C Amat

Anne-Pauline P Bellanger
email: apbellanger@chu-besancon.fr

F Bozon

R Léger

H Gbaguidi-Haore

P Marguet

Current practice of French health professionals regarding Japanese encephalitis vaccination Pratiques vaccinales contre l'encéphalite japonaise en France

Keywords: encéphalite japonaise, vaccination, centre de vaccination Japanese encephalitis, vaccination, vaccination center

CA was in charge of the study, which was the topic of her thesis. APB wrote the article.

FB provided her expertise on the subject. RL designed the questionnaire. HGH performed the statistical analysis. PM designed the study and provided his

Introduction

Japanese encephalitis (JE) is caused by a virus of the Flavivirus genus (Flaviviridae family) and is transmitted by Culex mosquitoes. The annual number of JE cases is estimated at 67,000 [START_REF] Campbell | Estimated global incidence of Japanese encephalitis: a systematic review[END_REF].

Although clinical JE develops in less than 1% of infected individuals, its case fatality is about 30% and it is associated with a risk of permanent neurological damage (30%-50%) [START_REF] Campbell | Estimated global incidence of Japanese encephalitis: a systematic review[END_REF][START_REF] Hills | Japanese encephalitis in travelers from non-endemic countries, 1973-2008[END_REF].

Individual risk factors usually taken into consideration are the destination, duration and season of travel, itinerary, type of accommodations and activities. However, travel-associated JE may occur among travelers of any profile.

No specific treatment is available for JE, but the disease is preventable by vaccination since IXIARO, an inactivated Vero cell culture-derived JE vaccine, was licensed in 2009 by the Center for Disease Control [START_REF] Fischer | Japanese encephalitis vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)[END_REF]. French guidelines recommend JE vaccination for adults traveling to endemic areas with extensive outdoor activities, irrespective of the duration of the stay [4].

However, health professionals have difficulties apprehending indications for JE vaccination.

An observational survey was undertaken in 2016 to assess the practice of French health professionals regarding JE vaccination.

Methods

An observational survey was conducted in 2016 as follows: standardized questionnaires were sent by email to a sample of French health professionals practicing in vaccination centers (one per center). They were asked to participate on a voluntary and anonymous basis. The addresses of vaccination centers were obtained from various sources: the website "mesvaccins.net", the website of the Travel Medicine Society (http://www.medecinevoyages.fr/), and from a previous survey on yellow fever vaccination in the elderly [START_REF] Bozon | Vaccination antiamarile du voyageur de plus de 60 ans[END_REF].

The questionnaire was designed to be short to encourage participation. It was made up of two parts: 1) five questions requesting sociodemographic details (sex, age group, number of years of practice in the vaccination center, geographical area of practice, and profession), 2) 10 practice-related questions (estimated number of JE vaccinations per year, reluctance to perform JE vaccinations, estimated frequency of JE vaccination refusal, use of the rapid protocol, booster vaccination and delay, observed adverse events, criteria taken into account to propose JE vaccination such as destination, type of travel, rainy season, and a concrete case was proposed).

The software package Stata v14.1 (StataCorp LP, College Station, TX, USA) was used for statistical analysis using Pearson's chi-square test or Fisher's exact test as appropriate, with a p-value of less than 0.05 as the threshold of statistical significance.

Results

The response rate was 38.5% (questionnaires returned completed). The answers corresponding to the first part of the questionnaires are presented in Table 1. Most of participating health professionals were physicians (93.4%) aged over 46 years (63.7%), who had been working for more than three years in a vaccination center (80.2%) (Table 1). Center East (Rhône-Alpes region -22%) and Ile-de-France (Paris area -17.6%) were the most represented areas in contrast with the North (4.4%) and Center (5.5%) areas (Table 1).

Answers corresponding to the second part of the questionnaires are presented in Table 2.

Most participating health professionals performed less than 50 JE vaccinations per year (65.9%) (Table 2). Those who had been working for more than 10 years in a vaccination center performed more than 30 JE vaccinations per year (54.8%). The proportion of health professionals performing more than 50 JE vaccinations per year was higher in mainland France than in the overseas regions (p<0.05, Fisher's exact test). Most participants declared that they were not reluctant to perform JE vaccinations (89%). Causes of reluctance mentioned by participants were primarily the vaccine cost (80%) and the difficulty to properly assess the risk for patients (20%). Patient's refusal of JE vaccination was estimated as rare by 63.7% of participants (Table 2). The statistical analysis did not show any significant differences between geographical area and patient's refusal. Most participants declared using the rapid protocol for JE vaccination (D0 + D7) (75.8%). The statistical analysis revealed that participants practicing in the overseas regions used the rapid protocol significantly less than participants practicing in mainland France (p<0.05, Fisher's exact test). More than half of participating health professionals (58.2%) declared using a booster vaccine and, for most of them, one year after the first vaccination (90.6%). Eleven per cent of participants reported adverse events.

Most participating health professionals suggest JE vaccination to people travelling to South Asia (99%) and China (72.5%). Most participants also declared taking into account the type of travel (97.9%), backpacking being the riskiest (98.9%) (Figure 1). A high proportion of participants said that they proposed JE vaccination all year round (72.5%). The questionnaire included a concrete case of a patient sightseeing for two weeks in June in Thailand, and sleeping at local people's home: 75.8% of participating health professionals declared that they would not propose JE vaccination to such patients.

Discussion

The aim of this observational survey was to investigate how French health professionals working in vaccination centers used the JE vaccination. The response rate of 38.5% was satisfactory and close to those obtained in other studies based on sending questionnaires by regular mail to family physicians [START_REF] Jeanpetit | Knowledge, attitudes and practices of primary care physicians in the Franche-Comte region (France) regarding the risk of rabies[END_REF][START_REF] Bourgeois | Alveolar echinococcosis: how knowledgeable are primary care physicians and pharmacists in the Franche-Comté region of France?[END_REF][START_REF] Piotte | Pre-travel consultation: evaluation of primary care physician practice in the Franche-Comté region[END_REF]. The use of questionnaires sent by email offered the opportunity to easily target all regions of France, including the overseas regions. Few significant statistical differences in practice were observed in the present study. One of them was the higher proportion of health professionals prescribing the JE vaccination in mainland France as compared with the overseas regions. Little data on the size and number of vaccination centers in mainland France is available to accurately interpret this result. An hypothesis could be that health professionals in mainland France tend to propose the JE vaccination more systematically.

