Prenatal exposure to per- and polyfluoroalkyl substances and pregnancy outcome in Austria.

Per- and polyfluoroalkyl substances (PFAS) are a large group of persistent industrial chemicals that can harm reproductive health. PFAS levels were analysed to determine the current sources of exposure and possible associations between prenatal PFAS exposure and adverse pregnancy outcome. Samples from 136 mother-newborn pairs recruited between 2017 and 2019 were analysed for the presence of 31 target PFAS in maternal serum, umbilical cord serum, and placental tissue by high-performance liquid chromatography coupled to a tandem mass spectrometer. Questionnaires and medical records were used to survey sources of exposure and pregnancy outcome, including small for gestational age (SGA), fetal growth restriction (FGR), preeclampsia (PE), preterm birth, large for gestational age (LGA) and gestational diabetes mellitus (GDM). Data were analysed for individual PFAS and sum4PFAS (sum of perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), perfluorohexane sulfonate (PFHxS), and perfluorooctane sulfonate (PFOS) serum levels) in logistic regression analyses and categorical regression analyses. Compared to data from a previous Viennese study in 2010-12, sum4PFAS levels were generally lower. Sum4PFAS serum levels of three women (2.2%) exceeded 6.9 µg/L, a level that corresponds to the recently established tolerable weekly intake (TWI) of EFSA for nursing mothers aged 35 years; in the 2010/2012 study it was 13.6%. The large contribution of unidentified extractable organofluorine (EOF) fractions to total PFAS exposure is a concern. Study site, mean maternal corpuscular hemoglobin (MCH), use of facial lotion, and owning upholstered furniture were significantly influencing maternal exposure. While no effect of sum4PFAS on pregnancy outcome could be detected, we found highest placental PFDA levels in SGA births. PFHxS levels in umbilical cord and placenta were highest in preterm births. Further studies are needed to elucidate the relationship of prenatal PFAS exposure and pregnancy outcome, in particular to confirm whether and how placental PFDA levels may contribute to an increased risk for SGA.

The Critical Importance of Molecular Biomarkers and Imaging in the Study of Electrohypersensitivity. A Scientific Consensus International Report.

Clinical research aiming at objectively identifying and characterizing diseases via clinical observations and biological and radiological findings is a critical initial research step when establishing objective diagnostic criteria and treatments. Failure to first define such diagnostic criteria may lead research on pathogenesis and etiology to serious confounding biases and erroneous medical interpretations. This is particularly the case for electrohypersensitivity (EHS) and more particularly for the so-called "provocation tests", which do not investigate the causal origin of EHS but rather the EHS-associated particular environmental intolerance state with hypersensitivity to man-made electromagnetic fields (EMF). However, because those tests depend on multiple EMF-associated physical and biological parameters and have been conducted in patients without having first defined EHS objectively and/or endpoints adequately, they cannot presently be considered to be valid pathogenesis research methodologies. Consequently, the negative results obtained by these tests do not preclude a role of EMF exposure as a symptomatic trigger in EHS patients. Moreover, there is no proof that EHS symptoms or EHS itself are caused by psychosomatic or nocebo effects. This international consensus report pleads for the acknowledgement of EHS as a distinct neuropathological disorder and for its inclusion in the WHO International Classification of Diseases.

Validity of reported indicators of pesticide exposure and relevance for cytotoxic and genotoxic effects on buccal cells.

Higher rates of nuclear anomalies in buccal cells of coffee workers exposed to pesticides in comparison to their unexposed peers were detected in our field study. Here, we extend our findings by examining other exposure indicators in this sample. Occupational exposure of 38 exposed and 33 non-exposed farmworkers was assessed as exposure days in the last month (0-25 days) and as years of exposure (0-47 years). Genotoxic and cytotoxic markers in buccal cells were analysed following standard procedures for buccal micronucleus cytome assay. Both exposure markers were associated with a higher frequency of nuclear anomalies with odds ratios more than 1. After restricting the analysis to the exposed workers only, this association remained only with the marker of recent exposure. In a secondary analysis also environmental exposure defined as proximity of the home to the nearest sprayed field (distance <1000 m) was assessed. Proximity led to increased rates (with odds ratios more than 3) of genotoxic but not cytotoxic nuclear anomalies. Reported recent frequency and intensity of pesticide use and application are a valid exposure marker relevant for cytological pathologies in the buccal mucosa. The exposure metric for environmental exposure was rather crude and confounding by some unmeasured factor cannot be fully excluded. Nevertheless, simple exposure indicators that can even be obtained under rather difficult field conditions do provide health-relevant and valid information.

