[Methods for mortality analysis in SENTIERI Project]. / Materiali e metodi dell'analisi della mortalità nel Progetto SENTIERI.

The methods of mortality analysis in Italian polluted sites (IPS) are described. The study concerned 44 IPSs; each one included one or more municipalities. Mortality at municipality level was studied in the period 1995-2002, using the following indicators: crude rate, standardized rate, standardized mortality ratio (SMR), and SMR adjusted for an ad hoc deprivation index. Regional populations were used as reference for indirect standardization. The deprivation index was constructed using the 2001 national census variables representing the following socioeconomic domains: education, unemployment, dwelling ownership, overcrowding. Mortality indicators were computed for 63 single or grouped causes. The results for all the 63 analysed causes of death are available for each IPS, and in this Chapter the results for each IPS for causes selected on the basis of a priori evidence of risk from local sources of environmental pollution are presented. The procedures and results of the evidence evaluation have been published in the 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI.

[Global burden of mortality in Italian polluted sites]. / Valutazioni globali del carico di mortalità nei siti di interesse nazionale per le bonifiche.

SENTIERI Project has assessed the overall mortality profile in all the IPSs combined, and performed IPS-specific analyses. The epidemiological evidence of the causal association between cause of death and exposure was classified into one of these three categories: Sufficient (S), Limited (L) and Inadequate (I). The procedures and results of the evidence evaluation have been presented in a 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI. Mortality for causes of death with a priori Sufficient or Limited evidence of association with the environmental exposure exceeds the expected figures, with a SMR of 115.8 for men (90%CI 114.4-117.2; 2 439 extra deaths) and 114.4 for women (90% CI 112.4-116.5; 1 069 extra deaths). These excesses are also observed when analysis is extended to all the causes of death (i.e. with no restriction to the ones with a priori Sufficient or Limited evidence): for a total of 403 692 deaths (men and women combined), an excess of 9 969 deaths is observed, with an average of around 1 200 extra deaths per year. Most of these excesses are observed in IPSs located in Southern and Central Italy. The distribution of the causes of deaths shows that the excesses are not evenly distributed: cancer mortality accounts for 30%of all deaths, but is 43.2%of the excess deaths (4 309 cases of 9 969). Conversely, the percentage of excesses in non cancer causes, 19%, is lower than their share of total mortality (42%). Consistently with previous studies, the results suggest that the health status of populations living in the IPSs is worse than what regional averages show. Compared to previous studies, the analysis of the causes selected in SENTIERI, on the basis of a priori Sufficient or Limited evidence of association with the environmental exposures, provides additional information on their role, though some limitations, due to methodology and data used, should be considered.

[Mortality results in SENTIERI Project]. / Risultati dell'analisi della mortalità nel Progetto SENTIERI.

SENTIERI Project (Mortality study of residents in Italian polluted sites) studies mortality of residents in 44 sites of national interest for environmental remediation (Italian polluted sites, IPS). The epidemiological evidence of the causal association between causes of death and exposures was a priori classified into one of these three categories: Sufficient (S), Limited (L) and Inadequate (I). In these sites various environmental exposures are present. Asbestos (or asbestiform fibres as in Biancavilla) has been the motivation for defining six sites as IPSs (Balangero, Emarese, Casale Monferrato, Broni, Bari-Fibronit, Biancavilla). In five of these, increases in malignant neoplasm or pleura mortality are detected; in four of them, results are consistent in both genders. In six other sites (Pitelli, Massa Carrara, Aree del Litorale Vesuviano, Tito, "Aree industriali della Val Basento", Priolo), where other sources of environmental pollution in addition to asbestos are reported, mortality from malignant neoplasm of pleura is increased in both genders in Pitelli, Massa Carrara, Priolo, "Litorale vesuviano". In the time span 1995-2002, a total of 416 extra cases of malignant neoplasm of pleura are detected in the twelve asbestos-polluted sites. Asbestos and pleural neoplasm represent an unique case. Unlike mesothelioma, most causes of death analyzed in SENTIERI have multifactorial etiology; furthermore, in most IPSs multiple sources of different pollutants are present, sometimes concurrently with air pollution from urban areas: in these cases, drawing conclusions on the association between environmental exposures and specific health outcomes might be complicated. Notwithstanding these difficulties, in a number of cases an etiological role could be attributed to some environmental exposures. The attribution could be possible on the basis of increases observed in both genders and in different age classes, and the exclusion of a major role of occupational exposures was thus allowed. For example, a role of emissions from refineries and petrochemical plants was hypothesized for the observed increases in mortality from lung cancer and respiratory diseases in Gela and Porto Torres; a role of emissions from metal industries was suggested to explain increased mortality from respiratory diseases in Taranto and in Sulcis-Iglesiente-Guspinese. An etiological role of air pollution in the raise in congenital anomalies and perinatal disorders was suggested in Falconara Marittima, Massa-Carrara, Milazzo and Porto Torres. A causal role of heavy metals, PAH's and halogenated compounds was suspected for mortality from renal failure in Massa Carrara, Piombino, Orbetello, "Basso bacino del fiume Chienti" and Sulcis-Iglesiente-Guspinese. In Trento-Nord, Grado and Marano, and "Basso bacino del fiume Chienti" increases in neurological diseases, for which an etiological role of lead, mercury and organohalogenated solvents is possible, were reported. The increase for non-Hodgkin lymphomas in Brescia was associated with the widespread PCB pollution. Mortality for causes of death with a priori Sufficient or Limited evidence of association with the environmental exposure exceeds the expected figures, with a SMR of 115.8% for men (90% IC 114.4-117.2; 2 439 extra deaths) and 114.4% for women (90% CI 112.4-116.5; 1 069 extra deaths). These excesses are also observed when analysis is extended to all the causes of death (i.e. with no restriction to the ones with a priori Sufficient or Limited evidence): for a total of 403 692 deaths (both men and women), an excess of 9 969 deaths is observed, with an average of about 1 200 extra deaths per year. Most of these excesses are observed in IPSs located in Southern and Central Italy. The procedures and results of the evidence evaluation are presented in a 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI.