Globally, this study highlighted that a large majority of participating health professionals were favorable to the JE vaccination. However, the cost of the vaccine is a limitation. A study analyzing reasons for refusal of recommended travel-related vaccines in American travelers revealed that 35% of those who refused JE vaccination were concerned about cost [START_REF] Lammert | Refusal of recommended travel-related vaccines among U.S. international travellers in Global TravEpiNet[END_REF]. In France, the cost of an injection of the JE vaccine is estimated at around 100 euros, which makes it one of the most expensive vaccines (the yellow fever vaccine costs about 70 euros; type A hepatitis, typhoid fever, rabies as well as meningococcal vaccines cost around 50 euros) [START_REF]Cost of vaccine per injection[END_REF]. Another practice difference concerned the rapid protocol (D0 + D7), significantly less frequently used in overseas regions than in mainland France. One hypothesis could be that travelers from mainland France do not seek information from vaccination centers early enough before the date of their departure, leaving the rapid protocol as the only option.

Although participating health professionals seemed to be aware that South Asia is endemic for JE, they do not consider India as a country at risk for JE as often as the other countries of this area. It is worth noting that India is regularly affected by outbreaks. Backpacking was considered by participating health professionals as a major risk factor for JE exposure. However, recent publications warned that business travelers should also be considered at risk of being exposed to JE, especially as business meetings are no longer organized exclusively in urban areas but also in peri-urban locations [START_REF] Deshpande | Global TravEpiNet Consortium. Use of Japanese encephalitis vaccine in US travel medicine practices in Global TravEpiNet[END_REF][START_REF] Connor | The changing epidemiology of Japanese encephalitis and New data: the implications for New recommendations for Japanese encephalitis vaccine[END_REF]. This shift increases the risk of JE exposure.

A high proportion of participants used the vaccination even if a trip was not planned during the rainy season; indeed, the risk of JE is observed all year round in tropical regions [START_REF] Connor | The changing epidemiology of Japanese encephalitis and New data: the implications for New recommendations for Japanese encephalitis vaccine[END_REF]. The concrete case proposed in the questionnaire tried to simulate a common situation encountered by health professionals in their practice as Thailand is a highly touristic country.

From 1992 to 2012, 43.6% of identified JE cases were acquired during travel to South Asia, and especially to Thailand [START_REF] Pavli | Travel-acquired Japanese encephalitis and vaccination considerations[END_REF].

The concrete case, for which most participants would not have proposed the JE vaccine, illustrates the difficulty encountered by health professionals when assessing risks. Contracting JE while traveling in Asia is rare. Travelers are 10 times less likely to contract JE when travelling than meningococcal meningitis while living in the United States [START_REF] Shlim | Japanese encephalitis vaccine for travelers: exploring the limits of risk[END_REF]. Moreover, the risk is low, especially without exposure to mosquito bites at night (camping, trekking). Assessing the risk of exposure is a delicate issue for health professionals who are responsible for implementing the current recommendations for JE vaccination. Travelers are exposed to many other diseases (malaria, dengue, typhoid fever, etc.) and non-infectious risks (e.g., cardiovascular risks), which are more frequent and common than JE. This explains why prioritizing risks cannot be avoided and also why the JE vaccination is underused.

Conclusion

The unpredictability of the epidemiology, the very low incidence of JE in travelers, and the high cost of the vaccine do not facilitate risk assessment and compliance with the current recommendations for JE vaccination among health professionals.

Figure 1 .Figure 1 .

 11 Figure 1. Types de voyages pour lesquels la vaccination était proposée Figure 1. Types of travel considered for JE vaccination

Table 1 .

 1 Geographical and demographical distribution of participating health professionals. Répartition géographique et démographique des professionnels de santé ayant participé à l'étude.

			98.9%
				29.2%
		6.7%
	2.2%
	Seaside	Package Tour	Backpacker	Business Travel

Duration of practice in a vaccination center

	Less than 3 years	18	19.8
	Between 3 and 10 years	31	34
	More than 10 years	42	46.2
	Profession
	Physician	85	93.4
	Nurse	6	6.5

Acknowledgements

We would like to thank Pamela Albert for editorial assistance.

Declaration of interests

The authors declare no conflict of interests.


Marion Glavier

Mathieu Puyade

France Roblot

MD Blandine Rammaert
email: blandine.rammaert.paltrie@univ-poitiers.fr

Vaccination of cancer patients treated with chemotherapy: a survey among general practitioners

Keywords: Cancer, chemotherapy, malignant blood disease, vaccination

Objectives. Despite specific recommendations issued by the French Public

Health Council (Haut Conseil de Santé Publique), the vaccination coverage of patients with cancer or malignant blood disease remains insufficient. The aim of this study was to assess the vaccination of chemotherapy patients by their general practitioner (GP).

Methods. A survey was conducted between March and July 2017 in 4 French departments to describe the immunization practices of GPs for their chemotherapy patients and provide solutions to help to increase the vaccination rate.

Results. Of the 1,610 GPs who received the questionnaire, 287 (17.8%) returned a usable form. 92.6% were globally pro-vaccine. One third of GPs (37.3%) declared that they vaccinated all their chemotherapy patients. The GPs (n = 180) who never or only sometimes vaccinated their chemotherapy patients mainly voiced concerns about not being properly trained (45.6%) and the lack of easily available information on vaccination (35.0%). Three-quarters (n = 212; 74%) of the GPs wanted to improve their level of medical knowledge via continuing education (52.4%) or by reading guidelines available on-line (39.6%). GPs suggested that a specific vaccination schedule be included in the letter they receive from the cancer specialist (72.8%) and that patient awareness be increased (50.5%) Conclusions. GPs are in favor of the vaccination of cancer patients. The main obstacles stated are the lack of education and the lack of easily available information.

Vaccination coverage could be increased by improving the doctor-to-doctor relation between GPs and cancer specialists.

