Patrick Levallois

Laval University, Quebec City, Quebec, Canada

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Publications (92)326.56 Total impact

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    ABSTRACT: The presence of chemical compounds formed as disinfection by-products (DBPs) is widespread in developed countries, and virtually whole populations are exposed to these chemicals through ingestion, inhalation, or dermal absorption from drinking water and swimming pools. Epidemiological evidence has shown a consistent association between long-term exposure to trihalomethanes and the risk of bladder cancer, although the causal nature of the association is not conclusive. Evidence concerning other cancer sites is insufficient or mixed. Numerous studies have evaluated reproductive implications, including sperm quality, time to pregnancy, menstrual cycle, and pregnancy outcomes such as fetal loss, fetal growth, preterm delivery, and congenital malformation. The body of evidence suggests only minor effects from high exposure during pregnancy on fetal growth indices such as small for gestational age (SGA) at birth. Populations highly exposed to swimming pools such as pool workers and professional swimmers show a higher prevalence of respiratory symptoms and asthma, respectively, although the direction of the association, and thus causality, is not clear among professional swimmers. The risk of asthma, wheezing, eczema, and other respiratory outcomes among children attending swimming pools has been the object of extensive research. Early studies suggested a positive association, while subsequent larger studies found no correlations or showed a protective association. Future research should develop methods to evaluate the effects of the DBP mixture and the interaction with personal characteristics (e.g., genetics, lifestyle), clarify the association between swimming pools and respiratory health, evaluate the occurrence of DBPs in low- and middle-income countries, and evaluate outcomes suggested by animal studies that have not been considered in epidemiological investigations
    01/2015; DOI:10.1007/s40572-014-0032-x
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    ABSTRACT: Past studies have examined the effects of maternal exposure to water chlorination disinfection by-products (DBPs), such as trihalomethanes (THMs) and haloacetic acids (HAAs) during pregnancy. However, no human-based study has yet evaluated the effect of emerging DBPs, such as haloacetaldehydes (HAs) and haloacetonitriles (HANs) on small-for-gestational-age (SGA) status in newborns. This study aims to assess the association between maternal multiroute exposure to HAs and HANs during the third trimester of pregnancy and SGA status at birth, among neonates delivered by women residing in the Quebec City area (Province of Quebec, Canada). We also evaluated the interaction between exposure to these emerging unregulated by-products and regulated DBPs also found in drinking water (THMs and HAAs), for which a positive association with adverse reproductive outcomes has been suggested in previous studies. We conducted a population-based case-control study in the Quebec City area. SGA newborns (n=330) were compared to 1100 controls, with matching based on calendar week of birth. HA and HAN concentrations in drinking water at participant's tap were estimated using spatio-temporal strategy based on bimonthly measurements carried out at several locations in the participant's distribution system. A computer-assisted telephone interview was completed to collect information on individual habits of water consumption and water related activities in order to determine individual multiroute exposure. This enabled us to estimate the dose of HAs and HANs absorbed daily by each participant. Associations between total HA, HAN concentrations in drinking water and SGA were analyzed. Associations between the daily-absorbed doses of these emerging DBPs and SGA were also analyzed. Odds ratios (ORs) comparing the 4th quartile of exposure to the reference group (the first three quartiles) were obtained by means of conditional logistic regression, and controlling for potential confounders. Globally, no evidence of increased risk of SGA was found with total HA and HAN concentrations in tap water when participants in the 4th quartile of exposure were compared to the first three quartiles (OR=1.0; 95% CI [0.7-1.5] and OR=0.8; 95% CI [0.6-1.2], respectively). Similarly, no association was found with the daily-absorbed doses of total HAs or HANs (OR=0.9; 95% CI [0.6-1.3] and OR=1.1; 95% CI [0.7-1.6], respectively). However, a small non statistically significant association was found between the dose of brominated HA and SGA (OR=1.4; 95% CI [0.9-2.1]). Also, in spite of the lack of interaction between other DBP classes, an unexpected negative interaction was observed between concentration of chloral hydrate (CH) (which represents the main HA species), and regulated DBPs (P=0.006). In this population, exposure to low levels of HAs and HANs during the third trimester of pregnancy through drinking water was not associated to SGA status in newborns. Nonetheless, more research is needed to clarify possible effect of brominated compounds and interaction between different DBPs. Copyright © 2015 Elsevier Inc. All rights reserved.
