• June 2017: Meeting of the National Steering Committee for the Gast initiative. The committee is responsible for approving the strategic directions proposed by the project team and for facilitating the implementation of the initiative’s objectives and its development. The Steering Committee is composed of representatives from the General Directorate of Labor, the Regional Directorate for Enterprises, Competition, Consumer Affairs, Labor, and Employment, the Occupational Disease Consultation Centers, the Regional Health Agencies, and Santé publique France.

• December 2017: Presentation of the Gast system to members of the Lyon Society of Occupational Medicine and Health; a focus will be placed on unexplained collective syndromes.

• December 2017: A course on managing reports of unusual health events in the workplace will be offered as part of the Master 2 in Public Health and Environmental Risks (EHESP, Paris Descartes, Paris Sud, and the University of Lorraine).

2008–2017: Ten years have passed since the first protocol was established to respond to unusual health incidents in the workplace, and ten years since the creation of the first GAST in Aquitaine. The accumulation of experience, with the rollout of GASTs (11 of 13 metropolitan regions covered in 2017) and the recurrence of alerts (40 between 2008 and 2015, including notably 40% of clustered cases, 25% involving suspected cases of occupational disease, and 15% involving exposures), justify conducting a lessons-learned review (RetEx) covering this period of implementation and development of the national occupational health surveillance and alert system.
The 10-year RetEx aims to identify strengths, weaknesses, and areas requiring vigilance in order to establish an action plan to improve the system. It is led at Santé publique France by the Occupational Health Directorate and the Regional Directorate via the Cire Nouvelle Aquitaine.
This RetEx brings together stakeholders from Santé publique France and partner members of the GASTs (Regional Occupational Health Inspection Groups), the Occupational Disease Consultation Centers (CCPP), the Poison Control and Toxicovigilance Centers (CAPTV), the Pension and Occupational Health Insurance Funds (Carsat), the National Research and Safety Institute (INRS), and the Regional Health Agencies (ARS).
In practice, it relied on a qualitative approach that allowed for the collection of insights from permanent members via a questionnaire asking about the strengths, weaknesses, and areas for improvement of the system. Three areas were identified: institutional, organizational, and scientific. In the 10 regions with a GAST in 2016, the questionnaire was completed at Santé publique France by 19 members. Outside of Santé publique France, it was completed by 17 “permanent” members, including 6 regional occupational health inspectors, 8 CCPP physicians, 2 Carsat staff members, and 1 INRS epidemiologist, as well as by 2 “guest” members, including 1 CAPTV physician and 1 ARS representative. The questionnaires were completed between April and June 2017, then analyzed from June to August. A summary was subsequently drafted, presenting the positive and negative aspects, areas requiring attention, and proposed recommendations to improve the system.
A discussion day was held on September 19, 2017, providing an opportunity to present and discuss the summary and exchange views on the proposed improvements. Working group sessions were also organized to develop an action plan based on the recommendations selected during the workshop.
Ultimately, the 10-year review of the GAST system will be documented in a report and distributed to all GAST members, whether they responded to the survey or not. Its findings and recommendations will complement the insights gained from the other two components of the internal evaluation of the GAST system. Following this evaluation process, a strategy for the development and improvement of this occupational health monitoring and alert system will be finalized by Santé publique France, in consultation with the GAST National Steering Committee.

As a reminder, the Gast system is based on the creation and coordination, within each Cire, of a group of specialists in occupational health and intervention epidemiology. It involves the Direccte and the CCPP of the university hospitals; other stakeholders may also be mobilized (Carsat, INRS, CAPTV).

Sandrine Auffinger,
Carsat Engineer, permanent member of the Centre-Val-de-Loire GAST

Have you noticed a before-and-after effect of GAST in your region?