INTRODUCTION

The World Health Organization (WHO) estimates that vaccination avoids 2 to 3 million deaths annually. In 2016, 130 countries had reached infant vaccination rates of at least 90% for diphtheria, tetanus and whooping cough [START_REF] Rammaert | Couverture vaccinale[END_REF]. In France, for three decades now, there is a feeling of relative mistrust in vaccination in the general population. While the vaccination rate is appropriate in children, it is much less so in adults. The last nationwide vaccination coverage data were published in 2002 and showed that only 58.4% of adults were up to date with their diphtheria vaccine, 66.1% with tetanus and 63.4% with polio, which means that 40% of the adult population is not correctly protected [START_REF] Beytout | Description du statut vaccinal de la population adulte française[END_REF].

The results are of even more concern in immunocompromised patients.

Patients treated with chemotherapy for a solid tumor or malignant blood disease should be immunized against invasive pneumococcal disease and seasonal influenza. A booster vaccine against diphtheria, tetanus and polio is also required six months after the end of treatment. In 2013, the AVNIR study, an anonymous online survey of 3,653 immunocompromised patients, 294 of whom had been treated with chemotherapy, revealed that only 72% of patients were immunized against influenza and 39% against pneumococcal disease [START_REF] Loubet | Attitude, knowledge and factors associated with influenza and pneumococcal vaccine uptake in a large cohort of patients with secondary immune deficiency[END_REF].

Despite specific national recommendations [START_REF] Hcsp | Vaccination des personnes immunodéprimées ou aspléniques[END_REF], the vaccination rate of immunocompromised oncology-hematology patients is still far from satisfactory.

Immunization is generally performed by local general practitioners (GPs) who are globally pro-vaccination [START_REF] Collange | Vaccinations : attitudes et pratiques des médecins généralistes[END_REF]. This study assumed that cancer patients treated with chemotherapy were rarely immunized by their GP and investigated the reasons that prevented such vaccination. Once the obstacles hindering immunization were identified, we suggested ways of improving the vaccination coverage rate.

MATERIAL AND METHODS

Study design. This study is based on a survey, sent to general practitioners, to describe vaccination practices for patients with cancer or malignant blood disease treated with chemotherapy. The following exclusion criteria were applied: retired GPs, new GPs registered in 2017, full-time hospital doctors, doctors who are neither primary care physicians nor self-employed, doctors who practice only as mesotherapists, acupuncture physicians, homeopathic physicians or chiropractors.

Study

Data collection. GP practices were contacted one by one between March 15 and

July 15, 2017, using the telephone directories available on Internet and asked by which means they preferred to receive the study questionnaire: fax, postal mail or email. The questionnaire consisted of 10 questions (see Supplementary figure). The demographic data collected for the GPs were: sex, start of practice (year), kind of practice, estimated total number of patients. Their general acceptance of vaccination was evaluated. GPs were asked to estimate the number of adult patients who received chemotherapy in 2016, the number who were given a prescription for immunization, and the number of chemotherapy patients who were actually immunized. They were also asked to assess the obstacles that hinder vaccination, their need for education on the vaccination of chemotherapy patients, and to propose potential solutions for improving the vaccination coverage of this at-risk patient population. A 5-point Likert scale including the category "Don't know" was used [START_REF] Likert | A technique for the measurement of attitudes[END_REF].

Statistical analysis.

Quantitative variables are reported as mean ± standard deviation (SD). Qualitative variables are reported as percentages with the 95% confidence interval (CI95). The qualitative data for the GPs included in the study were compared with the data for all GPs registered in the 4 departments by means of a Chi2 test. The significance threshold applied was p < 0.05. The primary endpoint was the proportion of general practitioners that immunized their cancer or malignant blood disease patients who were currently treated, or had been treated during the previous year with chemotherapy. Secondary endpoints were analyzed by logistic regression and were the proportion of vaccine recommendations fulfilled in immunocompromised patients treated with chemotherapy. Variable collinearity was tested. Variables with a p-value < 0.25 as determined by univariate analysis were then included in multivariate analysis, following log-linear assessment of quantitative variables. Bivariate interactions with a p-value < 0.25 were included. Finally, multivariate logistic regression analysis was performed using a descending stepwise selection procedure that first removed interactions, then variables with a p-value > 0.05. The goodness of fit of the model was determined using the Hosmer-Lemeshow test. Analyses were carried out using SAS9.4 (NYC, USA).

RESULTS

Study population. In all, 1,610 GPs working in 806 private primary care practices were contacted. Among the 708 practices (87.8%) that agreed to receive the questionnaire: 105 received it by fax, 317 by postal mail, and 286 by email. In all, 298 self-employed GPs (17.7%) completed the survey, and 287 questionnaires could be processed (Figure 1). GP demographic data is provided in Table 1. The population of GP responders was representative of the overall GP population in the 4 departments (p = 0.775). GPs who had been practicing medicine for over 30 years represented 29.6% of the sample (n = 85), those practicing for less than 10 years represented 26.8% (n = 77). On average, GPs cared for a pool of 1,203 ± 523 patients, among which 13 were treated with chemotherapy (that is 1.0% of the practice population). Most GPs (92.8%) were pro-vaccine or strongly pro-vaccine in general (Figure 2). Vaccination of chemotherapy patients by their GPs Only 37.3% (n = 107; CI95 [33-41%]) of GPs in the sample stated that they vaccinated all of their chemotherapy patients as per recommendations, 58.2% (n = 167; CI95 [54-62%]) vaccinated only certain patients, and 4.5% (n = 13; CI95 [3-7%]) vaccinated none of their patients. In the study sample, 32.4% (n = 93) of GPs said they had prescribed vaccination for at least half of their chemotherapy patients, and 67.6% (n = 194) for less than half of their patients. For example, in the Vienne department and according to health insurance services, 27.7% patients treated for cancer or blood disease were vaccinated against influenza between September 1, 2016 and March 31, 2017.

19.2% (n = 55) of GPs stated that they thought that their patients received a prescription for vaccination from the oncologist or hematologist. Multivariate analysis that took into account confusion factors (Table 2) showed that the 107 GPs who implemented the guidelines for vaccination were three times more likely to be willing to receive education on the vaccination of chemotherapy patients (OR = 3.23 [1.85-5.66]; p < 0.001).

