority, the organization of the process will have to distinguish the periods before and after the creation of the new institute. In-house, the aim should be to ensure regular updates of the variable documents, an assessment of their status, and work every three to five years devoted specifically to the micro- and macro-scenarios. Externally, prospective monitoring meetings could be organized every year with other institutions working in the field. They could be an opportunity to exchange information on common themes, for presentations, for drafting common project descriptions for distribution.

Resources will be needed to ensure the sustainability of this work: reserved time, partnerships, services, tools (including methods and software).

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For each of these issues, needs have been identified in terms of: - research (outsourced research, mixed units, interface

contracts, etc.); - in-house methodological development;

- partnership (with agencies, other countries, etc.); - legal and ethical tools; - in-house training or recruitment (of new specialties); - organizational evolution of InVS; - prospective monitoring.

ecommendations