Before GAST, our region was already operating in a highly collaborative manner. Occupational health reports for companies affiliated with the General Scheme (since I can only speak to what falls within my area of expertise) were already being handled, depending on their relevance, with the stakeholders represented within our GAST: Carsat, Direccte, occupational health services, and even CCPP. GAST, however, has made it possible to centralize alerts and introduced me to a new stakeholder, the Cire.

What has working within the GAST system brought you personally? For your practice? In your opinion, what are the main advantages and disadvantages of a GAST?

Working within the GAST brought epidemiology—with all its methodological power—into the processing of alerts and the analysis we could conduct. This allows us, for example, to draw conclusions regarding the prevalence of cancer cases within a company.
The main drawback, however, remains a lack of responsiveness due to the difficulty in finding a meeting date that suits all participants and an insufficient exchange of information within the GAST.

Is there a report that particularly stood out to you, and why?

We have had only a few reports to address since the GAST was established in 2012. However, the ongoing report regarding cases of lead poisoning linked to the removal of lead-sheathed telecommunications cables is, in my view, the most interesting.
This report mobilized a large number of stakeholders and highlights the need for effective communication between different organizations. In particular, two GASTs were brought together (the one in my region and the one in Île-de-France) to discuss this case because the employee in question lived with his family in my region but worked in Île-de-France.
As soon as I became aware of the report, I established a connection by informing the members of both GASTs about the action taken by my colleagues in Cramif’s Prevention Department, which addressed the same issue. Following this alert, together with the CCPP at the Tours University Hospital, we distributed an informational memo to occupational physicians regarding the risks posed by these removal operations. At the same time, in collaboration with the Direccte, we are currently meeting with companies whose employees are potentially exposed to this risk of lead poisoning. I am keeping both GASTs informed of our progress on the matter so that the information collected can be reported to the DGT and used at the national level. As for the employee, he has filed a claim for recognition of an occupational disease. The Caisse Primaire d’Assurance Maladie has taken charge of the case review and regularly updates me on its progress.
To date, prevention efforts have expanded, as four Carsat/Cramif offices are now involved in addressing this issue. We are currently meeting with the affected companies to verify that appropriate preventive measures have been implemented. In October 2017, this initiative was also presented at a seminar for the chemists in our funds to ensure everyone has the same level of information.

Describe how a report is handled in practice

Upon receiving a report, we schedule a conference call with the members of the Gast team. Collectively, we decide how to proceed with the case. Either it is closed without further action, with a justification for that decision, or it warrants investigation; in the latter case, we define the strategy to follow and assign roles.

In your opinion, what does the presence of a Carsat engineer in the Gast system bring to the table?

The Carsat engineer provides information on the preventive measures currently in place at companies potentially affected by an alert. They can also offer their expertise on possible substitutions when the health issue is related to the use of chemicals, consider the collective protective equipment to be implemented, and in some cases, arrange for samples to be taken or measurements to be made through the physical measurement centers or interregional chemistry laboratories of the Health Insurance network – Occupational Risks and, finally, consider the most appropriate personal protective equipment. Their presence thus helps inform discussions on cause-and-effect relationships thanks to their knowledge of companies and processes.
Thus, after reviewing the preventive measures previously requested by Carsat (or other partners in the system) from an establishment prior to the alert, GAST members may decide to wait for their implementation and verification of their effectiveness, and then confirm that the issue has been resolved. If the phenomenon recurs, the GAST must devise new avenues of investigation to develop a new intervention strategy. The consulting engineers specializing in occupational diseases at Carsat/Cramif/CGSS are organized into a network. This allows me to discuss ongoing cases or receive highly informative feedback if similar cases arise in other regions.

In your opinion, should a Carsat engineer systematically be part of the “permanent members” of each GAST?

In my opinion, yes, it is important for them to be part of it for the reasons stated above! For my part, I systematically participate in conference calls, even if the report to be addressed falls outside my area of expertise, which is limited to companies employing workers under the general social security scheme. However, I believe it is important for me to have a comprehensive view of all the reports being addressed in order to maintain my expertise.