Obstacles hindering the vaccination of chemotherapy patients. In the questionnaire, GPs who only vaccinated certain patients or vaccinated no patients

were asked what they believed the reasons that prevented vaccination were. There were no significant differences in the number of years of medical practice or the location of the practice (rural or urban area) between the GPs who stated that they vaccinated all their chemotherapy patients and those who did not. Among the 180 GPs (62.7%) who did not vaccinate all their chemotherapy patients, 45.6% (n = 82) mentioned inappropriate training and 35.0% (n = 63) stated they found no readily available information to overcome this drawback. At the same time, 39.4% (n = 71) stated they experienced difficulties trying to convince their patients, and for 23.9% (n = 43) of GPs the lack of vaccination was due to patient refusal. The brevity of primary care consultations were also a limiting factor for 14.4% (n = 26) of GPs.

DISCUSSION

The global opinion of general practitioners about vaccination has been repeatedly addressed in the literature [START_REF] Massin | Opinions et pratiques d'un panel de médecins généralistes français vis-à-vis de la vaccination[END_REF]. However, their position about the vaccination of immunocompromised patients is much less documented [START_REF] Wong | Increased risk of invasive pneumococcal disease in haematological and solid-organ malignancies[END_REF]. This survey that included 287 French GPs is to our best knowledge the first study to investigate vaccination by GPs in patients treated with chemotherapy for a solid tumor or malignant blood disease. Only one third of the GPs stated that they vaccinated all their chemotherapy patients (or patients having received chemotherapy) as per the guidelines. This subgroup of GPs showed raised awareness compared with other GPs about their need for education. The results of our survey are in line with a study conducted by the cancer center for the same French region that receives the patients of the four departments. The authors of that study demonstrated poor influenza vaccine coverage (33.5%) and very low antipneumococcal vaccine coverage (7.9%) [START_REF] Monier | Enquête sur la vaccination des patients d'onco-hématologie dans un pôle régional de cancérologie[END_REF]. Despite these findings, 92.6% of the GPs who responded to the survey stated that they were globally pro-vaccine. This is similar to national figures [START_REF] Massin | Opinions et pratiques d'un panel de médecins généralistes français vis-à-vis de la vaccination[END_REF] with over 95% of GPs claiming to be pro-vaccine. These figures are nevertheless tempered when GPs are questioned about a particular vaccine. For example, similarly to British GPs, French GPs are less favorable to the hepatitis B vaccine with only 69% of favorable British GPs and [START_REF] Mytton | Knowledge, attitudes and beliefs of health care workers towards influenza vaccination[END_REF] 74% of favorable French GPs [START_REF] Massin | Opinions et pratiques d'un panel de médecins généralistes français vis-à-vis de la vaccination[END_REF].

There are probably several explanations behind this poor vaccination coverage rate. In the subgroup of GPs who provided reasons to justify why they did not vaccinate all their chemotherapy patients, 45.6% complained of a lack of appropriate training. In a nationwide study on how 6 th -year medical school students felt about their initial education on vaccination, 33% stated that globally they did not feel adequately prepared for future practice [START_REF] Kernéis | Vaccine Education of Medical Students: A Nationwide Cross-sectional Survey[END_REF]. GPs often recommend the vaccines for which they feel comfortable about explaining to the patients the benefits and risks and when they trust the official sources of information. On the other hand, they are less likely to recommend a vaccine that they feel is associated with frequent adverse effects or if they doubt its clinical relevance [START_REF] Yaqub | Attitudes to vaccination: A critical review[END_REF][START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF]. In a survey conducted in 2014 by the French Directorate for Research, Evaluation studies and Statistics (DREES) and including over 1,500 GPs, 32% of the participants stated that the vaccine against seasonal flu contains an adjuvant (which is not the case) and 43% did not express an opinion [START_REF] Collange | Vaccinations : attitudes et pratiques des médecins généralistes[END_REF]. Only 6.7% of the GPs taking part in our study and questioned about the obstacles for vaccination claimed to be convinced of the safety of vaccines for chemotherapy patients. As a general rule, many GPs seem to doubt the usefulness of vaccines. A study conducted by Verger et al. that included 1,712 French GPs demonstrated that 16% of GPs never recommended any particular vaccine and 43% provided different levels of recommendation depending on the vaccine [START_REF] Verger | Vaccine Hesitancy Among General Practitioners and Its Determinants During Controversies: A National Cross-sectional Survey in France[END_REF]. This is not observed in France alone. In 2017, a meta-analysis conducted by Paterson et al. showed that articles addressing vaccination hesitancy among health professionals originated from 33 different countries. Among these countries, the most represented were the United States (16%), the United Kingdom (14%) and China (7%) [START_REF] Dubé | Vaccine hesitancy: an overview[END_REF].

The lack of easily available information was also an obstacle for 35.0% of the GPs. They often see the complexity of the immunization schedule and its constant changes to include new vaccines and new guidelines as a constraint [START_REF] François | Hepatitis B virus vaccination by French family physicians[END_REF]. To this should be added a new tendency to critic official recommendations and guidelines, that they consider to be ill-suited to primary care practices and to the patients themselves [START_REF] Clerc | General Practitioners and Clinical Practice Guidelines: A Reexamination[END_REF]. It is therefore obvious that if a physician expresses reservations over the usefulness of a vaccine, he/she will be less likely to recommend it to his/her patients and less likely to answer the patient's questions about the safety of vaccination in a satisfactory manner [START_REF] Paterson | Vaccine hesitancy and healthcare providers[END_REF]. In our study, 39.4% of GPs claimed to experience difficulties when trying to convince their chemotherapy patients about vaccination when the patients were not aware of the risks.

Many infectious diseases have disappeared from western countries but are still not fully eradicated. When the patient perceives that he/she is not at risk, then GPs are confronted with their refusal to be vaccinated, as for 23.9% of the cases in our study. Confusion between adverse events and adverse effects has given rise to much controversy since the end of the 90s, for example neurodegenerative diseases imputed to hepatitis B vaccination [START_REF] Hernán | Recombinant hepatitis B vaccine and the risk of multiple sclerosis[END_REF] and criminal complaints filed for adverse effects attributed to the vaccine against papillomavirus. A link between autism and the MMR vaccine was suggested in a study on 12 cases published in 1998 in the Lancet [START_REF] Wakefield | RETRACTED: Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children[END_REF]. There was no serious scientific basis behind this affirmation and it has since been dismantled by numerous studies using sound methodologies [START_REF] Taylor | Measles, mumps, and rubella vaccination and bowel problems or developmental regression in children with autism: population study[END_REF][START_REF] Madsen | A Population-Based Study of Measles, Mumps, and Rubella Vaccination and Autism[END_REF][START_REF] Mäkelä | Neurologic Disorders After Measles-Mumps-Rubella Vaccination[END_REF].

