Contexte : Le rôle de l’exposition professionnelle aux solvants dans la survenue de cancers des voies aéro-digestives supérieures (VADS), suggéré dans quelques études, n’a été que peu examiné, malgré leur utilisation très répandue en milieu de travail. Objectif : L’objectif de cette thèse état d’évaluer les associations entre les expositions professionnelles aux solvants et le risque de cancer des VADS. Méthodes : Ce travail est basé sur les données de l’étude Icare, une large étude cas-témoins en population générale conduite en France entre 2001-2007. L’analyse a été restreinte aux hommes et a porté sur 1857 cas de carcinome épidermoïde de la cavité buccale, du pharynx et du larynx, et 2780 témoins. L’histoire professionnelle détaillée ainsi que les consommations de tabac et d’alcool ont été recueillies par questionnaire. Les expositions aux solvants ont été évaluées à l’aide de matrices emplois-expositions et incluaient cinq solvants chlorés (perchloroéthylène, trichloroéthylène, chlorure de méthylène, chloroforme, tétrachlorure de carbone), cinq solvants pétroliers (benzène ; essences carburant ; gazole, fiouls et kérosène ; essences spéciales ; white spirits) et cinq solvants oxygénés (cétones et esters ; alcools ; éther éthylique ; éthylène glycol ; tétrahydrofurane). Les odds-ratios ajustés sur les consommations de tabac et d’alcool et d’autres facteurs de confusion potentiels, et les intervalles de confiances à 95% ont été estimés par régression logistique. Résultats : Aucune association significative n’a été mise en évidence entre exposition professionnelle aux solvants chlorés, pétroliers et oxygénés étudiés et le risque de cancer de l’ensemble des VADS. Dans l’analyse par localisation, le risque de cancer du larynx augmentait significativement avec l’exposition cumulée au perchloroéthylène. Des risques élevés de cancer de l’hypopharynx, bien que non significatifs, étaient observés pour les hommes exposés à des niveaux élevés de chlorure de méthylène, de white spirits et de tétrahydrofurane. Une association entre exposition au tétrahydrofurane et cancer de la cavité buccale était également suggérée. Aucune association claire n’était observée pour les autres solvants, quelle que soit la localisation de cancer. Conclusion : Des associations positives ont été observées avec plusieurs solvants spécifiques. Toutefois, dans l’ensemble, nos résultats ne sont pas en faveur d’un rôle majeur de l’exposition aux solvants dans la survenue de cancer des VADS. / Background : The role of occupational exposure to solvents in the risk of head and neck cancer has been suggested in some studies but has been few investigated, despite their widespread use in the workplace. Objective: The objective of this thesis was to examine the associations between occupational exposure to solvents and the risk of head and neck cancer. Methods: This work is based on data from the ICARE study, a large population-based case-control study conducted in France between 2001 and 2007. The analysis was restricted to men and included 1,857 cases of squamous cell carcinoma of the oral cavity, pharynx and larynx and 2,780 controls. Detailed occupational lifetime as well as alcohol and tobacco consumptions were collected by questionnaires. Exposure to solvents was assessed by job exposure matrices and included five chlorinated solvents (perchloroethylene, trichloroethylene, methylene chloride, chloroform, carbon tetrachloride), five petroleum-based solvents (benzene; gasoline; diesel, fuels and kerosene; special petroleum products; white spirits) and five oxygenated solvents (ketones and esters; alcohols; diethyl ether; ethylene glycol; tetrahydrofuran). Odds-ratios adjusted for smoking, alcohol drinking and other potential confounders and 95% confidence intervals were estimated with logistic models. Results: No significant association was found between occupational exposure to chlorinated, petroleum-based and oxygenated solvents and the risk of head and neck cancer overall. In subsite analysis, the risk of laryngeal cancer increased with cumulative exposure to perchloroethylene. Non-significantly elevated risks of hypopharyngeal cancer were found in men exposed to high cumulative levels of methylene chloride, white spirits and tetrahydrofuran. An association between exposure to tetrahydrofuran and oral cavity cancer was also suggested. No other clear association was found for the other solvents under study, for any cancer site. Conclusion: Although positive associations were observed for several solvents, overall the results do not suggest a substantial role of exposure to solvents in head and neck cancer risk.