    Environmental Research 01/2015; 137C:338-348. DOI:10.1016/j.envres.2015.01.005 · 3.95 Impact Factor
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    ABSTRACT: Drinking water represents a potential source of lead exposure. The purpose of the present study was to estimate the magnitude of winter-to-summer changes in household water lead levels (WLLs), and to predict the impact of these variations on BLLs in young children. A study was conducted from September, 2009 to March, 2010 in 305 homes, with a follow-up survey carried out from June to September 2011 in a subsample of 100 homes randomly selected. The first 1-L sample was drawn after 5min of flushing, followed by a further 4 consecutive 1-L samples after 30min of stagnation. Non-linear regression and general linear mixed models were used for modelling seasonal effects on WLL. The batchrun mode of Integrated Exposure Uptake Biokinetic (IEUBK) model was used to predict the impact of changes in WLL on children's blood lead levels (BLLs). The magnitude of winter-to-summer changes in average concentrations of lead corresponded to 6.55μg/L in homes served by lead service lines (LSL+ homes) and merely 0.30μg/L in homes without lead service lines. For stagnant samples, the value reached 10.55μg/L in 'LSL+ homes' and remained very low (0.36μg/L) in 'LSL- homes'. The change in the probability of BLLs ≥5μg/dL due to winter-to-summer changes in WLL was increased from <5% (in winter) to about 20% (in summer) in children aged 0.5-2years. The likelihood of having BLLs ≥5μg/dL in young children during warm months was reduced by at least 40% by flushing tap-water.
    Environment International 07/2014; 73C:57-65. DOI:10.1016/j.envint.2014.07.005 · 5.66 Impact Factor
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    ABSTRACT: Hypertension is the leading risk factor for cardiovascular disease, but its cause is not always known. Interest is increasing in the potential role of environmental chemicals, including lead.
  • N Savard, P Levallois, L P Rivest, S Gingras
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    ABSTRACT: We evaluated associations between ecological variables and the risk of very small for gestational age (VSGA) birth in Quebec in 2000-2008. Ecological variables came from the Canadian Community Health Survey, the Canadian census and Quebec's birth registry; individual variables also came from Quebec's birth registry. Odds ratios (ORs) adjusted for mother's age, academic qualification, parity, marital status and country of birth were estimated using multilevel logistic regression (generalized estimating equations method). Births in neighbourhoods with a high proportion of people leading a sedentary lifestyle (OR: 1.07, 95% confidence interval [CI]: 1.01-1.11) and those with a high/middle proportion of residents with food insecurity (OR: 1.09, 95% CI: 1.05-1.15; OR: 1.05, 95% CI: 1.01-1.11) had higher odds of VSGA birth. Those with middle proportion of married residents had lower odds of VSGA birth (OR: 0.94, 95% CI: 0.90-0.98).
    Chronic Diseases and Injuries in Canada 02/2014; 34(1):46-54. · 1.22 Impact Factor
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    Gerard Ngueta, Catherine Gonthier, Patrick Levallois
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    ABSTRACT: Objective To estimate the extent of changes in mean BLLs from colder to warmer months, in children aged 1 to 5 years with different status of lead in colder months. Methodology We performed a systematic review using an in-house algorithm developed in MEDLINE, EMBASE, Web of Science, and CINHAL. Search was performed between November, 2012 and July, 2013, and data evaluation and extraction were subsequently conducted. The mean BLLs observed in the warmer months was divided by the one observed in the colder months to obtain the warmer-to-colder ratio (WCR). Study-specific WCRs were pooled using the fixed-effects method of Mantel-Haenszel to estimate the combined WCR. Results From 4,040 papers initially identified, eight cohort studies were considered relevant for inclusion. The combined WCR was inversely related to the BLLs observed during colder months. The values were 1.25 (95% CI: 0.90–1.60), 1.06 (95% CI: 0.92–1.19), and 0.95 (95% CI: 0.51–1.39) for children showing baseline BLLs of < 10 μg dl−1, 10–20 μg dl−1and ≥ 20 μg dl−1, respectively. The combined WCR was influenced neither by children's age nor place/date of study. Conclusion The extent of the summer increase in BLLs depends on the BLLs in the colder months.