However, the rumor caused by this assertion led to a decrease in the vaccination coverage rate in English-speaking countries and an increase of the incidence of measles and the related morbidities. The presence of aluminum in some vaccines is also controversial. The debate about macrophagic myofasciitis that arose exclusively in France, originated from the results reported by a single team, now largely proven wrong [START_REF] Park | Macrophagic myofasciitis unrelated to vaccination[END_REF]. The inappropriate management of the vaccination campaign during the 2009 H1N1 flu pandemic also contributed to the global feeling of discontent, both in patients and health professionals, even those in favor of vaccination [START_REF] Schwarzinger | Positive attitudes of French general practitioners towards A/H1N1 influenzapandemic vaccination: A missed opportunity to increase vaccination uptakes in the general public?[END_REF].

Despite the doubts voiced by patients, and sometimes by doctors, the benefits of vaccination have been ascertained and due to the efficacy of vaccines, the individual and collective memories of the diseases they prevent are being forgotten.

Discussing the respective risks and benefits of vaccination assumes that doctors are better informed than their patients. However, it should be noted that 73.9% of them requested education on vaccines via various complementary means and materials.

Continuing medical education, easier access to guidelines and articles in medical journals are the main means of providing information to GPs found in the literature [START_REF] Pham | Médecins généralistes : de quelle information avons-nous besoin ? : une étude quantitative auprès des médecins adhérents à l'Unaformec RA[END_REF]. According to a study on GPs working in rural areas in three different countries, distance learning is also a relevant tool, as shown in our study [START_REF] Gagnon | Internet: un moyen alternatif au présentiel pour la formation pédagogique de médecins isolés?[END_REF]. Distance learning is more readily accessible, would therefore help train a greater number of GPs, and would be just as efficient as face-to-face education.

In our study, 72.8% of the GPs stated that a vaccination schedule should be included in the letter they receive from the oncologist. Many GPs criticize a lack of communication and coordination between hospital doctors and primary care practices [START_REF] Piterman | Part II. General practitioner-specialist referral process[END_REF][START_REF] Martinez | L'engagement des médecins généralistes français dans la vaccination : l'étude DIVA (Déterminants des Intentions de Vaccination)[END_REF], and take for example hospital reports that are of little use to GPs [START_REF] Hubert | Information médicale : de l'hôpital à la ville. Que perçoit le médecin traitant ?[END_REF].

According to a study performed in 2004 by DREES and the French National Institute of Health & Medical Research (INSERM), patients being treated by chemotherapy globally declared to be satisfied by the information provided by their oncologist or organ specialist, but considered in 33% of cases that "too much information" was provided and in 48% of cases that it "was too complicated" [START_REF] Corroler-Soriano | Les conditions de vie des patients atteints du cancer deux ans après le diagnostic[END_REF]. Providing different kinds of crucial information when announcing to a patient that he/she has a solid tumor or malignant blood disease explains why vaccination might seem to be of lesser importance during this period. However the risk of contracting pneumococcal disease is 12 to 14 times higher for patients with acute leukemia or lung cancer than in the general population [START_REF] Wong | Increased risk of invasive pneumococcal disease in haematological and solid-organ malignancies[END_REF], and flu-related mortality ranges from 11-33% in cancer patients, depending on studies [START_REF] Kunisaki | Influenza in immunosuppressed populations: a review of infection frequency, morbidity, mortality, and vaccine responses[END_REF].

The challenge of including vaccination in chemotherapy patient follow-up when only a very few such patients are followed by each GP (approx. 1%) and because they consult their GP less during chemotherapy because of their frequent visits to the onco-hematology department, are some of the reasons that explain the suboptimal vaccination rate. Although the vast majority of GPs are in favor of the outpatient management of cancer and blood disease patients [START_REF] Laouisset | Le médecin généraliste face à la prise en charge des patients atteints de cancer[END_REF], some insist that in fact they receive very few visits from chemotherapy patients during this period [START_REF] Anvik | When patients have cancer, they stop seeing me » -the role of the general practitioner in early follow-up of patients with cancer -a qualitative study[END_REF]. At the same time, oncologists report that they receive an increasing number of requests from their patients during their treatment about primary care conditions.

The French healthcare authorities, in collaboration with public consultation and several patient associations have proposed to create an individual electronic vaccination record, as suggested in our study [START_REF]Concertation citoyenne sur la vaccination[END_REF]. Other measures have also been considered such as simplifying the vaccination schedule, regaining patient trust by a greater transparency of the proceedings of health authorities and more involvement of public health services via the vaccination of immunocompromised patients in hospitals. The latter was approved by one third of the GPs who took part in our study.

This study has a few limitations. Due to controversy that exists only in France regarding the potential harmfulness of some vaccines that significantly increases vaccination hesitancy, some of our results apply only to France. On the other hand, the solutions we suggest could be applied in other countries [START_REF] Yaqub | Attitudes to vaccination: A critical review[END_REF][START_REF] Larson | Measuring vaccine confidence: analysis of data obtained by a media surveillance system used to analyse public concerns about vaccines[END_REF]. Furthermore, even though the size of our sample of GPs is limited compared with the 88,886 GPs practicing in France in 2016, it is representative of the GPs in 4 French departments and the participation rate obtained is higher than for other similar studies [START_REF] Rouge | La prise en charge par le médecin généraliste du patient atteint de cancer : enquête de pratiques dans la région Midi-Pyrénées[END_REF].

It should also be noted that the study is based on declarative data. It is therefore subject to the same biases as other surveys on declarative data. There is potentially a selection bias caused by the fact that doctors in favor of vaccination are more likely to respond to this kind of survey. Declarative bias is also possible, that is a difference between the doctors' opinions, their declared vaccination practices and their real practices. Finally, memory bias should also be taken into consideration, mainly because of the low number of chemotherapy patients followed by each GP and their less frequent visits during chemotherapy [START_REF] Anvik | When patients have cancer, they stop seeing me » -the role of the general practitioner in early follow-up of patients with cancer -a qualitative study[END_REF].