Objective: To determine the association between smoking and occupational exposures, and DNA methylation levels in the lung cancer-related genes, AHRR and F2RL3. Methods: CARTaGENE is the largest ongoing prospective cohort study in Quebec, Canada. Currently, a nested case-control study in CARTaGENE is examining the association between AHRR and F2RL3 gene methylation and lung cancer risk (200 cases; 400 controls). Using the methylation data measured from this nested case-control study, information on participants’ smoking behavior and longest-held occupation were obtained from questionnaires. Information on smoking status and, where applicable, the average number of cigarettes smoked, duration of smoking, and time since cessation, was parameterized into a cumulative smoking index (CSI, continuous). Occupational exposures were estimated using the Canadian Job Exposure Matrix. Eighteen agents present in the occupational environment that are also found in cigarette smoke were of interest. In DNA isolated from blood samples collected at baseline, methylation ratios of 40 CpG sites in the AHRR and F2RL3 genes were measured using the Sequenom Epityper. In each gene, average methylation levels across all CpG sites were calculated and parametrized as a continuous variable. Separate least squares regression models were used to estimate the associations between smoking and occupational exposures, and AHRR and F2RL3 methylation levels while adjusting for potential confounders identified using directed acyclic graphs. Results: In both genes, smoking was associated with lower average methylation levels after adjusting for confounding factors (AHRR: -0.014 per standard deviation increase in CSI, 95% CI: -0.019, -0.010; F2RL3: -0.019 per standard deviation increase in CSI, 95% CI: -0.025, -0.012). No association was found between the selected occupational exposures and average DNA methylation levels in the two genes. Conclusion: Our findings support the hypothesis that tobacco smoking is associated with DNA hypomethylation of the AHRR and F2RL3 genes. / Objectif: Déterminer l’association entre le tabagisme et les expositions professionnelles, et les niveaux de méthylation dans les gènes AHRR et F2RL3, deux gènes impliqués dans le cancer du poumon. Méthodes : CARTaGENE est la plus grande étude de cohorte prospective au Québec, Canada. Actuellement, une étude de cas-témoin nichée dans CARTaGENE examine l’association entre la méthylation des gènes AHRR et F2RL3 et le risque de cancer du poumon (200 cas; 400 témoins). En utilisant les données de méthylation mesurées à partir de cette étude de cas-témoin nichée, les informations à propos du comportement tabagique et de l’emploi avec la plus longue durée des participants ont été obtenues à partir de questionnaires. Les informations concernant le statut tabagique, le nombre moyen de cigarettes fumées, la durée du tabagisme et le temps depuis la cessation (quand applicable) ont été paramétrées sous la forme d’un index cumulatif de tabagisme (continu). Les expositions professionnelles ont été estimées à partir de la matrice canadienne de l’exposition professionnelle. Dix-huit agents présents dans les milieux professionnels et également présents dans la fumée de tabac ont été retenus. Les ratios de méthylation de 40 sites CpG dans les gènes AHRR et F2RL3 ont été mesurés avec le Sequenom Epityper. La moyenne des ratios de méthylation de tous les sites CpG a été calculée par gène et paramétrée comme une variable continue. Des modèles séparés de régression des moindres carrés ont été utilisés pour estimer les associations entre chacun des facteurs de risque et les niveaux de méthylation des gènes AHRR et F2RL3 tout en ajustant pour des variables confondantes identifiées à l’aide de graphes acycliques dirigés. Résultats : Le tabagisme est associé avec des niveaux moyens de méthylation plus faible dans chacun des gènes après ajustement pour les variables confondantes (AHRR : -0.014 par augmentation de l’écart-type de l’index cumulatif de tabagisme, 95% IC : -0.019, -0.010; F2RL3 : -0.019 par augmentation de l’écart-type de l’index cumulatif de tabagisme, 95% IC : -0.025, -0.012). Aucune association n’a été observée entre les expositions occupationnelles sélectionnéeset les niveaux de méthylation dans ces deux gènes. Conclusion : Nos observations indiquent que le tabagisme est associé avec une hypométhylation des gènes AHRR et F2RL3.