    Journal of Trace Elements in Medicine and Biology 01/2014; DOI:10.1016/j.jtemb.2014.07.004 · 2.49 Impact Factor
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    ABSTRACT: Drinking water intake of arsenic (As) from private wells may represent a significant exposure pathway and induce oxidative DNA damage. We measured total As concentrations in hair and nails, and concentrations of the different species of As and its metabolites as well as 8-OHdG in urine of 110 non-smoking adults living in a rural region of the Province of Quebec, Canada. Significant differences in exposure biomarker levels were observed between individuals consuming drinking water with As levels of≤1.0,>1.0 -≤10 and>10 μg/l. Multivariate linear regression analysis also showed a significant relationship between estimated daily drinking water intakes of As and biomarker levels. Conversely, 8-OHdG levels were not significantly related to daily drinking water intakes of As or to hair, nail or urinary exposure biomarker levels, according to multivariate linear regression analysis. Even at the relatively low levels of As found in well water of our participants, water consumption significantly increases their body load of As, as confirmed by multiple matrix measurements, which reflected exposure over different time frames. However, this increased internal As dose was not associated with higher oxidative damage to DNA as reflected by urinary 8-OHdG levels.Journal of Exposure Science and Environmental Epidemiology advance online publication, 6 November 2013; doi:10.1038/jes.2013.80.
    Journal of Exposure Science and Environmental Epidemiology 11/2013; DOI:10.1038/jes.2013.80 · 3.05 Impact Factor
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    ABSTRACT: Childhood nonviral gastroenteritis is a priority for various public health authorities. Given that waterborne transmission is sometimes incriminated during investigation of gastroenteritis outbreaks, the authors hypothesized that watershed characteristics may influence the occurrence of this disease and could contribute additional insights for better prevention and control. The study described here aimed to investigate watershed characteristics in relation to nonviral gastroenteritis and specifically three bacterial and parasitic forms of childhood gastroenteritis to assess their relative importance in the province of Quebec, Canada. Information on children aged 0-4 years with bacterial or parasitic enteric infections reported through ongoing surveillance between 1999 and 2006 in the province of Quebec was collected. Factors measured at the municipal and watershed levels were analyzed using multilevel models with a Poisson distribution and log link function. Childhood nonviral gastroenteritis, giardiasis, and campylobacteriosis were positively associated with small ruminants and cattle density. Childhood salmonellosis was positively associated with cattle density. Also, childhood campylobacteriosis incidence was positively associated with larger watershed agricultural surface. In addition to local agroenvironmental factors, this analysis revealed an important watershed effect.
    Journal of environmental health 10/2013; 76(3):34-45. · 0.89 Impact Factor
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    ABSTRACT: Diverse fecal and nonfecal bacterial contamination and nutrient sources (e.g. agriculture, human activities and wildlife) represent a considerable non-point source load entering natural recreational waters which may adversely affect water quality. Monitoring of natural recreational water microbial quality is most often based mainly on testing a set of microbiological indicators. The cost and labour involved in testing numerous water samples may be significant when a large number of sites must be monitored repetitively over time. In addition to water testing, ongoing monitoring of key environmental factors known to influence microbial contamination may be carried out as an additional component. Monitoring of environmental factors can now be performed using remote sensing technology which represents an increasingly recognized source of rigorous and recurrent data, especially when monitoring over a large or difficult to access territory is needed. To determine whether this technology could be useful in the context of recreational water monitoring, we evaluated a set of agroenvironmental determinants associated with fecal contamination of recreational waters through a multivariable logistic regression model built with data extracted from satellite imagery. We found that variables describing the proportions of land with agricultural and impervious surfaces, as derived from remote sensing observations, were statistically associated (odds ratio, OR = 11 and 5.2, respectively) with a higher level of fecal coliforms in lake waters in the southwestern region of Quebec, Canada. From a technical perspective, remote sensing may provide important added-value in the monitoring of microbial risk from recreational waters and further applications of this technology should be investigated to support public health risk assessments and environmental monitoring programs relating to water quality.