Gender aspects of recreational sun-protective behavior: results of a representative, population-based survey among Austrian residents.

PURPOSE: Lifetime risk for melanoma skin cancer is enlarged by sunlight exposure and reduced by sun protection. Austrian melanoma incidence and mortality rates are constantly rising with higher rates in males. Thus, we aimed at investigating gender-specific recreational sun exposure habits among the Austrian population. METHODS: We conducted a telephone survey among 1500 adults (50.5% females) representing sociodemographic characteristics of the Austrian population. Using a structured questionnaire, we studied gender-specific sun exposure-related knowledge, motives to tan, and behavior. RESULTS: Overall, using sunscreen, wearing sunglasses, and seeking shade were among the three most frequent sun safe measures. Basic skin health knowledge and tanning motives were similar among genders, although females protected themselves more. In general, sunburn occurrence (odds ratio [OR] = 1.4, 95% confidence interval [CI] = 1.0-1.8), skin type IV (OR = 2.4, 95% CI = 1.3-4.5), ex-/non-smoking (OR = 1.4-1.6, 95% CI = 1.0-2.1), low motives to tan (both OR = 1.3, 95% CI = 1.0-1.7), no outdoor sport (OR = 1.3, 95% CI = 1.0-1.7), all P < 0.05, as well as the use of sunscreen with lower SPF values (OR = 1.0-3.0, 95% CI = 1.4-4.3) and male gender (OR = 1.6, 95% CI = 1.2-2.0), both P < 0.001, increased the odds of practicing low sun protection. CONCLUSION: The results of this investigation suggest considering gender specificity when planning Public (Skin) Health-related educative campaigns and programs, for example, by highlighting the appearance-related benefits of sun light avoidance.

Health impacts of anthropogenic biomass burning in the developed world.

Climate change policies have stimulated a shift towards renewable energy sources such as biomass. The economic crisis of 2008 has also increased the practice of household biomass burning as it is often cheaper than using oil, gas or electricity for heating. As a result, household biomass combustion is becoming an important source of air pollutants in the European Union.This position paper discusses the contribution of biomass combustion to pollution levels in Europe, and the emerging evidence on the adverse health effects of biomass combustion products.Epidemiological studies in the developed world have documented associations between indoor and outdoor exposure to biomass combustion products and a range of adverse health effects. A conservative estimate of the current contribution of biomass smoke to premature mortality in Europe amounts to at least 40 000 deaths per year.We conclude that emissions from current biomass combustion products negatively affect respiratory and, possibly, cardiovascular health in Europe. Biomass combustion emissions, in contrast to emissions from most other sources of air pollution, are increasing. More needs to be done to further document the health effects of biomass combustion in Europe, and to reduce emissions of harmful biomass combustion products to protect public health.

Nuclear anomalies in exfoliated buccal cells in Pakistani cotton weavers.