Les effets délétères sur la santé de certaines expositions professionnelles, prises indépendamment, ont été observés dans un large nombre d’études. Pourtant, la prévalence et l'impact de multi-exposition ou co-exposition à des diverses nuisances ont plus rarement été explorée, malgré le caractère ubiquitaire de nombreuses nuisances. Par conséquent, l’étude de multi-exposition/co-exposition dans le cadre professionnel est considérée comme un enjeu majeur de la recherche épidémiologique en santé au travail. Une revue systématique de la littérature concernant le secteur de l’agriculture a été réalisé en s'appuyant sur le titre, le résumé, et le texte intégral des 36.404 articles originaux grâce à 5 bases de données reconnues et 2 sources de données nord-américaines complémentaires. Les résultats des 15 articles inclus suggèrent que l’exposition aux multiples chimiques est significativement associée au risque de maladies respiratoires, de cancers, de dommages sur l’ADN et les cytogénétiques. L’exposition aux multiples physiques a été associée à une augmentation du risque de perte d'audition, tandis que la co-exposition aux facteurs physiques et biomécaniques a été associée à un risque accru de troubles musculo-squelettiques. Aucune étude n'a exploré la co-exposition professionnelle à des facteurs chimiques et physiques, ainsi qu'à la co-exposition professionnelle à des facteurs chimiques et biomécaniques. Les résultats de cette revue de la littérature indiquent la nécessité l’évaluer la prévalence de l’exposition professionnel à des multiples nuisances en France. Les multiple/co-expositions aux agents neurotoxiques chimiques(ANCs) et aux contraintes physiques intenses (CPIs) ont ainsi été analysées chez 5587 hommes ouvriers français des secteurs de l'agriculture, de l’industrie manufacturière, et de la construction à partir de l’enquête nationale transversale SUMER 2010. Environ 6% des ouvriers étaient co-exposés aux ANCs et CPIs dans les trois secteurs étudiés (p = 0,29). La multi-exposition aux CPIs était plus nettement plus fréquente (35%, p <0,001) que la multi-exposition aux ANCs (2%, p <0,001) chez les hommes de trois secteurs. Ces recherches mettent en évidence la nécessité de conduire davantage d’études liées à multi-exposition/coexposition professionnelle. Elles seront essentielles pour améliorer la sécurité au travail et permettre la surveillance et la prévention risques et des maladies professionnelles. / A wide range of studies has demonstrated the relationships between diverse types of occupational exposures,taken independently, and adverse health outcomes. Yet, the prevalence and impact of multiple occupational exposures or co-exposures have rarely been explored despite the ubiquity of numerous hazards. Therefore, multiple occupational exposures/co-exposures and their impact on health are considered as a major challenge of epidemiologic research inthe occupational health and safety area. A systematic review concerning the agriculture sector was carried out based on the titles, abstracts and fulltexts screening of 36,404 initial articles from 5 well-known databases and 2 North American complementary sources. The findings from the 15 papers finally included suggested that multiple chemical exposures were significantly associated with an increased risk of respiratory diseases, cancers, DNA and cytogenetic damages. Multiple physical exposures were shown to increase the risk of hearing loss while co-exposures to physical and biomechanical hazardswere associated with an increased risk of musculoskeletal disorders. However, no studies included in the systematic review explored either occupational co-exposures to both physical and chemical factors or occupational co-exposures to biomechanical and chemical factors.The results described in the systematic review raised the necessity to conduct further studies multipleoccupational exposures and co-exposures among workers. Therefore, multiple occupational exposures and coexposures’ prevalences to chemical neurotoxic agents (CNAs) and intense physical constraints (IPCs) were examined among 5,587 French male blue-collar workers (BCWs) in the agriculture, manufacturing, and construction sectors based on the cross-sectional and national SUMER 2010 survey. About 6% of male BCWs were co-exposed to IPCs andCNAs in these three sectors (p=0.29). Multiple exposures to IPCs was predominantly observed (35%, p <0.001), while multiple exposures to CNAs was much lower (2%, p <0.001) among male BCWs in three sectors.The findings highlight the necessity to carry out further studies on multiple occupational exposures/coexposures to diverse hazards and their impact on workers’ health. These further researches are required to improve occupational safety and the efficiency of health care surveillance and occupational disease prevention.

Many serious illnesses are linked to everyday exposures to toxic chemicals. In the U.S., most chemical exposure comes from common consumer products such as pesticides, fragranced products, cleaning supplies, and building materials--products so widely used that people consider them "safe." As the links between everyday toxic exposures and potential health effects become better understood, evidence increasingly shows that reducing exposures can create a healthier society. Although some individuals may choose to build a healthy home and maintain a healthy household, they are still exposed to pollutants at their residences from the actions of others, such as to pesticides that are used by neighbors, businesses, and governments. They need healthy residential developments in environmentally healthy communities. This research investigates "healthy residential developments," defined as a property that aims to reduce pollutant exposures to the extent required by vulnerable populations, which for this research are individuals with multiple chemical sensitivities (MCS). Through a case study approach, this research investigates two exemplars of healthy residential developments, and explains how and why they form and continue. It also examines their implementation methods, and implications for planning and policy. Primary data collection methods included in-person interviews, telephone interviews, and site visits. Research strategies included the analysis of interview data, and categorical aggregation using thematic categories within and across cases. The categories focused on factors of formation and continuation for the two healthy residential developments. Findings include the challenges of people disabled with MCS to find safe housing; the importance of planning to address these challenges; the role of individuals, funding, and zoning in the formation of healthy residential developments; the role of funding, safe maintenance, and property management in their continuation; and, the need for affordable and safe housing for vulnerable populations. Future research can address the need to develop methods to create and sustain healthy residential developments, understand and reduce sources of exposure that initiate and trigger chemical sensitivity, and investigate experiences and implementation strategies in other countries.

