Correspondence
A health strategy for 20 000 chlordeconemia results clinical, therapeutic, and dietary)
already gathered in Guadeloupe and is essential. Such a paradigm shift
chlordecone (Kepone) Martinique since 2021 but almost no requires a tight collaboration Published Online
exposure in the French substantial change in exposed people between institutional stakeholders, May 24, 2023
https://doi.org/10.1016/
management, except for dietary governmental bodies, health-
Territories of America adjustments, the need for an effective care professionals, and affected
S0140-6736(24)00883-3
The French National Assembly’s formal therapy has become urgent.4 This is communities to develop strategies
recognition on March 14, 2024, of the context for our CHLOR-DETOX that genuinely address the needs of
the state’s responsibility for the clinical trial (NCT06026228), which individuals affected by chlordecone.6,8
chlordecone contamination affecting investigates the effectiveness of In light of the French Government’s
populations in Martinique and an oral 6-month probiotic intake recent acknowledgment of the
Guadeloupe represents an important as a potential therapeutic solution state’s responsibility for chlordecone
advancement in public health and for increasing faecal excretion of contamination, ensuing health and
environmental justice. After a wait of the 2-deconjugated form of the compensation strategies must reflect
nearly four decades, this acknowled chlordecone molecule, hereby lowering the actual clinical conditions of the
gment lays the groundwork for chlordeconemia concentrations and affected populations. We advocate for
compensating the victims and devis reducing acute chlordecone toxicity a decisive move from relying solely
ing medical interventions to address in study participants over a 6-month on chlordeconemia concentrations
health problems resulting from observation period. Although reducing towards an inclusive, evidence-based
chlordecone contamination. However, serum chlordecone levels and reducing approach to care, management, and
the decision to use plasma chlordecone acute toxicity should remain one of compensation, ensuring an effective
concentrations (chlordeconemia) the pursued health objectives, in line fair response to this ongoing public
as the basis for these actions has with the recommendations of the health crisis.
generated considerable debate French National Chlordecone Plan IV,5 We declare no competing interests.
regarding its effectiveness and fairness chlordeconemia concentration can in
*Dabor Resiere, Fréderic Lapostolle,
in addressing the health consequences no way be construed as indicative of Jonathan Florentin, Rishika Banydeen,
of chlordecone exposure.1 the level of chronic intoxication of a Papa Gueye, Jean Pujo,
Since 2020, residents of the French given individual, and of the health risk Bruno Mégarbane, Hatem Kallel,
West Indies have had access to blood it entails.6 Rémi Névière
chlordecone measurements, intended Relying on chlordeconemia for [email protected]
to gauge individual exposure intensity medical and compensation decisions Department of Critical Care (DR) and Emergency
and promote personalised preventive is also questionable. This strategy Department (JF, PG), Centre Hospitalier Universitaire
measures. Yet, by focusing on the risk overlooks the complex clinical conse Martinique, Fort-de-France, Martinique 97261,
France (RB, RN); Service d’Aide Médicale Urgente,
of exposure, rather than diagnosing quences of prolonged chlordecone Université Paris XIII, Paris, France (FL); Cardiovascular
specific illnesses, this approach might exposure and the wide interindividual Research, Université des Antilles, Schoelcher,
not fully capture the health conse variability in response to the toxicant,7 Martinique, France (RB, RN, DR, PG, JF); Intensive
quences of chlordecone, a potentially risking both exclusion of symptomatic Care Unit, Cayenne General Hospital, Cayenne,
French Guiana, France (JP, HK); Department of
carcinogenic organochlorine insecti individuals with low chlordeconemias Medical and Toxicological Critical Care, Lariboisière
cide that is linked to neurological, and the unnecessary inclusion of Hospital, Paris Cité University, Paris, France (BM)
reproductive, and developmental individuals with chlordeconemias 1 French National Assembly. Law bill to recognize
issues, as well as multiple other effects above the generally admitted the State’s responsibility and compensate
chlordecone victims. Paris, France: French
on health.2,3 Despite the cessation of actual threshold (ie, 0·4 μg/L of National Assembly no 2061. Jan 16, 2024.
chlordecone use for over four decades, plasma). 7,8 Given the widespread https://www.assembleenationale.fr/dyn/16/
textes/l16b2061_proposition-loi (accessed
its persistent nature in soils, bodies exposure in the communities of April 1, 2024).
of water, food chains, and biological Guadeloupe and Martinique islands 2 International Agency for Research on Cancer,
systems poses both environmental and the long environmental half- WHO. IARC monographs on the evaluation of
carcinogenic risk of chemicals to humans.
and health challenges. life (100–600 years) of chlordecone Some halogenated hydrocarbons. 1979.