    Water Science & Technology 04/2013; 67(7):1503-11. DOI:10.2166/wst.2013.020 · 1.21 Impact Factor
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    ABSTRACT: The spatiotemporal presence of eight N-nitrosamines in the water of seven supply systems in Quebec considered to be susceptible to these emerging disinfection by-products was evaluated. This is the first study on the presence of N-nitrosamines in drinking water utilities in Quebec. Seven sampling campaigns were carried out at several sampling points in each of the systems over a period of 1 year. The results show that N-nitrosamines, primarily N-nitrosodimethylamine (NDMA), were not commonly detected in the water of the facilities under study (10 % of samples). The concentrations measured were lower than those reported in recent North American studies. None of the 195 samples taken exceeded the Ontario standard of 9 ng/L for NDMA (maximum value observed of 3.3 ng/L). N-nitrosomethylethylamine and N-nitrosopiperidine were detected once, with concentrations of 3.7 and 6.0 ng/L, respectively. Chloramination was identified as being the main risk factor regarding the presence of N-nitrosamines, but water quality and some operating parameters, in particular disinfectant residual, also seem to be related to their presence. NDMA concentrations at the end of the distribution systems were generally higher than water leaving the plant. No seasonal trends were observed for the formation of N-nitrosamines in the investigated supply systems. Finally, an association between the presence of N-nitrosamines and the levels of trihalomethanes and haloacetic acids was observed in some facilities.
    Environmental Monitoring and Assessment 02/2013; DOI:10.1007/s10661-013-3128-0 · 1.68 Impact Factor
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    ABSTRACT: Dwellings with/without a lead service line [LSL] were sampled for lead in tap water in Montreal, during different seasons. Short-term simulations using these results and the batchrun mode of the Integrated Exposure Uptake Biokinetic (IEUBK) model showed that children's exposure to lead at the tap in the presence of an LSL varies seasonally, and according to the type of dwelling. From July to March, for single-family homes, the estimated geometric mean [GM] blood lead level [BLL] decreased from 2.3-3.6 μg/dL to 1.5-2.5 μg/dL, depending on the children's age. The wide seasonal variations in lead exposure result in a minimal fraction (0-6%) of children with a predicted BLL >5 μg/dL in winter, as opposed to a significant proportion (5-25%) in summer. These estimations are in close agreement with the BLLs measured in Montreal children in fall and winter, and simulations using summer water lead levels illustrate the importance of measuring BLLs during the summer. Finally, simulations for wartime residences with long LSLs confirm the need to prioritize the control of this lead exposure from tap water.
    Water Research 02/2013; 47(7). DOI:10.1016/j.watres.2013.02.010 · 5.32 Impact Factor
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    ABSTRACT: This study was designed to evaluate the epidemiology of severe gastroenteritis in children living in Québec rural areas with intensive livestock activities. From September 2005 through June 2007, 165 cases of gastroenteritis in children aged from 6 months to 5 years, hospitalized or notified to the public health department were enrolled, and 326 eligible controls participated. The parents of cases and controls were asked questions about different gastroenteritis risk factors. The quality of the drinking water used by the participants was investigated for microbial indicators as well as for four zoonotic bacterial pathogens (Campylobacter spp, Escherichia coli, Salmonella spp and Yersinia spp) and two enteric parasites (Cryptosporidium spp and Giardia spp). From 134 stool specimen analysed, viruses were detected in 82 cases (61%), while 28 (21%) were found with at least one of the bacteria investigated, and five cases were infected by parasites. Campylobacteriosis was the main bacterial infection (n = 15), followed by Salmonella sp (n = 7) and E. coli O157:H7 (n = 5) among cases with bacterial gastroenteritis. No significant difference was found between cases and controls regarding the quality of water consumed; the frequency of faecal contamination of private wells was also similar between cases and controls. Considering the total cases (including those with a virus), no link was found between severe gastroenteritis and either being in contact with animals or living in a municipality with the highest animal density (4th quartile). However, when considering only cases with a bacterial or parasite infection (n = 32), there was a weak association with pig density that was not statistically significant after adjusting for potential confounders. Contact with domestic, zoo or farm animals were the only environmental factor associated with the disease.