近年來許多的產險公司因為買不到比例性的天災再保險合約，不得不使用超額賠款再保險方式以規避和轉嫁天災風險，但也因此承擔相當大的天災累積風險。 本文將企業風險管理的概念引進，把保險公司的再保部門模擬成企業的風險管理部門，期能更精確地定位保險公司再保險部門的功能、應該扮演的角色及未來經營策略。 超額賠款再保險之使用與產物保險的經營關聯密切，其最重要關鍵在於風險自行承擔，因此其間的保費收入、再保費成本支出等有關費率釐定計算方式，可說是超額賠款再保險之精華所在，亦為保險相關從業人員必備之專業知識。由於超額賠款再保險運用到許多統計相關的計算說明，本文之論述期能幫助保險相關從業人員找到各方的均衡點，有助於保險事業將資源做最有效率、效能的經營。 本文針對財產保險運用超額賠款再保險經營實務之考量加以介紹，同時強調經營者必須提升專業，包括損防服務、專業化核保、作業流程電腦化、財務風險管理等，尤其在計算天災的累積和購買適當再保險的承保容量方面，這亦有助於保險公司對天災風險的評估與認識。 最後，本文籲請保險公司主管必須重視目前以超額賠款再保險風險自留方式所承保之業務其費率是否適當，尤其是天災風險，所謂多算勝，少算不勝，而況於無算乎？否則會和賭場的賭客一樣， 大部分人是輸光退場的。 / Excess of Loss Reinsurance has become the viable solution in Taiwan’s insurance community, since the constraints were imposed by reinsrers a few years ago that natural catastrophe exposures could not be fully transferred to proportional treaties. But, the insurers also take very large natural risks at the same time. The aforementioned is the key issue to be discussed at the first part of this text, which introduces the concept of “corporate risk management” that Risk Management Department in enterprise is playing a role very similar to Reinsurance Department in an insurance company. We can, from this perspective, easier and clearer identify the functions and business objectives of Reinsurance Department in an insurance company. One distinctive advantage over proportional reinsurance is that, by adopting XOL reinsurance, ceding companies can expect to retain more premiums. Virtually, the performance of XOL operations is directly linked to the level of reinsurance cost, so it is very vital for insurance people to be fully aware of the connections between their insured exposures and reinsurance prices. A number of charts, tables, and cases are illustrated in the text for the calculation of XOL prices, and readers, particularly those who are doing insurance business, of this text are able to fairly locate the equilibrium of reinsurance cost that can be mutually accepted by the insured、brokers、reinsurers and insurers. Actual practices of applying property XOL reinsurance are analyzed in the text, which has also highlighted the importance of upgrading insurers’ professionalism, including loss prevention, underwriting, work-flow computerization, financial risk management, in particular, aggregate control on natural perils and adequate reinsurance protection. My conclusions and recommendations are pinpointing the issues required to be dealt with by the authorities for the adequacy of direct premium rates, particularly for the business with natural perils that are retained under XOL programs. Insurers are destined to be out of the market, sooner or later, if they are unable to charge sufficient premiums to finance their losses in the long run.

Objectif : Ce travail s’inscrit dans le cadre d’une recherche étiologique sur les leucémies aigues (LA) de l’enfant, pathologies dont les facteurs de risque sont peu connus. Plusieurs hypothèses ont été testées : 1) le rôle protecteur d’une supplémentation maternelle en acide folique avant et pendant la grossesse et l’investigation par une approche gène-candidat du rôle de polymorphismes communs rs1801133 et 1801131 de MTHFR et rs1801394 et rs1532268 de MTRR supposés modifier le métabolisme des folates, 2) l’association entre la profession et des expositions professionnelles maternelles lors de la grossesse, 3) l’existence d’un lien positif avec l’exposition des enfants au trafic routier. Matériel et méthodes : Les données analysées proviennent d’une étude cas-témoins française, ESCALE, basée sur le Registre National des Hémopathies malignes de l’Enfant et réalisée en population générale sur la période 2003-2004. L’échantillon comportait 648 cas de leucémie aiguë lymphoblastique [LAL], 116 cas de leucémie aiguë non lymphoblastique [LANL], et 1681 témoins de moins de 15 ans. L’échantillonnage a été stratifié sur l’âge et le sexe. Les données ont été recueillies auprès des mères à l’aide d’un questionnaire téléphonique standardisé, identique pour les cas et les témoins. Les génotypes ont été obtenus par génotypage à haut débit, pangénomique pour les cas et à façon pour les témoins, et par imputation pour les polymorphismes non génotypés. Le géocodage des adresses et des indicateurs dérivés de données d’émission de trafic ont permis d’estimer l’exposition des enfants au trafic routier. Les odds ratios (OR) ont été estimés à l’aide de modèles de régression logistique non conditionnelle, incluant les facteurs de confusion potentiels. Résultats : Le risque de LA était significativement inversement associé à une supplémentation maternelle en acide folique avant ou pendant la grossesse (OR=0.4 [0.3-0.6]). Aucun des polymorphismes génétiques de MTHFR et de MTRR n’était associé au risque de LA. Cependant, le fait d’être à la fois porteur homozygote des allèles variants de l’un des polymorphismes de MTHFR, et porteur de deux allèles variants des polymorphismes de MTRR était positivement associé au risque de LA (OR=1.6 [0.9-3.1]). Nous n’observions pas d’interaction entre