CONCLUSION

Despite being regarded as central for prevention practices, GPs do not always follow current recommendations and routinely vaccinate their chemotherapy patients.

According to primary physicians, the lack of easily available up-to-date information and education are a serious obstacle when trying to convince vaccine hesitant patients. The solutions put forward are based on continuing medical education, articles in medical journals and specific recommendations. Increasing the vaccination coverage rate in chemotherapy patients will also be achieved by improving the coordination between hospital services and outpatient care. Information and instructions on both preventive measures via vaccination and treatment when necessary should be included in the letter the GP receives from the oncologist or hematologist. This study also reveals that GPs call for stronger involvement of public authorities by providing better information on vaccination for patients.

  population. Doctors registered in 2016 with the French Medical Association (Conseil National de l'Ordre des Médecins) as working actively as a general practitioner, either partially or totally self-employed (self-owned private practice), in four departments in the west of France (Vienne, Deux-Sèvres, Charente, Charente Maritime). Based on the data collected by the French National Institute of Statistics and Economic Studies (Institut National de la Statistiques et des Etudes Economiques, INSEE), 1,683 GPs were registered in these 4 departments on January 1, 2016, that is a density of 1 GP for 1,075 inhabitants. Among the 88,886 GPs registered in France in 2016, 63.4% were either totally or partially selfemployed (i.e. 56,353).

Finally, 6 .Figure 3 .

 63 Figure 3. The GPs who suggested including a vaccination schedule in the letter from

Figure 1 .

 1 Figure legend

Figure 2 .

 2 Figure 2. Opinion on vaccination among the 287 French general practitioners who

Figure 3 .

 3 Figure 3. Solutions proposed by general practitioners to improve the vaccination

Figure 2 .

 2 Figure 2. Opinion on vaccination among the 287 French general practitioners who

Figure 3 .

 3 Figure 3. Solutions proposed by general practitioners to improve the vaccination

Table 1 .

 1 Demographic characteristics of the 287 French general practitioners questioned about the vaccination of their chemotherapy patients

	Study population.	All GPs in the
		4 departments*
	n (%)	n (%)

Table 2 .

 2 Univariate and multivariate analysis regarding compliance with recommendations in the population of 287 French general practitioners

	Variable	Univariate	Multivariate analysis
		analysis
			OR (CI95)	p value
	Sex	0.95
	1st year of practice	0.18
	Total number of	0.62
	patients
	Kind of practice	0.22
	Number of	0.52
	chemotherapy patients
	Opinion on vaccination	0.05		0.50
	Need for information	< 0.001	3.23 (1.85-5.66)	< 0.001
	OR: Odds Ratio; CI95: 95% confidence interval

AUTHOR CONTRIBUTIONS

MG, BR, and FR designed the study protocol. MP performed statistical analyses. MG collected the data. MG, BR, and MP analyzed the data. MG and BR wrote the manuscript. All authors read and approved the complete manuscript.

FINANCIAL SUPPORT

None


Jabiol Jérémy
email: jeremy.jabiol@gmail.com

Fanny Colas

François Guérold

Cotton-strip assays: Let's move on to eco-friendly biomonitoring!

Keywords:

There is increasing recognition that functional bioindicators are needed for ecosystem health assessments. In this perspective, cotton strip assays are widely considered as a standard method to account for organic matter decomposition in streams. However, cotton cultivation and manufacture raise both environmental and societal dramatic issues that are -in our opinion -irreconcilable with the objectives of bioindication. In this study, we assessed the relevance of four alternative -eco-friendlytextiles (made of organic cotton, hemp and linen) by comparing their chemical composition and degradation rates in six streams. Chemical composition exhibited low variations among textiles, but contrasted sharply with the expectation that cotton is mostly composed of cellulose. Moreover, surprisingly high nutrient (0.49% N) contents occurred in the conventional cotton strips compared with the organic textiles (N < 0.12%). All textiles provided similar degradation rates across the six streams, meaning that they could be interchangeably used as alternatives to conventional cotton strips.

We thus call for the adoption of such ethical and eco-friendly tools as 'next-generation' indicators for the functioning of stream ecosystem.

Introduction

The global trend of decreased water quality [START_REF] Vörösmarty | Global threats to human water security and river biodiversity[END_REF] and aquatic biodiversity worldwide [START_REF] Dudgeon | Prospects for sustaining freshwater biodiversity in the 21st cen-tury: linking ecosystem structure and function[END_REF] urges the development of reliable and standardized indicators of the ecological status for water bodies. Historically based on the species composition of aquatic communities, mounting evidence indicates that bioindication approaches could be enriched by the quantification of ecosystem functions (i.e. functional indicators), as straightforward links to ecosystem services. The decomposition of terrestrial leaf litter -a key process in many streams -has been recommended for that purpose [START_REF] Gessner | A case for using litter breakdown to assess functional stream integrity[END_REF][START_REF] Chauvet | Litter decomposition as an indicator of stream ecosystem functioning at local-to-continental scales : Insights from the EUropean RivFunction project[END_REF], since it is known to be largely affected by anthropogenic perturbations such as acidification [START_REF] Ferreira | Leaf litter decomposition as a bioassessment tool of acidification effects in streams: Evidence from a field study and meta-analysis[END_REF], hydromorphological alterations [START_REF] Colas | Scale dependency in the hydromorphological control of a stream ecosystem functioning[END_REF], or contamination by nutrients [START_REF] Ferreira | A metaanalysis of the effects of nutrient enrichment on litter decomposition in streams[END_REF], pesticides [START_REF] Rasmussen | Impacts of pesticides and natural stressors on leaf litter decomposition in agricultural streams[END_REF], and heavy metals [START_REF] Ferreira | Effects of anthropogenic heavy metal contamination on litterdecomposition in streams: A meta-analysis[END_REF]. The use of litter decomposition as a functional indicator, however, poses some issues of standardization, since variations in litter quality (even within species) has a tremendous influence on decomposition rates [START_REF] Lecerf | Intraspecific variability in leaf traits strongly affects alder leaf decomposition in a stream[END_REF]. This shortcoming can be overcome by the use of a standard cellulosic substrate (e.g. cotton) as a surrogate for organic matter decomposition [START_REF] Tiegs | Cotton strips as a leaf surrogate to measure decomposition in river floodplain habitats[END_REF]. Cotton-strip assays repeatedly provided satisfactory results as an indicator of stream ecological status [START_REF] Imberger | Searching for effective indicators of ecosystem function in urban streams: assessing cellulose decomposition potential[END_REF][START_REF] Tiegs | A standardized cotton-strip assay for measuring organic-matter decomposition in streams[END_REF], and are on track to become a key routine indicator of aquatic ecosystem health [START_REF] Tiegs | Global patterns and drivers of ecosystem functioning in rivers and riparian zones[END_REF].