    Zoonoses and Public Health 02/2013; DOI:10.1111/zph.12039 · 2.07 Impact Factor
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    ABSTRACT: Lead is neurotoxic at very low dose and there is a need to better characterize the impact of domestic sources of lead on the biological exposure of young children. A cross-sectional survey evaluated the contribution of drinking water, house dust and paint to blood lead levels (BLLs) of young children living in old boroughs of Montréal (Canada). Three hundred and six children aged 1 to 5 years and currently drinking tap water participated in the study. For each participant, residential lead was measured in kitchen tap water, floor dust, windowsill dust and house paint and a venous blood sample was analyzed. Multivariate logistic regression was used to evaluate the association between elevated BLL in the children (≥ 75th percentile) and indoor lead contamination by means of odds ratios (OR) using 95% confidence intervals (CI). There was an association between BLL ≥75th percentile (1.78 μg/dL) and water lead when the mean water concentration was >3.3 μg/L: adjusted OR=4.7 (95% CI: 2.1-10.2). Windowsill dust loading >14.1 μg/ft(2) was also associated with BLL ≥1.78 μg/dL: adjusted OR=3.2 (95% CI: 1.3-7.8). Despite relatively low BLLs, tap water and house dust lead contribute to an increase of BLLs in exposed young children.Journal of Exposure Science and Environmental Epidemiology advance online publication, 30 January 2013; doi:10.1038/jes.2012.129.
    Journal of Exposure Science and Environmental Epidemiology 01/2013; 24(2). DOI:10.1038/jes.2012.129 · 3.05 Impact Factor
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    ABSTRACT: Safe drinking water is essential for wellbeing. Although microbiological contamination remains the largest cause of water-related morbidity and mortality globally, chemicals in water supplies may also cause disease, and evidence of the human health consequences is limited or lacking for many of them. We aimed to summarize the state of knowledge, identify gaps in understanding, and provide recommendations for epidemiological research relating to chemicals occurring in drinking water. The assessment of exposure and the health consequences of chemicals in drinking water is challenging. Exposures are typically at low concentrations, measurements in water are frequently insufficient, chemicals are present in mixtures, exposure periods are usually long, multiple exposure routes may be involved, and valid biomarkers reflecting the relevant exposure period are scarce. In addition, the magnitude of the relative risks tends to be small. Research should include well designed epidemiological studies covering regions with contrasting contaminant levels and sufficient sample size; comprehensive evaluation of contaminant occurrence in combination with bioassays integrating the effect of complex mixtures; sufficient numbers of measurements in water to evaluate geographical and temporal variability; detailed information on personal habits resulting in exposure (e.g., ingestion, showering, swimming, diet); collection of biological samples to measure relevant biomarkers; and advanced statistical models to estimate exposure and relative risks, considering methods to address measurement error. Lastly, the incorporation of molecular markers of early biological effects and genetic susceptibility is essential to understand the mechanisms of action. There is a particular knowledge gap and need to evaluate human exposure and risks of a wide range of emerging contaminants.
    Environmental Health Perspectives 01/2013; 122(3). DOI:10.1289/ehp.1206229 · 7.03 Impact Factor
  • Marc Rhainds, Patrick Levallois
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    ABSTRACT: The purposes of this study were to determine the umbilical cord blood lead levels in a nonindustrialized city and the effect of place of residence on the blood lead levels of newborns. During spring 1990, we conducted a survey of umbilical cord blood lead levels from 823 live newborns in two hospitals from the Québec City area. The geometric mean of cord blood lead levels was 0.094 mumol/l (95% confidence interval [95% CI] = 0.088-0.099). Less than 1% (95% CI = 0.2-1.7) of the babies had cord blood lead levels at 0.48 mumol/l or greater. We estimate that each year in the Québec City area between 150 and 200 newborns are at risk for developing psychoneurological problems during their first years of life. Frequency distribution of cord blood lead level did not differ significantly among urban, suburban, and rural areas; however, a higher proportion of cord blood lead levels greater than 0.25 mumol/l was observed in the urban area (9.4%), compared with suburban (2.6%) and rural (3.1%) areas. The proximity of potential environmental lead sources (highway, industry, city center) located within 1/2 mile (.8 km) of the mother's residence was associated with a high cord blood lead level. Cord blood lead levels were also elevated for newborns whose mothers lived in newer (< or = 5 y) and older buildings (> or = 50 y). We concluded that the environmental characteristics of the mother's residence are a better indicator of environmental lead exposure than the place of residence.(ABSTRACT TRUNCATED AT 250 WORDS)