MTHFR, MTRR et une supplémentation maternelle en acide folique. Des associations positives et significatives on été mises en évidence entre le risque de LA et des expositions auto-déclarées professionnelles maternelles pendant la grossesse, aux teintures de cheveux (OR=3.0 [1.7-5.2]), à des peintures ou vernis et/ou colles (OR=1.5 [1.1-2.2]), et à des rayonnements ionisants (OR=2.4 [1.3-4.6]). Cependant, ces associations étaient limitées aux fréquences d’exposition de moins d’1 heure par semaine et peuvent refléter une sur-déclaration chez les cas. L’exposition maternelle professionnelle aux pesticides n’était pas associée aux LA dans notre étude.Les LA étaient significativement associées à des concentrations élevées de NO2 de fond liées au trafic estimées au lieu de résidence (OR=1.2 [1.0-1.5]) et avec la présence de routes à fort trafic dans un rayon de 500 m centré sur ce lieu (OR=2.0 [1.0-3.6]). Nous observions une association significative entre les LA et une densité élevée de routes à fort trafic dans un rayon de 500 m (OR=2.2 [1.1-4.2]), avec une tendance linéaire positive significative de l’association des LAL avec la longueur totale de routes à fort trafic dans un rayon de 500 m.Conclusion : Cette thèse apporte des arguments en faveur du rôle protecteur d’une supplémentation maternelle périconceptionnelle en acide folique. Elle suggère également un rôle des polymorphismes de MTHFR et MTRR dans le risque des LA, sans interaction toutefois avec la supplémentation. Enfin, elle renforce l’hypothèse que vivre près de routes à fort trafic pourrait augmenter le risque de LA. / Objectives: This work investigated three hypotheses related to the etiology of childhood acute leukemia (AL):1) maternal folic acid supplementation before or during pregnancy reduces AL risk, accounting for the SNPs rs1801133 (C677T) and rs1801131 (A1298C) in MTHFR and rs1801394 (A66G) and rs1532268 (C524T) in MTRR, assumed to modify folate metabolism, 2) maternal occupation and occupational exposure during pregnancy may be link to LA 3) traffic is a source of environmental exposures, including benzene, which may be related to childhood leukemia. Methods: The data were obtained from the national registry-based case-control study ESCALE, carried out in France in 2003-2004. The ESCALE study included 764 cases and 1681 controls less than 15 years old and the controls were frequency matched with the cases on age and gender. The data were collected by a standardized telephone interview of the mothers. Various indicators of exposure to traffic and pollution were determined using the geocoded addresses at the time of diagnosis for the cases and of interview for the controls. The genotypes were obtained using high-throughput platforms and imputation for untyped polymorphisms. CITP-68 classification was used to classify maternal occupation during pregnancy. Indicators of the distance from, and density of, main roads and background traffic NO2 concentrations data were used. Odds ratio (OR) were estimated using unconditional regression models adjusted for potential confounders. Results: AL was significantly inversely associated with maternal folic acid supplementation before and during pregnancy (OR=0.4 [0.3–0.6]). MTHFR and MTRR genetic polymorphisms were not associated with AL. However, AL was positively associated with homozygosity for any of the MTHFR polymorphisms and carriership of both MTRR variant alleles (OR=1.6 [0.9–3.1]). No interaction was observed between MTHFR, MTRR, and maternal folate supplementation. Significant positive associations were observed between childhood AL and self-reported maternal occupational exposures during pregnancy to hair dye (OR=3.0 [1.7-5.2]), to paints or polishs and/or glues (OR=1.5 [1.1-2.2]), and to ionising radiations (OR=2.4 [1.3-4.6]). However, these associations were limited to exposure frequencies of less than 1 hour by week. Maternal occupational exposure to pesticides during pregnancy was not related to AL. AL was significantly associated with high estimates of traffic NO2 concentration at the place of residence(OR=1.2 [1.0-1.5]) and with the presence of a heavy-traffic road within 500 meters compared to the absence of a heavy-traffic road in the same area (OR=2.0 [1.0-3.6]). There was a significant association between AL and a high density of heavy-traffic roads within 500 meters in comparison to the reference category with no heavy-traffic road within 500 meters (OR=2.2 [1.1-4.2]), with a significant positive linear trend of the association of AL with the total length of heavy-traffic road within 500m. Conclusion: The study findings support the hypothesis that maternal folic acid supplementation may reduce the risk of childhood AL. The findings also suggest that the homozygous genotype for any of the MTHFR variants and carrying both MTRR variants could be a risk factor for AL. Finally, the results support the hypothesis that living close to heavy-traffic roads may increase the risk of childhood leukemia.