Cotton textile is produced from shrubs belonging to the genus Gossypium (Malvaceae). Its cultivation heavily relies on fertilizers, pesticides and irrigation, which raises both environmental and societal issues [START_REF] Chen | Environmental analysis of textile products[END_REF][START_REF] Chapagain | The water footprint of cotton consumption: An assessment of the impact of worldwide consumption of cotton products on the water resources in the cotton producing countries[END_REF]. A well-known example is the drying, pollution and salinization of the Aral Sea that followed the exponential development of cotton production during the 1960s' [START_REF] Aladin | Changes in the Aral Sea ecosystems during the period 1960-1990[END_REF][START_REF] Micklin | The Aral Sea disaster[END_REF]. Not only the cultivation, but also the processing of fibers to fabrics leads to the abstraction and/or contamination of surface waters [START_REF] Chapagain | The water footprint of cotton consumption: An assessment of the impact of worldwide consumption of cotton products on the water resources in the cotton producing countries[END_REF]. Other consequences of cotton production include the exposure of cotton growers to pesticides, which causes health and fertility issues (e.g. [START_REF] Rupa | Chromosomal aberrations in peripheral lymphocytes of cotton field workers exposed to pesticides[END_REF][START_REF] Rupa | Reproductive performance in population exposed to pesticides in cotton fields in India[END_REF] for which the only alternative seems to be the use of transgenic cotton [START_REF] Hossain | Genetically modified cotton and farmers' health in China[END_REF][START_REF] Morse | Environmental impact of genetically modified cotton in South Africa[END_REF], a remedy that is also subject to controversy [START_REF] Liu | Development time and resistance to Bt crops[END_REF][START_REF] Dhurua | Field-evolved resistance to Bt toxin Cry1Ac in the pink bollworm, Pectinophora gossypiella (Saunders) (Lepidotera : Gelechiidae), from India[END_REF]. Ironically, cotton production is mostly distributed in areas where water abstraction and pollution (e.g. arid climates), access to health care, and costs associated with chemicals or transgenic seeds supply (e.g. developing countries) are a paramount concern for ecosystems and human populations.

An improvement of the cotton strip assay could thus be achieved by using a more sustainable substrate derived from organic production chains, including organic cotton and/or other textile fibers such as hemp (Cannabis sativa L.) and linen (Linum usitatissimum L). Hemp and flax cultivation is considered environmental friendly (EEA, 2007;[START_REF] Piotrowski | Ecological benefits of hemp and flax cultivation and products[END_REF] as it requires lower pesticides (particularly hemp), fertilizers (particularly flax) and irrigation than cotton. In this study, we compared the degradation of 'conventional' cotton with various organic textiles (cotton, hemp, linen and a mix of hemp and cotton) in 6 headwater streams. We aimed to determine if they would provide satisfactory alternatives to 'conventional' cotton materials as bio-indicators, i.e comply with the following: exhibit degradation rates that are similar and equally affected by environmental conditions (i.e. exhibiting similar variations across environmental contexts) than 'conventional' cotton. Finally, we expected that differences in the degradation rates among textiles could be related to contrasting chemical composition.

Methods

The different textiles included 'conventional' unbleached cotton (CFT E-222, Testfabrics, St Gallen, Switzerland) as well as several organic textiles certified by 'Global Organic Textile Standards' label, including cotton (13/CT-001, La Cantate du Chanvre, Dole, France), hemp (POLLEN, Naturellement Chanvre, Coudeyras, France) linen (Bio Tissus, Plouzané, France) and a cotton-hemp mix (5TX-3000, La Cantate du Chanvre, Dole, France). All exhibited similar grammage (200-250 g.m - 2 ). The chemical analysis of textiles was performed on ground material (Retsch MM400 ball mill).

Carbon and nitrogen contents were determined using a CHN analyser (Carlo Erba NA 2100), phosphorus was determined spectrophotometrically after digestion in persulfate [START_REF] Ebina | Simultaneous determination of total nitrogen and total phosphorus in water using peroxodisulfate oxidation[END_REF], and fiber content using the Goering & Van Soest method [START_REF] Goering | Forage fiber analyses (apparatus, reagents, procedures and some applications)[END_REF]. Results are provided in Table 1.

Strip assays were performed following [START_REF] Tiegs | A standardized cotton-strip assay for measuring organic-matter decomposition in streams[END_REF]. Strips of 2 × 8 cm made of each textile were deployed in 6 headwater streams that drain forested catchments and are located in the northern Vosges regional park (Zinsel catchment area, Baerenthal town). Streams were circumneutral (pH = 6. 1-7.6) and exhibited contrasting nutrient concentrations representative of the study area (PO4 2-0.004 -0.120 mg L -1 ; NO3 -1.15 -8.89 mg L -1 ), as assessed year-round (n = 4 analyses) prior to the beginning of the experiment. In each stream, strips made of each different textiles were deployed and retrieved after 10 and 20 days (2 sampling dates). With 5 replicates per stream × textile combination, our design involved the deployment of 6 (streams) × 5 (textiles) × 2 (dates) × 5 (replicates) = 300 strips. After retrieval, strips were promptly and gently cleaned into 95% ethanol for 30s, transported to the laboratory and dried in aluminum pans at 40°C for 30 hours. Maximal tensile strength was then determined using a digital force tester (AMETEK CS 225), as well as on 5 control (non-exposed) strips per textile that were cleaned and dried following the same procedure as experimental strips. For each replicate, the calculation of tensile strength loss was based on the 2 sampling dates using a regression between tensile strength (initial, at day 10 and day 20) and time. It was expressed as the percentage of initial (i.e. control) tensile strength loss per day (% day -1 ). Correlations were used to compare the loss of tensile strength between each textile and the 'conventional' cotton, and to analyze the relationships between tensile strength loss and textile chemical composition. Moreover, a ANOVA was used to test for the effects of stream identity, textile and stream × textile interaction on the loss of tensile strength. Compliance with normality and homoscedasticity assumptions was checked graphically. All statistics were performed using R 3.3.1 (R core team, 2016).