[Deprivation indices in small-area studies of environment and health in Italy]. / L'indice di deprivazione negli studi di piccola area su ambiente e salute.

The use of deprivation indices in small-area studies of environment and health is described, with particular reference to the Italian context. Deprivation indices can represent a proxy for individual deprivation and/or contextual deprivation. In Italy, deprivation indices have been constructed using Census variables. They are applied at census tract level in studies with a local basis; in national based studies, they can be used at municipality level. In SENTIERI Project (Mortality study of residents in Italian polluted sites) an ad hoc deprivation index at municipal level was used (DI SENTIERI). Its strength and weaknesses are discussed. In addition, suggestions about the use of socioeconomic indices in small area studies of environment and health are given. For a description of SENTIERI, refer to the 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI Project.

Mesothelioma associated with environmental exposures.

BACKGROUND: The main sources of environmental, non-occupational exposure to asbestos or asbestiform fibres are: a) industrial plants in which asbestos was used in the production process; b) asbestos "in place" (mainly in buildings); c) contaminated soils. The association of these exposures with increasing risk of mesothelioma has been documented since 1960 in many places. OBJECTIVES AND METHODS: The present paper is aimed at describing the main results of studies performed in the locations with soils naturally contaminated with asbestos or asbestiform fibres. Environmental exposure data and asbestos-related health outcomes, mainly mesothelioma, are analyzed through a review of the literature. RESULTS: The sites with asbestos or other mesotheliomatogenous fibres in soils are characterized by low concentration levels of airborne fibres. Furthermore, exposure levels may increase when specific activities are carried out (mainly related to building construction), involving mechanical disturbance of fibre-containing materials. The type of fibres found are mainly amphiboles (tremolite). The population at risk of exposure is the general population, which can be exposed from birth. In these sites, the sex ratio of mesothelioma cases is close to 1.0 and the average age of cases ranges from 50 to 60 years. CONCLUSIONS: Both "natural"and industrial environmental asbestos or asbestiform fibre exposures increase potential risk for mesothelioma. Strategies of environmental reclamation and risk communication should be implemented in these areas.

Microbiological influences in 'blue water' copper corrosion.

AIMS: To investigate the influence of micro-organisms associated with copper corrosion on 'blue water' corrosion in drinking water. METHODS AND RESULTS: Laboratory rigs comprising of polycarbonate containers attached to annealed copper plumbing tubes were filled with Melbourne drinking water and sterilized by autoclaving. The copper tubes were inoculated with sterile or nonsterile extracts obtained from corroding copper and allowed to stand for 7 days. The extracts were drained and the tubes flushed and filled with sterile water from the rig. The water within the tubes was removed weekly for analysis and the tubes were refilled with freshly aerated water. The tube water sampled was analysed for pH, total copper and the presence of micro-organisms. Sterile rigs and rigs containing nonsterile water, both without tube inoculums, were used as controls. The results demonstrated that tubes inoculated with nonsterile corrosion extracts showed statistically higher copper release compared with the other rigs. Copper release as blue water was only observed after a lag period of 9 weeks. The internal surfaces of tubes releasing copper showed significant amounts of corrosion products and the presence of biofilm. Bacteria isolated from the corroding tubes included Acidovorax spp. and Sphingomonas sp. CONCLUSIONS: The results demonstrate a microbial role in blue water, as corrosion was induced in new copper tubes by exposure to nonsterile copper corrosion products. SIGNIFICANCE AND IMPACT OF THE STUDY: The potential for micro-organisms present in corrosion products to initiate blue water corrosion presents significant implications for the management of corrosion in distribution systems.