Contexte: La compréhension de l’histoire naturelle de l’asthme et des allergies au cours de la petite enfance est encore parcellaire. De plus, il persiste encore des incertitudes quant à la contribution des facteurs comportementaux et environnementaux au développement de ces maladies. Objectifs: 1) Etudier l’histoire naturelle des symptômes respiratoires et allergiques chez l’enfant de 0 à 4 ans en identifiant des phénotypes basés sur ces symptômes par des analyses de cluster, 2) Caractériser ces phénotypes au regard de leurs co-morbidités et de leurs facteurs de risque, en particulier ceux liés à l’environnement de vie des enfants incluant leur exposition précoce à la pollution atmosphérique d’origine automobile (PAA). Matériel et méthodes: Ce travail de thèse s’inscrit dans le cadre du suivi de la cohorte de naissances PARIS (Pollution and Asthma Risk: an Infant Study) mise en place en 2003 et incluant 3840 nouveau-nés. Des auto-questionnaires régulièrement renseignés par les parents ont permis de documenter l’état de santé des enfants en termes de symptômes et de pathologies respiratoires/allergiques, ainsi que leur mode et cadre de vie. La sensibilisation allergénique a été déterminée par dosage des IgE spécifiques dans le sang à l’âge de 18 mois. L’exposition à la PAA intégrant les différents lieux de vie (domicile, lieu de garde) a été évaluée pour la première année de vie des enfants par un modèle de dispersion, l’indice ExTra. L’identification de phénotypes respiratoires/allergiques entre 0 et 4 ans a été effectuée par des analyses de cluster transversales et longitudinales. Les co-morbidités et facteurs de risque associés aux phénotypes ont été étudiés. Résultats : Entre 0 et 4 ans, des sifflements ont été rapportés chez 31% des enfants, et une toux sèche nocturne chez 38%. Ils sont respectivement 43% et 38% à avoir éprouvé des symptômes évocateurs de rhinite allergique et de dermatite atopique. La prévalence cumulée des maladies diagnostiquées par un médecin était de 12,2% pour l’asthme, 39,4% pour l’eczéma et 3,8% pour le rhume des foins. L’étude des trajectoires des symptômes de sifflements, toux sèche nocturne, rhinite allergique et dermatite atopique a permis d’identifier un groupe avec une faible prévalence de symptômes [n=1236, 49,0%] et quatre phénotypes respiratoires/allergiques distincts: deux transitoires («rhinite transitoire» [n=295, 11,7%] et «sifflements transitoires» [n=399, 15,8%]), non associés avec la sensibilisation IgE dépendante, et deux persistants («toux/rhinite» [n=284, 11,3%] et «dermatite» [n=308, 12,2%]), associés à la sensibilisation allergénique. Le phénotype «rhinite transitoire» était associé à l'exposition postnatale au tabagisme, pouvant irriter les voies respiratoires. Le phénotype «sifflements transitoires» était lié au sexe masculin et au contact avec d'autres enfants (frères et sœurs plus âgés, fréquentation d'une crèche). Les facteurs de risque des deux phénotypes associés aux IgE comprenaient la présence d’antécédents parentaux d'allergie, ainsi que l'exposition potentielle à des allergènes et au stress, connues pour jouer un rôle dans le développement des maladies allergiques. Nos résultats montrent également qu’au regard de la symptomatologie allergique, l’exposition précoce à la PAA semble impacter davantage certains sous-groupes d’enfants (ceux de sexe masculin, ceux ayant un terrain familial d’asthme/d’allergie et ceux dont la mère a souffert d’un problème grave de santé). Conclusion: Ce travail contribue à mieux comprendre l’histoire naturelle des manifestations respiratoires et allergiques durant les années préscolaires et suggère l'existence de différents phénotypes avant l'âge scolaire. Le fait qu'ils diffèrent en termes de facteurs de risque et de sensibilisation renforce la plausibilité de profils distincts, potentiellement liés aux irritations et aux infections pour les phénotypes transitoires, et à l'allergie pour les phénotypes persistants. / Background: The natural history of asthma and allergies during childhood is still not fully understood. In addition, there are still some uncertainties about the contribution of behavioral and environmental factors to the development of these pathologies. Objectives: 1) To study the natural history of respiratory and allergic symptoms in children from birth to age 4 years by identifying phenotypes based upon these symptoms using cluster analyses, 2) To characterize these phenotypes with regard to their comorbidity and risk factors, especially those related to the life environment of children, including their early exposure to traffic-related air pollution (TAP). Methods: This work is part of the follow-up of the PARIS (Pollution and Asthma Risk: an Infant Study) birth cohort, implemented in 2003 and including 3840 newborns. Self-administered questionnaires regularly filled in by parents were used to collect information about the health status of children in terms of