The current protocol for populational elimination,9 a shift towards a more https://publications.iarc.fr/Book-And-Report-
Series/Iarc-Monographs-On-The-
recourse to chlordeconemia tests, holistic approach that considers Identification-Of-Carcinogenic-Hazards-To-
which relies on voluntary individual medical background, symptoms, Humans/Some-Halogenated-Hydrocarbons-
1979 (accessed Jan 4, 2024).
participation and does not have a environmental and occupa Submissions should be
3 Multigner L, Kadhel P, Rouget F, Blanchet P, made via our electronic
comprehensive adequate follow- tional exposure history, lifestyle Cordier S. Chlordecone exposure and adverse submission system at
up, raises the question of the value habits, individual vulnerability, and effects in French West Indies populations.
http://ees.elsevier.com/
Environ Sci Pollut Res Int 2016; 23: 3–8.
of acquired test results. With over multi d isciplinary approaches (eg, thelancet/
www.thelancet.com Vol 403 June 8, 2024 2481
Correspondence
4 Haute Autorité de Santé. Pertinence du dosage cardiopulmonary resuscitation (ECPR) favour the patient before making an
de la chlordéconémie et prise en charge des
patients avec une chlordéconémie élevée.
had not yet been developed. irreversible decision.
July 19, 2023. https://www.has-sante.fr/upload/ Since 2010, adopting ECPR for LL lectures for Getinge and Carl, is President of
docs/application/pdf/2023-07/reco467_ refractory cardiac arrests has required SAUV Life (a non-profit organisation), and is on the
cadrage_chlordecone_coi_2023_07_19_vd.pdf cardiac arrest board of the French Society of
(accessed April 1, 2024). meticulous organisational planning Emergency Medicine. All other authors declare no
5 French Government. Plan stratégique de lutte in both prehospital and in-hospital competing interests.
contre la pollution par la chlordécone. 2021-
settings. Stringent criteria aim to
2027. February, 2021. https://solidarites-sante. *Tal Soumagnac, Jean-Herlé Raphalen,
gouv.fr/IMG/pdf/plan_chlordecone_iv_ identify patients who could benefit
Richard Chocron, Alice Hutin,
fevrier_2021-2.pdf (accessed Jan 4, 2024). most from this technique in terms of Lionel Lamhaut
6 Emond C, Multigner L. Chlordecone survival. Nevertheless, the integration
development of a physiologically based [email protected]
pharmacokinetic tool to support human health of ECPR not only unlocks the potential
Services d’Aide Médicale Urgente de Paris, Necker
risks assessments. Arch Toxicol 2022; for increased survival, but also University Hospital (TS, J-HR, AH, LL) and Emergency
96: 1009–19.
7 Agence Nationale Sécurité Sanitaire
facilitates organ stabilisation and Department, Georges Pompidou European Hospital
Alimentaire Nationale. Valeurs sanitaires de organ donation through the controlled (RC), Greater Paris University Hospitals, Paris 75015,
reference—le chlordecone—avis révisé de France; Paris Cité University, Paris, France (RC, LL);
l’Anses Rapport révisé d’expertise collective.
donation after circulatory death and INSERM U970, Paris Research Cardiovascular Center,
November, 2021. https://www.anses.fr/fr/ the donation after brainstem death Paris, France (RC, LL); INSERM U955, National
system/files/ERCA2018SA0166Ra.pdf protocols. Furthermore, the use of Veterinary School of Alfort, Créteil, France (AH, LL)
(accessed Jan 4, 2024).