Results

The average tensile strength loss across streams and textiles was 4.20 % day -1 ± 2.0 (SD). It varied among textiles (F4,120 = 13.8, P < 0.001), with a significantly higher loss for hemp (TukeyHSD; P < 0.001) (Table4 1). Differences also occurred between streams (F5,120 = 25.9; P < 0.001), but no significant stream × textile interaction occurred (F20,120 = 0.9; P = 0.535), indicating that the tensile strength losses of different textiles were similarly affected by stream characteristics. Significant correlations (Fig. 1) indicate a relatively high similarity in the degradation of 'conventional' cotton and alternative textiles, with the highest similarity found for the organic cotton (Fig. 1a), and the weakest correlation for linen textile (Fig. 1c). Chemical composition exhibited limited variation across textiles, though the conventional cotton exhibited the lowest cellulose and the highest nutrient content (Table 1). No significant correlation was found between textile chemical contents and tensile strength losses.

Discussion

Our results suggest that all organic textiles we tested could be considered as eco-friendly alternatives to the conventional cotton strips for the monitoring of functional processes in streams.

Though slight differences occurred across textiles (higher degradation for hemp), tensile strength loss of our five textiles ranged within the same order of magnitude as previously reported for 'conventional' cotton strips (e.g. [START_REF] Tiegs | Cotton strips as a leaf surrogate to measure decomposition in river floodplain habitats[END_REF][START_REF] Tiegs | A standardized cotton-strip assay for measuring organic-matter decomposition in streams[END_REF][START_REF] Imberger | Searching for effective indicators of ecosystem function in urban streams: assessing cellulose decomposition potential[END_REF][START_REF] Clapcott | Exploring the response of functional indicators of stream health to land-use gradients[END_REF].

Most importantly, patterns of tensile strength loss were similar across streams and textiles (i.e. no significant interaction between stream and textile identity), which means that all textiles were affected similarly by the environmental conditions covered in our experiment. This gives a first hint that they could be similarly appropriate for biomonitoring purposes. The least satisfactory fabric, which should probably be excluded as a potential bioindicator, was the linen textile. Its tensile strength measurement was less repeatable than for other textiles, leading to high variability in the initial tensile strength (Table 1) and a comparatively weak correlation with the 'conventional' cotton tensile strength loss (Fig. 1).

All substrates exhibited very similar contents of lignin (almost nil) and cellulose (Table 1). The 'conventional' cotton, though, exhibited a surprisingly high nutrient content compared with other textiles. The root cause of this difference is unknown. Since conventional cotton is the only nonorganic fabric, we strongly suspect that they are due to chemicals or processes that are banned in ecofriendly textile production (see GOTS Standard Committee, 2017). Higher nutrient content in cotton, for instance, can originate from fertilizers and chemicals used for cotton cultivation [START_REF] Boquet | Nitrogen rate effect on partitioning of nitrogen and dry matter by cotton[END_REF][START_REF] Ferrigno | Is cotton conquering its chemical addiction? A review of pesticide use in global cotton production[END_REF], but also from fiber processing and textile finishing [START_REF] Babu | Cotton textile processing: waste generation and effluent treatment[END_REF]. Lower contents of cellulose than expected in all substrates -and particularly in 'conventional' cotton -are more intriguing, and contrast sharply with the cellulose content of the raw cotton fiber (88-96% cellulose;[START_REF] Mccall | Chemical composition of cotton[END_REF]. Surprisingly, we could not find any previous analysis of cotton chemical composition despite the widespread use of the method in both terrestrial and aquatic ecology [START_REF] Harrison | Cotton strip assay: an index of decomposition in soils[END_REF][START_REF] Tiegs | A standardized cotton-strip assay for measuring organic-matter decomposition in streams[END_REF].

With this paper we are calling for the use of ethical and eco-friendly tools as 'next-generation' functional indicators. In the case of cotton strip assays as indicators of stream ecosystem functioning, our results show that organic cotton could be used as an eco-friendly alternative to conventional cotton fabric. Clearly, amounts of cotton used for bioindication purposes are a negligible fraction of the total cotton world production. However, using ecological indicators aims to assess -and improve -the ecological status of ecosystems. This goal cannot be meaningfully achieved if these tools cause any societal or environmental damage -no matter how small, as far as satisfactory alternatives are available. We share the idea that weighing the benefits against the environmental and societal costs of the tools and methods we use is probably one of our greatest responsibility as scientific ecologists (e.g. [START_REF] Rosen | A greener culture[END_REF].

Conclusions

-Organic textiles decompose at similar rates than conventional cotton across 6 different streams.

-The relatively low cellulose and high nutrient content exhibited by the conventional cotton fabric bring into question its use as a 'pure cellulose' standard substrate.

-Organic textiles, and in particular organic cotton, can be used as an eco-friendly alternatives to conventional cotton for the cotton-strip assay in streams.

Table 1

Properties of the 5 different textiles used in the experiment (average ± SD). Results are expressed in % of dry mass except tensile strength loss (% day -1 ) and initial maximal tensile strength (N).

Carbon

Acknowledgments

We are grateful to Quentin Bachelet for technical assistance and Philippe Rousselle for nutrient analyses, as well as 2 anonymous referees for their comments on the manuscript. Fiber analyses were performed at the French National Institute for Agricultural Research (Department P3F). This work was supported by the Agence de l'Eau Rhin-Meuse and a research fellowship to JJ from the Agence Française de la Biodiversité (ImpactCE project)

Competing financial interests

The authors declare no competing financial interests Author contributions JJ, FC and FG designed the study, JJ and FG carried out the experiment and data analysis. JJ, FC and FG wrote the manuscript.