respiratory/allergic symptoms and diseases, as well as about lifestyle/environment characteristics. IgE-mediated sensitisation was determined at the age of 18 months. Exposure to TAP integrating the different places of residence and day-care was assessed in the first year of life of children using a dispersion model, the ExTra index. Respiratory/allergic phenotypes were identified between 0 and 4 years by cross-sectional and longitudinal cluster analyses. Comorbidity and risk factors associated with phenotypes were studied. Results: Between 0 and 4 years, wheezing has been reported in 31% of children, and dry night cough in 38%, whereas 43% and 38% have experienced symptoms suggestive of allergic rhinitis and atopic dermatitis, respectively. The prevalence of doctor-diagnosed diseases in the first 4 years was 12.2% for asthma, 39.4% for eczema and 3.8% for hay fever. The study of joint trajectories of symptoms such as wheezing, dry night cough, allergic rhinitis and atopic dermatitis identified a group with low prevalence of symptoms [n=1236, 49.0%] and four distinct phenotypes: two transient ("transient rhinitis" [n=295, 11.7%] and "transient wheeze" [n=399, 15.8%]), without any relation with IgE sensitisation, and two persistent ("cough/rhinitis" [n=284, 11.3%] and "dermatitis" [n=308, 12.2%]) associated with allergic sensitisation. Transient rhinitis phenotype was only associated with tobacco smoke exposure, which could irritate the airways. Transient wheeze phenotype was related to male sex and contact with other children (older siblings, day-care attendance). Lastly, risk factors for both IgE-associated phenotypes encompassed parental history of allergy, potential exposure to allergens and stress, known to be associated with the development of allergic diseases. With regard to allergic symptomatology, our results also show that the impact of early exposure to TAP could be more important in some subgroups of children (boys, children with parental history of allergy, and children whose mother experienced a serious health problem). Conclusion: This work contributes to a better understanding of the natural history of respiratory/allergic symptoms during preschool years, and provides evidence for the existence of different phenotypes before school age. The fact they differ in terms of sensitisation and risk factors reinforces the plausibility of distinct profiles, potentially linked to irritation and infections for the transient phenotypes, and to allergy for the persistent phenotypes.

Epidemiological studies have shown strong and consistent associations between exposure to air pollution and increases in morbidity and mortality. Key air pollutants that have been identified include fine particulate matter (PM) and ozone (O3), both major contributors to smog. However, there is a lack of understanding of the mechanisms involved and the relative contributions of individual pollutants. A controlled human exposure facility was used to carry out inhalation studies of concentrated ambient fine particles (CAP), O3, CAP+O3 and filtered air following a randomized design. Exposures were 2 hrs in duration at rest. Subjects included mild asthmatics and non-asthmatics. This thesis focuses on acute cardiovascular responses including blood pressure (BP), brachial artery reactivity (flow-mediated dilatation [FMD]) and markers of systemic inflammation (blood neutrophils and interleukin [IL]-6). Results showed that for CAP-containing exposures (CAP, CAP+O3) there were small but significant transient increases in diastolic BP (DBP) during exposures. Furthermore, neutrophils and IL-6 increased 1 - 3 hrs after and FMD decreased 20 hrs after CAP-containing exposures. Responses to O3 were smaller, comparable to filtered air. The data suggests that adverse responses were mainly driven by PM. The DBP increase was rapid-developing and quick to dissipate, which points to an autonomic irritant response. The magnitude of the DBP increase was strongly negatively associated with the high frequency component of heart rate variability, suggesting parasympathetic withdrawal as a mechanism. In comparison, IL-6, neutrophil and FMD responses were slower to develop, indicative of an inflammatory mechanism. An intriguing finding was that IL-6 increased 3 hrs after CAP, but not after CAP+O3. Further investigation revealed that exposure to CAP+O3 in some individuals may trigger a reflex inhibition of inspiration, decreasing their tidal volume and inhaled pollutant dose, leading to a reduction in systemic IL-6, a potential protective mechanism. Together the findings support the epidemiological evidence of adverse fine PM health effects. Many questions remain to be answered about the health effects of air pollution including a better understanding of how inhaled pollutants result in cardiovascular effects. It is hoped that the insights gained from this thesis will advance the understanding of air pollution health effects.