8 Resiere D, Florentin J, Kallel H, et al. ECPR enhances diagnostic capabilities 1 Morrison LJ, Sandroni C, Grunau B, et al. Organ
donation after out-of-hospital cardiac arrest:
Chlordecone (Kepone) poisoning in the French and provides extended time for family a scientific statement from the international
Territories in the Americas. Lancet 2023;
401: 916.
support. Recent data suggest that this liaison committee on resuscitation. Circulation
2023; 148: e120–46.
9 Préfet de la Martinique. Durée de contamination approach holds promising efficacy for
2 Af Geijerstam P, Forsberg S, Claesson A, et al.
des sols par la chlordécone. Jan 25, 2018. organ retrieval, generating grafts of Potential organ donors after out-of-hospital
https://www.martinique.gouv.fr/index.php/
Actions-de-l-Etat/Environnement-sante- comparable quality to those from other cardiac arrest during a ten-year period in
Stockholm, Sweden. Resuscitation 2019;
publique/Chlordecone/La-pollution-des- donors who did not experience cardiac 137: 215–20.
milieux-terrestres-et-marins/Pollution-des-sols/
Duree-de-contamination-des-sols-par-la-
arrests.4,5 3 Del Río F, Andrés A, Padilla M, et al. Kidney
chlordecone (accessed April 1, 2024). Although the intent behind organ transplantation from donors after
uncontrolled circulatory death: the Spanish
donation is evident with uDCD, it experience. Kidney Int 2019; 95: 420–28.
becomes uncertain in ECPR, where the 4 Raphalen JH, Soumagnac T, Blanot S, et al.
Organ donation in outcomes of survival, death, or organ Kidneys recovered from brain dead cardiac
arrest patients resuscitated with ECPR show
donation remain undetermined. From
Published Online
refractory cardiac arrest an ethical standpoint, the coexistence
similar one-year graft survival compared to
other donors. Resuscitation 2023; 190: 109883.
5 Smalcova J, Havranek S, Pokorna E, et al.
May 24, 2023 Established in 1995, the Maastricht of uDCD and ECPR has created a grey Extracorporeal cardiopulmonary resuscitation-
https://doi.org/10.1016/
S0140-6736(24)00298-8
classification, which defines four organ area, posing a substantial risk for based approach to refractory out-of-hospital
cardiac arrest: a focus on organ donation,
donor categories, is still widely used patients swiftly directed towards uDCD, a secondary analysis of a Prague OHCA
today.1 The second category provides who might thereby irreversibly miss randomized study. Resuscitation 2023;
a structured framework for the the option of ECPR and subsequent 193: 109993.
See Online for appendix uncontrolled donation after circulatory survival benefits (appendix). Although
death (uDCD) protocol, encompassing the inclusion criteria in both protocols
patients who have unexpected are often similar, it seems that uDCD Responding to India’s
cardiac arrests and are unresponsive precludes survival opportunities,
Published Online to conventional cardiopulmonary whereas ECPR maintains them.
data and transparency
May 29, 2024 resuscitation. However, beyond the The extensive discussions on the I am intrigued by The Lancet’s
https://doi.org/10.1016/
S0140-6736(24)01012-2 theoretical potential of uDCD to expand survival outcomes of patients under Editorial on India’s elections,1 urging
the donor pool, its effectiveness has going ECPR sometimes overshadow data transparency before the 2024
been low. The protocol demands the inherent stakes of organ donation parliamentary elections. Despite
substantial prehospital logistics in a very which, until now, have typically been setbacks caused by the COVID-19
specific timeframe (ie, 120–150 min), perceived as a secondary benefit of pandemic, initiatives such as Aadhaar
places families in a challenging situation ECPR. Can we envision a shift—in (national unique identity number
requiring simultaneous acceptance of which patients in refractory cardiac for each individual) and e-census
death and organ donation, and yields arrest, who do not meet full survival aim to streamline health-care data
mixed results for transplantation.2,3 criteria, would be primarily included in collection for efficient monitoring
The protocol originated at a time an ECPR protocol for organ donation? and planning. India’s assumption
when identifying suitable patients In any case, if an opportunity for of the G20 presidency symbolises
was straightforward, as extracorporeal survival arises, doubt should always a historic moment for Indian
2482 www.thelancet.com Vol 403 June 8, 2024