Cotton workers in small weaving household factories (power looms) in Pakistan are typically exposed to high levels of cotton dusts. Working in the textile manufacturing industry has been classified as a possible human carcinogen (group 2B) by the International Agency for Research on Cancer. The study set out to determine potential cytotoxic and genotoxic effects of occupational exposure to cotton dusts in exfoliated buccal cells of exposed cotton workers. Nuclear anomalies reflecting cytotoxic and genotoxic effects were evaluated in a representative sample of 51 exposed male cotton weavers and in the same number of age-matched male non-exposed subjects applying the micronucleus cytome assay. Nuclear anomalies reflecting cytotoxicity (karyolysis, karyorrhexis, condensed chromatin and pyknosis) were significantly elevated in exposed cotton workers. The frequency of micronucleated cells increased significantly with increasing years of work in power looms (odds ratio = 1.043 per year; 95% confidence interval: 1.012-1.076, P = 0.007). Results were consistent with the typical inflammatory pattern and injury in epithelia due to unprotected occupational exposure to cotton dusts and other toxic, allergic and infectious substances in the working areas of the cotton industry. Occupational exposure in power looms induces cytotoxic effects and, upon chronic exposure, DNA damage. This may eventually result in typical obstructive patterns of pulmonary symptoms and in a clinical condition called byssinosis in exposed cotton workers. Long exposure may lead to chronic inflammation and cumulative damage of DNA in buccal stem cells that may indicate an increased risk of oropharyngeal cancer.

Diminished pulmonary function in long-term workers exposed to cotton dust determined in a cross-sectional study in small Pakistani enterprises.

PURPOSE: While large cotton industry plants producing for the foreign market have undergone improvements of occupational hygiene lately, working conditions in power looms producing mainly for the local market are still poor. The respiratory health in workers of power looms has not been studied so far. METHODS: In a cross-sectional study, 51 male cotton workers from power looms, 58 from large cotton factories and 52 controls were investigated by spirometry and a symptoms questionnaire. Spirometric measurements and respiratory symptoms were related to exposure duration in large and small factories by multivariate linear regression and logistic regression, respectively, with smoking, age and anthropometric parameters considered as confounders. RESULTS: Work duration in power looms was associated with declines in forced expiratory volume in 1 s, peak flow, maximum midexpiratory flow and forced expiratory flow 75 and an increased risk of obstruction (OR 1.09/year; 95% CI: 1.002 to 1.18) by applying the Global Lung Initiative equations. Except cough that was only associated with smoking, all respiratory symptoms (chest tightness, shortness of breath, fever) increased as a function of duration of exposure in power looms but not in large factories. CONCLUSIONS: Despite limitations inherent in the cross-sectional approach, there is evidence for workers in small weaving factories to face an increased risk of pulmonary function loss and respiratory symptoms. Industrial hygiene measures in these small enterprises should be encouraged. Failure to detect adverse respiratory outcomes from occupation in large factories could be due to a 'survivor' (healthy worker) effect.

Early prognosis of noise-induced hearing loss.

OBJECTIVE: Occupationally acquired noise-induced hearing loss (NIHL) is the most prevalent occupational disease in Austria and among the most common in many other countries. Because of the wide variation in hearing loss after equivalent exposures it has long been assumed that some individuals are more vulnerable to occupational NIHL than others. Earlier attempts to define predictors of NIHL before starting occupational noise exposure have largely failed. We present results of a prospective study evaluating the potential of temporary threshold shift (TTS) after a test exposure to predict NIHL. METHODS: Between 1982 and 1989, overall 311 apprentices were included into a prospective study during their initial health screening visit. At this occasion, a standardised noise exposure was applied (20 min, 200-500 Hz, 100 dBA) and the TTS at 4 kHz was determined during at least 10 min after exposure. Hearing loss was monitored at follow-up visits every 3-5 years. Follow-up was 13 years on average. RESULTS: Permanent threshold shift was predicted by duration of noise exposure, frequency of wearing noise protectors and especially by the initial TTS at 4 kHz. Using 14 dB TTS as a cut-off had 82% sensitivity and 53% specificity to predict 20 dB or higher levels of NIHL. CONCLUSIONS: The TTS model can be successfully applied as a method to detect individuals at greater risk of occupational NIHL. It is recommended to routinely include such a procedure into initial workers' examinations for suitability to work under occupational noise conditions and for counselling on the use of hearing protectors.

Dust is in the air. Part II: Effects of occupational exposure to welding fumes on lung function in a 9-year study.