Epidemiological studies have shown strong and consistent associations between exposure to air pollution and increases in morbidity and mortality. Key air pollutants that have been identified include fine particulate matter (PM) and ozone (O3), both major contributors to smog. However, there is a lack of understanding of the mechanisms involved and the relative contributions of individual pollutants. A controlled human exposure facility was used to carry out inhalation studies of concentrated ambient fine particles (CAP), O3, CAP+O3 and filtered air following a randomized design. Exposures were 2 hrs in duration at rest. Subjects included mild asthmatics and non-asthmatics. This thesis focuses on acute cardiovascular responses including blood pressure (BP), brachial artery reactivity (flow-mediated dilatation [FMD]) and markers of systemic inflammation (blood neutrophils and interleukin [IL]-6). Results showed that for CAP-containing exposures (CAP, CAP+O3) there were small but significant transient increases in diastolic BP (DBP) during exposures. Furthermore, neutrophils and IL-6 increased 1 - 3 hrs after and FMD decreased 20 hrs after CAP-containing exposures. Responses to O3 were smaller, comparable to filtered air. The data suggests that adverse responses were mainly driven by PM. The DBP increase was rapid-developing and quick to dissipate, which points to an autonomic irritant response. The magnitude of the DBP increase was strongly negatively associated with the high frequency component of heart rate variability, suggesting parasympathetic withdrawal as a mechanism. In comparison, IL-6, neutrophil and FMD responses were slower to develop, indicative of an inflammatory mechanism. An intriguing finding was that IL-6 increased 3 hrs after CAP, but not after CAP+O3. Further investigation revealed that exposure to CAP+O3 in some individuals may trigger a reflex inhibition of inspiration, decreasing their tidal volume and inhaled pollutant dose, leading to a reduction in systemic IL-6, a potential protective mechanism. Together the findings support the epidemiological evidence of adverse fine PM health effects. Many questions remain to be answered about the health effects of air pollution including a better understanding of how inhaled pollutants result in cardiovascular effects. It is hoped that the insights gained from this thesis will advance the understanding of air pollution health effects.

Parkinson's disease (PD) is a progressive, degenerative, neurological disease. The progressive disability associated with PD results in substantial burdens for those with the condition, their families and society in terms of increased health resource use, earnings loss of affected individuals and family caregivers, poorer quality of life, caregiver burden, disrupted family relationships, decreased social and leisure activities, and deteriorating emotional well-being. Currently, no cure is available and the efficacy of available treatments, such as medication and surgical interventions, decreases with longer duration of the disease. Whilst the cause of PD is unknown, genetic and environmental factors are believed to contribute to its aetiology. Descriptive and analytical epidemiological studies have been conducted in a number of countries in an effort to elucidate the cause, or causes, of PD. Rural residency, farming, well water consumption, pesticide exposure, metals and solvents have been implicated as potential risk factors for PD in some previous epidemiological studies. However, there is substantial disagreement between the results of existing studies. Therefore, the role of environmental exposures in the aetiology of PD remains unclear. The main component of this thesis consists of a case-control study that assessed the contribution of environmental exposures to the risk of developing PD. An existing, previously unanalysed, dataset from a local case-control study was analysed to inform the design of the new case-control study. The analysis results suggested that regular exposure to pesticides and head injury were important risk factors for PD. However, due to the substantial limitations of this existing study, further confirmation of these results was desirable with a more robustly designed epidemiological study. A new exposure measurement instrument (a structured interviewer-delivered questionnaire) was developed for the new case-control study to obtain data on demographic, lifestyle, environmental and medical factors. Prior to its use in the case-control study, the questionnaire was assessed for test-retest repeatability in a series of 32 PD cases and 29 healthy sex-, age- and residential suburb-matched electoral roll controls. High repeatability was demonstrated for lifestyle exposures, such as smoking and coffee/tea consumption (kappas 0.70-1.00). The majority of environmental exposures, including use of pesticides, solvents and exposure to metal dusts and fumes, also showed high repeatability (kappas &gt0.78). A consecutive series of 163 PD case participants was recruited from a neurology clinic in Brisbane. One hundred and fifty-one (151) control participants were randomly selected from the Australian Commonwealth Electoral Roll and individually matched to the PD cases on age (± 2 years), sex and current residential suburb. Participants ranged in age from 40-89 years (mean age 67 years). Exposure data were collected in face-to-face interviews. Odds ratios and 95% confidence intervals were calculated using conditional logistic regression for matched sets in SAS version 9.1. Consistent with previous studies, ever having been a regular smoker or coffee drinker was inversely associated with PD with dose-response relationships evident for packyears smoked and number of cups of coffee drunk per day. Passive smoking from ever having lived with a smoker or worked in a smoky workplace was also inversely related to PD. Ever having been a regular tea drinker was associated with decreased odds of PD. Hobby gardening was inversely associated with PD. However, use of fungicides in the home garden or occupationally was associated with increased odds of PD. Exposure to welding fumes, cleaning solvents, or thinners occupationally was associated with increased odds of PD. Ever having resided in a rural or remote area was inversely associated with PD. Ever having resided on a farm was only associated with moderately increased odds of PD. Whilst the current study's results suggest that environmental exposures on their own are only modest contributors to overall PD risk, the possibility that interaction with genetic factors may additively or synergistically increase risk should be considered. The results of this research support the theory that PD has a multifactorial aetiology and that environmental exposures are some of a number of factors to contribute to PD risk. There was also evidence of interaction between some factors (eg smoking and welding) to moderate PD risk.