    Archives of Environmental Health An International Journal 12/2012; 48(6):421-7. DOI:10.1080/00039896.1993.10545964
  • Revue d Épidémiologie et de Santé Publique 09/2012; 60:S109-S110. DOI:10.1016/j.respe.2012.06.243 · 0.66 Impact Factor
  • G. Ngueta, P. Levallois, C. Gonthier
    Revue d Épidémiologie et de Santé Publique 09/2012; 60:S110. DOI:10.1016/j.respe.2012.06.244 · 0.66 Impact Factor
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    ABSTRACT: There is concern about possible effects of disinfection by-products on reproductive outcomes. The purpose of this study was to evaluate the association between maternal exposure to chlorination by-products and the risk of delivering a small for-gestational-age (SGA) neonate. We conducted a population-based case-control study in the Québec City (Canada) area. Term newborn cases with birth weights <10th percentile (n = 571) were compared with 1925 term controls with birth weights ≥10th percentile. Concentrations of trihalomethanes and haloacetic acids in the water-distribution systems of participants were monitored during the study period, and a phone interview on maternal habits was completed within 3 months after childbirth. We estimated chlorination by-products ingestion during the last trimester of pregnancy and trihalomethanes doses resulting from inhalation and dermal exposure. We evaluated associations between chlorination by-products in utero exposure and SGA by means of unconditional logistic regression with control of potential confounders. When total trihalomethanes and the 5 regulated haloacetic acids concentrations were divided into quartiles, no clear dose-response relationship was found with SGA. However, increased risk was observed when haloacetic concentrations were above the fourth quartile and when either trihalomethanes or haloacetic acids concentrations were above current water standards (adjusted OR= 1.5 [95% confidence interval = 1.1-1.9] and 1.4 [1.1-1.9], respectively). Inhalation and dermal absorption of trihalomethanes did not contribute to this risk, but a monotonic dose-response was found with haloacetic acids ingestion. Oral exposure to high levels of chlorination by-products in drinking water could be a risk factor for term SGA.
    Epidemiology (Cambridge, Mass.) 03/2012; 23(2):267-76. DOI:10.1097/EDE.0b013e3182468569 · 6.18 Impact Factor
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    ABSTRACT: Human exposure to antimicrobial-resistant bacteria may result in the transfer of resistance to commensal or pathogenic microbes present in the gastrointestinal tract, which may lead to severe health consequences and difficulties in treatment of future bacterial infections. It was hypothesized that the recreational waters from beaches represent a source of antimicrobial-resistant Escherichia coli for people engaging in water activities. To describe the occurrence of antimicrobial-resistant E coli in the recreational waters of beaches in southern Quebec. Sampling occurred over two summers; in 2004, 674 water samples were taken from 201 beaches, and in 2005, 628 water samples were taken from 177 beaches. The minimum inhibitory concentrations of the antimicrobial-resistant E coli isolates against a panel of 16 antimicrobials were determined using microbroth dilution. For 2004 and 2005, respectively, 28% and 38% of beaches sampled had at least one water sample contaminated by E coli resistant to one or more antimicrobials, and more than 10% of the resistant isolates were resistant to at least one antimicrobial of clinical importance for human medicine. The three antimicrobials with the highest frequency of resistance were tetracycline, ampicillin and sulfamethoxazole. The recreational waters of these beaches represent a potential source of antimicrobial-resistant bacteria for people engaging in water activities. Investigations relating the significance of these findings to public health should be pursued.
    The Canadian journal of infectious diseases & medical microbiology = Journal canadien des maladies infectieuses et de la microbiologie medicale / AMMI Canada 01/2012; 23(2):e20-5. · 0.49 Impact Factor
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    Journal of Exposure Science and Environmental Epidemiology 01/2012; · 3.05 Impact Factor

Publication Stats

1k Citations
326.56 Total Impact Points

Institutions

  • 2000–2014
    • Laval University
      • Department of Social and Preventive Medicine
      Quebec City, Quebec, Canada
  • 1997–2014
    • Institut National de Santé Publique du Québec (INSPQ)
      Quebec City, Quebec, Canada
  • 1997–2011
    • Centre Hospitalier Universitaire de Québec (CHUQ)
      Québec, Quebec, Canada
  • 2006
    • Université de Montréal
      Montréal, Quebec, Canada
  • 2005–2006
    • Health Canada
      Ottawa, Ontario, Canada
  • 1998–2005
    • Université du Québec
      Québec, Quebec, Canada
  • 2003
    • Environment Canada
      Montréal, Quebec, Canada
  • 1994
    • Centre hospitalier de l'Université de Montréal (CHUM)
      Montréal, Quebec, Canada