PURPOSE: Adverse health effects of work-related contact with respirable hazardous substances are of great public interest. Because related prospective and long-term follow-up studies are rare, the extent of acute and chronic pulmonary health risks of occupational exposure to welding fumes is discussed controversially in the scientific literature. The objective of the present longitudinal study during a 9-year period was to investigate the annual changes of lung function in welders. METHODS: Anthropometric measures and smoking behaviour, and spirometric tests (FVC, FEV1, and MEF50) obtained during routine occupational health checkups of female and male workers (n = 1,982) in Austria during the years 2002-2010 were analyzed. RESULTS: The study participants displayed average lung function values lower than the age- and sex-specific norm. Decrease in respiratory capacity was dependent on smoking habits and duration of occupational exposure. Specifically for welders (n = 1,326), decrease of pulmonary function was significantly associated with heavy smoking (FVC -70.7 ml, p = 0.07; FEV1 -167.4 ml, p < 0.001; MEF50 -356.2 ml/s, p < 0.001), but not with moderate smoking habits, and also with duration of occupational exposure to welding fumes per year (FVC -0.89 ml, p = 0.36; FEV1 -2.91 ml, p < 0.001; MEF50 -4.7 ml/s, p = 0.047). CONCLUSIONS: Individual smoking habits as well as duration of occupational exposure to welding fumes showed a negative impact on lung function parameters. To reduce the risk of work-associated respiratory morbidity, smoking cessation is highly recommended to personnel engaged in welding fumes- and dust-exposed occupations.

Determinants of Knowledge, Attitudes, Perceptions and Behaviors Regarding Air Pollution in Schoolchildren in Pristina, Kosovo.

Air pollution poses a significant public health challenge, and Kosovo, a low-middle-income country in the Balkan peninsula, suffers from particularly poor air quality, especially around the area of the capital Pristina. The availability of accurate and timely information is crucial in mitigating the adverse effects of air pollution. This study aimed at evaluating the knowledge, attitudes, behaviors, and perceptions (KAPB) related to poor air quality in Pristina's low-middle schools. Furthermore, the study explored the connections between these factors and socio-demographic and health attributes and provided valuable inputs for the development of future strategies and policies in air pollution mitigation. Regression analysis provided insights into how these various factors interacted with KAPB scores. The results revealed limited knowledge about air pollution sources and risks among pupils, with insufficient awareness of reliable information sources. While attitudes were generally positive, they declined with higher grade levels. Parental education significantly influenced knowledge and attitudes, and better health correlated with more positive attitudes. Perceptions of air pollution risks were influenced by grade, gender, and parental education, with better-educated parents associated with improved perceptions. Overall behavior scores increased with higher levels of parental education. Understanding the factors that shape pupils' responses to air pollution is critical for strategy and policy development. These findings can guide strategies to enhance environmental awareness and promote healthy behavior, helping address the pressing issue of air pollution in the country.

Chronic burden of near-roadway traffic pollution in 10 European cities (APHEKOM network).

Recent epidemiological research suggests that near road traffic-related pollution may cause chronic disease, as well as exacerbation of related pathologies, implying that the entire "chronic disease progression" should be attributed to air pollution, no matter what the proximate cause was. We estimated the burden of childhood asthma attributable to air pollution in 10 European cities by calculating the number of cases of 1) asthma caused by near road traffic-related pollution, and 2) acute asthma events related to urban air pollution levels. We then expanded our approach to include coronary heart diseases in adults. Derivation of attributable cases required combining concentration-response function between exposures and the respective health outcome of interest (obtained from published literature), an estimate of the distribution of selected exposures in the target population, and information about the frequency of the assessed morbidities. Exposure to roads with high vehicle traffic, a proxy for near road traffic-related pollution, accounted for 14% of all asthma cases. When a causal relationship between near road traffic-related pollution and asthma is assumed, 15% of all episodes of asthma symptoms were attributable to air pollution. Without this assumption, only 2% of asthma symptoms were attributable to air pollution. Similar patterns were found for coronary heart diseases in older adults. Pollutants along busy roads are responsible for a large and preventable share of chronic disease and related acute exacerbations in European urban areas.