Cases of occupational and non-occupational lead poisoning during the renovation of the underground telephone network

Nadine Fréry/Annabelle Lapostolle
Epidemiologists at the Occupational Health Directorate, Santé publique France

The Report

An alert was issued by Santé publique France on June 2, 2017, following reports of occupational lead poisoning among subcontracted employees of a major mobile phone company assigned to underground telephone network renovation sites, as well as cases of para-occupational lead poisoning among the children of at least one of these employees. Their work involved removing telephone communication cables located in underground tunnels and ducts; these used cables were sheathed in lead. This source of occupational lead exposure is well-known but was clearly poorly assessed or overlooked by employers.

Elevated Blood Lead Levels in Exposed Workers and Their Family Members

Elevated blood lead levels (>350 µg/L) were detected in the three employees and the company manager by the occupational physician and the CCPP. The blood lead level of one of them reached 1,115 µg/L. Following the ordering of blood lead level tests for this employee’s family members, the Poison Control and Toxicovigilance Center reported 4 cases of lead poisoning in children aged 4 to 12, with blood lead levels ranging from 50 to 97 µg/L; among these same siblings, a 6-month-old infant had a blood lead level of 42 µg/L. As a reminder, the threshold defining childhood lead poisoning in France has been 50 µg of lead/L since June 2015.

Measures Taken

Issuance of a health alert
Although this company employs only a few workers, the decision to alert the national health authorities and the General Directorate of Labor to this situation was based on several factors:

• the high blood lead levels measured in exposed workers;

• the clearly inadequate control of occupational exposure at this subcontracting company;

• the possible existence of the same problem of severe lead poisoning among employees of other subcontractors performing similar work nationwide;

• and finally, non-occupational exposure affecting the children of these poisoned workers.

Environmental investigation within the family involving cases of childhood lead poisoning

A specific investigation of the family of the most severely poisoned worker, following the mandatory reporting of lead poisoning cases among his children, found no domestic or environmental source of lead exposure: a public housing unit renovated in January 2016, no exposure to peeling paint, traditional cosmetics, or glazed kitchenware, etc. The negative results of this investigation therefore pointed to a work-related exposure for the children, linked to the likely massive transfer of lead dust from their father’s workplace into the home.

Therapeutic Management of Lead Poisoning

The employee with the highest blood lead level was treated at the hospital. He received chelation therapy, which reduced his serum lead concentration to less than 400 µg/L.

Action by the General Directorate of Labor

The nationwide expansion of the internet and fiber-optic networks currently underway constitutes a significant risk factor for this type of occupational lead exposure. Telecom operators often outsource this work to first-tier or even second-tier subcontractors, who do not always adhere to health and safety protocols, employ unskilled workers, and sometimes have lax standards regarding working conditions. The Director General of Labor met with the management of the mobile phone operator to inform them of the situation and ensure they implement the necessary control measures with their subcontractors, while the Occupational Health Inspection Office took charge of alerting all regional occupational health inspectors by mail so that they could relay the information to occupational physicians.
At the same time, studies and measurements conducted at construction sites by Cramif’s Prevention Department helped mobilize other Carsat offices on this issue, so that the principal contractor could raise awareness among its subcontractors regarding the health risks associated with the removal of used cables and require them to implement appropriate preventive measures.

¹Chelating agents are medications capable of binding to heavy metals in the blood, thereby facilitating their elimination via the kidneys or bile.

• Expansion of the GAST program to the entire mainland: GAST will be launched in the Provence-Alpes-Côte d'Azur and Île-de-France regions in the coming months.

• Hosting of an “occupational health alert” workshop led by ANSES and Santé publique France at the National Congress on Occupational Medicine and Health in June 2018 in Marseille.

• Continuation of the internal evaluation of the GAST system: the Retex component will be presented and discussed by the National Steering Committee in 2018.