[Estimates of pleural mesothelioma incidence in the Lazio region (Italy), 1997-2000]. / Stime di incidenza del mesotelioma pleurico nel Lazio, 1997-2000.

BACKGROUND: Malignant mesothelioma is indicative of past exposure to asbestos. In recent years an increase of incidence and mortality from malignant mesothelioma has been observed. Recent legislation in Italy requires nation-wide registration of asbestos-related pathologies. We conducted a preparatory study for systematic recording of cases of malignant pleural mesothelioma in the Lazio region. OBJECTIVES: To register new diagnoses of malignant mesothelioma, to estimate the incidence in the Lazio region, and to evaluate possible survey instruments. METHODS: We conducted a systematic study of hospital admissions in the region with diagnosis of cancer of the pleura (ICD-IX 163) in the period 1997-2000. Clinical information and results of diagnostic tests were requested for 530 patients from the hospitals involved. Using the capture-recapture method, it was possible to estimate the accuracy of the data we compiled using hospital admissions as the data source (76.8%, 95% C.I.=76.4-77.3). RESULTS: After careful review of clinical documentation, the diagnosis of malignant mesothelioma of the pleura was confirmed in 31.6% of cases (156 cases diagnosed). The percentage of confirmed cases has risen over the years (from 21% in 1997 to 45.1% in 2000) and it was higher in large public hospitals than in other types of health care facilities. On the basis of 156 confirmed cases of mesothelioma (116 males and 40 females), we estimated the annual incidence of the disease in the Lazio region as 1.73 new cases per 100,000 inhabitants among men and 0.47 new cases per 100,000 inhabitants among women. CONCLUSIONS: The results show that the incidence of mesothelioma in the region is consistent with national data, falling in the middle of the range for all Italian regions. However, some areas emerge (for example, Colleferro, Civitavecchia, Tarquinia, Ferentino, Gaeta, Aprilia, Pomezia) that have particularly high rates, probably in relation to past occupational asbestos exposure. The role of diffuse environmental exposure in Rome may warrant further investigation.

[Indications of public health in areas naturally polluted with asbestiform fibers]. / Indicazioni di sanità pubblica in aree con contaminazione naturale da fibre asbestiformi.

Adverse health effects of naturally occurring asbestiform fibres have been reported since the Seventies in various countries. The present paper describes the case of Biancavilla, a municipality located in Eastern Sicily, where the occurrence of the amphibolic fibre fluoro-edenite has been associated to a cluster of pleural mesotheliomas. The public health recommendations aimed at reducing exposure to fluoroedenite are described. This case study shows the importance of public-driven remedial action, including interruption of activities of previously operating quarries and asphalt paving of roads, in influencing population's compliance to recommendations aimed at modifying individual behaviours. In order to pursue the goal of fostering community's autonomy in decision making, the optimal approach is ensuring timely and transparent information dissemination.

[Malignant mesothelioma in the industrial area of Colleferro]. / Mesotelioma maligno nel comprensorio industriale di Colleferro.

The study describes the occurrence of pleural and peritoneal malignant mesothelioma in the Colleferro industrial area (Province of Rome, 9 municipalities, population 63,000, period 1993-98) which is the site of a large chemical plant (BPD) producing organic chemicals, acid mixtures, insecticides, explosives and dynamite, and was involved in manufacturing/maintenance of railroad rolling stock. Asbestos was extensively used in these plants in the past. Mesothelioma cases were actively searched from data in files of pathology archives, hospital admission and discharge (records), and death certificates recorded at local health authority register. 23 potential cases were identified for whom clinical charts and pathological slides were reviewed. A multidisciplinary evaluation of all collected information confirmed 18 cases of cyto-histologically proven malignant mesothelioma (pleural/peritoneal ratio of 2.75:1) among residents and/or workers at BPD. The remaining 5 cases were defined as not mesothelioma; however, two were cases of lung cancer (both occupationally exposed to asbestos). All subjects with malignant mesothelioma had been occupationally exposed to asbestos (14 males and 3 females), except one (1 female with domestic exposure). No mesothelioma case was attributable to environmental exposure. Of the 17 cases with occupational asbestos exposure, 15 occurred in BPD workers employed in manufacturing/maintenance of railroad rolling stock (3 cases), general maintenance services (5 cases), or in the armaments sector (7 cases) and 2 in residents but not BPD workers (1 baker, 1 pipefitter). The incidence rate in residents of the 9 municipalities was 5.5 in males and 1.3 in females (standardized on the Italian population x100,000, census 1981). For Colleferro municipality only, the incidence was 10.1 in males and 4.1 in females, which are the highest rates reported so far in Italy. Besides confirming the risk of mesothelioma risk in railroad rolling stock manufacturing and asbestos-insulated pipe maintenance workers, this study identifies a cluster of malignant mesothelioma in explosives production workers.