Dust is in the air: effects of occupational exposure to mineral dust on lung function in a 9-year study.

BACKGROUND: Occupational mineral dust exposure is a well-known risk factor for numerous respiratory and systemic diseases. The aim of the present longitudinal study was to assess the influence of work-associated dust exposure on spirometric results. Furthermore, the impact of implementation of stricter limit values for occupational contact with quartz dust on lung function was evaluated. METHODS: Anthropometric data (age, gender, BMI), smoking behavior, and lung function parameters (FVC, FEV1, MEF50) from 7,204 medical examinations of 3,229 female and male workers during the years 2002-2010 were examined following Austrian standards for occupational medicine and the guidelines of the European Respiratory Society. Analysis of data was performed using models of multiple linear regression. RESULTS: Lung function decrease over time was associated with smoking habits and duration of occupational dust exposure. Specifically, occupational quartz exposure negatively influenced the annual lung function parameters (FVC, -6.68 ml; FEV1, -6.71 ml; and MEF50, -16.15 ml/s, all p < 0.001). Thus, an overadditive effect of smoking and work-related contact with quartz was found regarding decline in MEF50 (p < 0.05). Implementation of stricter occupational limit values for dust exposure resulted in a highly significant deceleration of the annual decrease in respiratory function (p = 0.001). CONCLUSIONS: Individual smoking habits and occupational dust exposure had a negative impact on lung function. To reduce the risk of loss of respiratory capacity, smoking cessation is especially recommended to workers exposed to quartz dust. Moreover, stricter limit values could prevent chronic occupational damage to the respiratory system.

Time series analysis in environmental epidemiology: challenges and considerations.

In environmental epidemiology, time series analyses represent a widely used statistical tool. However, though being commonly used, there is soften confusion regarding the specific requirements, such as which link function might be most appropriate, when or how to control for seasonality or how to account for lags. The present overview draws from experiences in other disciplines and discusses the proper execution of time series analyses based on considerations that are relevant in environmental epidemiology. Time series analysis in environmental epidemiology focuses on acute events caused by short-term changes in exposure. These exposures should be fairly wide-spread affecting a large number of persons, usually all inhabitants of a political entity. Pollutants in air or drinking water as well as meteorological factors serve as typical examples. Despite the many time series analyses performed world-wide, some health effects that would lend themselves to that approach are still under-explored. This would include also some neurological and psychiatric endpoints. Int J Occup Med Environ Health. 2023;36(6):704-16.

Determinants of COVID-19 Knowledge, Perception and Attitudes in Indonesia: A Cross-Sectional Survey.

Many countries, including Indonesia, were gravely affected by the COVID-19 pandemic. While younger people were rarely severely affected by an infection, they still served as important spreaders of the disease. Therefore, the knowledge, perception and attitudes regarding COVID-19 of a mostly younger population was assessed in this study using a quantitative survey and semi-structured questionnaire. Out of 15 questions on COVID-19, males answered fewer questions (-1.26) correctly. Persons reporting more diseases in the last year (+0.49 per disease) that lived in a central area of Indonesia, and that had a better socio-economic status defined through household condition scores, had better knowledge of the symptoms, causes of and measures against COVID-19. Better knowledge independently predicted more responsible attitudes and stated behavior. Knowledge and understanding should be enhanced through information campaigns targeted specifically towards men, persons with poor socio-economic backgrounds and those living in the periphery of the state.

Determinants of exposure to acrylamide in European children and adults based on urinary biomarkers: results from the "European Human Biomonitoring Initiative" HBM4EU participating studies.

Little is known about exposure determinants of acrylamide (AA), a genotoxic food-processing contaminant, in Europe. We assessed determinants of AA exposure, measured by urinary mercapturic acids of AA (AAMA) and glycidamide (GAMA), its main metabolite, in 3157 children/adolescents and 1297 adults in the European Human Biomonitoring Initiative. Harmonized individual-level questionnaires data and quality assured measurements of AAMA and GAMA (urine collection: 2014-2021), the short-term validated biomarkers of AA exposure, were obtained from four studies (Italy, France, Germany, and Norway) in children/adolescents (age range: 3-18 years) and six studies (Portugal, Spain, France, Germany, Luxembourg, and Iceland) in adults (age range: 20-45 years). Multivariable-adjusted pooled quantile regressions were employed to assess median differences (ß coefficients) with 95% confidence intervals (95% CI) in AAMA and GAMA (µg/g creatinine) in relation to exposure determinants. Southern European studies had higher AAMA than Northern studies. In children/adolescents, we observed significant lower AA associated with high socioeconomic status (AAMA:ß = - 9.1 µg/g creatinine, 95% CI - 15.8, - 2.4; GAMA: ß = - 3.4 µg/g creatinine, 95% CI - 4.7, - 2.2), living in rural areas (AAMA:ß = - 4.7 µg/g creatinine, 95% CI - 8.6, - 0.8; GAMA:ß = - 1.1 µg/g creatinine, 95% CI - 1.9, - 0.4) and increasing age (AAMA:ß = - 1.9 µg/g creatinine, 95% CI - 2.4, - 1.4; GAMA:ß = - 0.7 µg/g creatinine, 95% CI - 0.8, - 0.6). In adults, higher AAMA was also associated with high consumption of fried potatoes whereas lower AAMA was associated with higher body-mass-index. Based on this large-scale study, several potential determinants of AA exposure were identified in children/adolescents and adults in European countries.

PM10, and children's respiratory symptoms and lung function in the PATY study.

Studies of the impact of long-term exposure to outdoor air pollution on the prevalence of respiratory symptoms and lung function in children have yielded mixed results, partly related to differences in study design, exposure assessment, confounder selection and data analysis. We assembled respiratory health and exposure data for >45,000 children from comparable cross-sectional studies in 12 countries. 11 respiratory symptoms were selected, for which comparable questions were asked. Spirometry was performed in about half of the children. Exposure to air pollution was mainly characterised by annual average concentrations of particulate matter with a 50% cut-off aerodynamic diameter of 10 µm (PM(10)) measured at fixed sites within the study areas. Positive associations were found between the average PM(10) concentration and the prevalence of phlegm (OR per 10 µg · m(-3) 1.15, 95% CI 1.02-1.30), hay fever (OR 1.20, 95% CI 0.99-1.46), bronchitis (OR 1.08, 95% CI 0.98-1.19), morning cough (OR 1.15, 95% CI 1.02-1.29) and nocturnal cough (OR 1.13, 95% CI 0.98-1.29). There were no associations with diagnosed asthma or asthma symptoms. PM(10) was not associated with lung function across all studies combined. Our study adds to the evidence that long-term exposure to outdoor air pollution, characterised by the concentration of PM(10), is associated with increased respiratory symptoms.

Indoor air in schools and lung function of Austrian school children.

The Children's Environment and Health Action Plan for Europe (CEHAPE) of WHO focuses (inter alia) on improving indoor environments where children spend most of their time. At present, only little is known about air pollution in schools and its effect on the lung function of school children. Our project was set up as an Austrian contribution to CEHAPE. In a cross-sectional approach, differences in indoor pollution in nine elementary all-day schools were assessed and 34 of these pollutants were analyzed for a relationship with respiratory health determined by spirometry using a linear regression model. Overall 596 children (aged 6-10 years) were eligible for the study. Spirometry was performed in 433 children. Socio-economic status, area of living (urban/rural), and smoking at home were included in the model as potential confounders with school-related average concentration of air pollutants as the variable of primary interest. A negative association with flow volumes (MEF(75)) was found for formaldehyde in air samples, benzylbutylphthalate and the sum of polybrominated diphenylethers in school dust. FVC and FEV(1) were negatively associated with ethylbenzene and xylenes in air samples and tris(1,3-dichlor-2-propyl)-phosphate on particulates. Although, in general, the quality of school indoor air was not worse than that reported for homes, effects on the respiratory health of children cannot be excluded. A multi-faceted strategy to improve the school environment is needed.

Temporal patterns of weekly births and conceptions predicted by meteorology, seasonal variation, and lunar phases.

BACKGROUND: Data reporting the number of births given by women resident in Vienna for each week between 1999 and 2019, and the duration (in weeks) of their pregnancies, were used to estimate the week of conception. When preliminary examinations detected cyclical patterns for births and conceptions, a series of Poisson regressions for births and conceptions were performed to assess whether these cycles could be associated with lunar or solar phases. METHODS: To that end 2 sine-cosine functions, 1 with a wavelength of 1 year (365.25 days) and 1 with a wavelength of 29.529 days, the latter resembling the average length of a lunar cycle, were constructed. In addition, also average weekly temperatures were included in the models. RESULTS: Same week temperature was a strong non-linear predictor for both births and conceptions. Extreme temperatures, especially hot temperatures, increased the number of births while the numbers of successful conceptions were decreased by extreme temperatures. Regarding annual variation in conceptions, the lowest values were found in May and the highest in late autumn and early winter. Therefore, the highest numbers of births are observed in the summer. As per lunar variations, the highest numbers of conceptions occurred at the full moon and the highest numbers of births at the waxing crescent to first quarter moon. DISCUSSION: The latter results should be treated with caution, as they are not hypothesis driven. Furthermore, literature reports on this topic are conflicting. Nevertheless, these findings will be useful in further analyses examining air pollution effects.

COVID-19: Regional Differences in Austria.

In the turbulent year 2020, overshadowed by the global COVID-19 pandemic, Austria experienced multiple waves of increased case incidence. While governmental measures to curb the numbers were based on current knowledge of infection risk factors, a retrospective analysis of incidence and lethality at the district level revealed correlations of relative infection risk with socioeconomic, geographical, and behavioral population parameters. We identified unexpected correlations between political orientation and smoking behavior and COVID-19 infection risk and/or mortality. For example, a decrease in daily smokers by 2.3 percentage points would be associated with an increase in cumulative incidence by 10% in the adjusted model, and an increase in voters of the right-wing populist party by 1.6 percentage points with an increase in cumulative mortality by 10%. While these parameters are apparently only single elements of complex causal chains that finally lead to individual susceptibility and vulnerability levels, our findings might have identified ecological parameters that can be utilized to develop fine-tuned communications and measures in upcoming challenges of this and other pandemics.

Environmental health, COVID-19, and the syndemic: internal medicine facing the challenge.

Internists are experts in complexity, and the COVID-19 pandemic is disclosing complex and unexpected interactions between communicable and non-communicable diseases, environmental factors, and socio-economic disparities. The medicine of complexity cannot be limited to facing comorbidities and to the clinical management of multifaceted diseases. Evidence indicates how climate change, pollution, demographic unbalance, and inequalities can affect the spreading and outcomes of COVID-19 in vulnerable communities. These elements cannot be neglected, and a wide view of public health aspects by a "one-health" approach is strongly and urgently recommended. According to World Health Organization, 35% of infectious diseases involving the lower respiratory tract depend on environmental factors, and infections from SARS-Cov-2 is not an exception. Furthermore, environmental pollution generates a large burden of non-communicable diseases and disabilities, increasing the individual vulnerability to COVID-19 and the chance for the resilience of large communities worldwide. In this field, the awareness of internists must increase, as privileged healthcare providers. They need to gain a comprehensive knowledge of elements characterizing COVID-19 as part of a syndemic. This is the case when pandemic events hit vulnerable populations suffering from the increasing burden of chronic diseases, disabilities, and social and economic inequalities. Mastering the interplay of such events requires a change in overall strategy, to adequately manage not only the SARS-CoV-2 infection but also the growing burden of non-communicable diseases by a "one health" approach. In this context, experts in internal medicine have the knowledge and skills to drive this change.