Environmental Impact Assessment, Human Health and the Sustainable Development Goals.

Objectives: Developmental processes influence the determinants of health and, consequently, human health. Yet, assessing human health impacts in impact assessment, with exception of health impact assessment, is still rather vague. Inclusion of Sustainable Development Goal indicators in environmental impact assessment (EIA) is an opportunity to enhance addressing human health in EIA practices. Methods: We reviewed a list of health-related targets and indicators for SDGs as defined by the Institute of Health Metrics and Evaluation (IHME) in Seattle, WA, United States with the aim of identifying those to be suggested as outcome indicators within EIA. Results: Among 42 health-related indicators, we identified 17 indicators which could be relevant for impact assessment procedures and categorized them into three groups: 1) direct health indicators (e.g., under five mortality). 2) complex indicators (e.g., cancer). 3) environmental determinant indicators (e.g., mean PM2.5). Conclusion: All 17 indicators can be employed to improve quantification assessing human health impacts and bring SDGs into EIA processes. Though our assessment has been conducted for Denmark and the set of suggested indicators could be different for contexts in other countries, the process of their identification can be generalized.

Prostate cancer incidence and mortality in selected countries of Central Europe.

BACKGROUNDS: This paper analyzes the incidence and mortality of prostate cancer in the Slovak (SR) and Czech (CR) Republics (as Central European countries with population-based cancer registries) before and after the introduction of PSA testing, the possible reasons for any differences disclosed, and compares the results with selected regions and countries around the world. MATERIAL, METHODS AND RESULTS: In SR, the age-adjusted incidence of prostate cancer rose from 14.6/100,000 in 1968 to 36.2/100,000 in 2005. The estimated annual increase of incidence from 1968 to 1991 (before nation-wide PSA testing) was 0.421 and 1991-2003 it reached 0.941. The mortality rates rose from 7.3/100,000 in 1968 to 14.9/100,000 in 2005. The increase in incidence occurred faster in CR than in SR, from 15.8/100,000 in 1977 to 59.5/100,000 in 2005. The estimated annual increase of incidence in CR in 1977-1991 was 0.581,while in 1991-2003 it reached 1.981. Before 1991, mortality rose more sharply in CR than in SR while after the introduction of PSA testing mortality stabilized more quickly in the CR than in SR. In SR a significant reduction of mortality was observed after 2002 and is probably affected by more factors than those associated with the increase in PSA testing. CONCLUSION: The difference in the incidence and mortality of prostate cancer in SR and in CR results from a difference in the intensity of PSA testing as well as from the earlier introduction of effective treatment in CR.

Public health research in Denmark in the years 1995--2005.

BACKGROUND: The objective of this study was to find out the number of publications (in Danish) and research projects (including grey literature) either carried out or ongoing within the field of public health in Denmark, using the same criteria as the SPHERE project, but looking at Danish research databases. METHODS: The Danish research database served as the main resource for the study supported by national research reports. RESULTS: There is an increasing trend in the number of public health research projects and publications. Compared with public health research projects published in English there are differences in some categories. Overall, public health research in Denmark seems to contribute around 4.8%-6.5% of the total amount of health research. CONCLUSIONS: Public health research has a relatively low share of overall health research in Denmark.

Mortality from diseases other than cancer following low doses of ionizing radiation: results from the 15-Country Study of nuclear industry workers.

BACKGROUND: Ionizing radiation at very high (radio-therapeutic) dose levels can cause diseases other than cancer, particularly heart diseases. There is increasing evidence that doses of the order of a few sievert (Sv) may also increase the risk of non-cancer diseases. It is not known, however, whether such effects also occur following the lower doses and dose rates of public health concern. METHODS: We used data from an international (15-country) nuclear workers cohort study to evaluate whether mortality from diseases other than cancer is related to low doses of external ionizing radiation. Analyses included 275 312 workers with adequate information on socioeconomic status, over 4 million person-years of follow-up and an average cumulative radiation dose of 20.7 mSv; 11 255 workers had died of non-cancer diseases. RESULTS: The excess relative risk (ERR) per Sv was 0.24 [95% CI (confidence intervals) -0.23, 0.78] for mortality from all non-cancer diseases and 0.09 (95% CI -0.43, 0.70) for circulatory diseases. Higher risk estimates were observed for mortality from respiratory and digestive diseases, but confidence intervals included zero. Increased risks were observed among the younger workers (attained age <50 years, identified post hoc) for all groupings of non-cancer causes of death, including external causes. It is unclear therefore whether these findings reflect real effects of radiation, random variation or residual confounding. CONCLUSIONS: The most informative low-dose radiation study to date provides little evidence for a relationship between mortality from non-malignant diseases and radiation dose. However, we cannot rule out risks per unit dose of the same order of magnitude as found in studies at higher doses.

The 15-Country Collaborative Study of Cancer Risk Among Radiation Workers in the Nuclear Industry: design, epidemiological methods and descriptive results.

Radiation protection standards are based mainly on risk estimates from studies of atomic bomb survivors in Japan. The validity of extrapolations from the relatively high-dose acute exposures in this population to the low-dose, protracted or fractionated environmental and occupational exposures of primary public health concern has long been the subject of controversy. A collaborative retrospective cohort study was conducted to provide direct estimates of cancer risk after low-dose protracted exposures. The study included nearly 600,000 workers employed in 154 facilities in 15 countries. This paper describes the design, methods and results of descriptive analyses of the study. The main analyses included 407,391 nuclear industry workers employed for at least 1 year in a participating facility who were monitored individually for external radiation exposure and whose doses resulted predominantly from exposure to higher-energy photon radiation. The total duration of follow-up was 5,192,710 person-years. There were 24,158 deaths from all causes, including 6,734 deaths from cancer. The total collective dose was 7,892 Sv. The overall average cumulative recorded dose was 19.4 mSv. A strong healthy worker effect was observed in most countries. This study provides the largest body of direct evidence to date on the effects of low-dose protracted exposures to external photon radiation.

The 15-Country Collaborative Study of Cancer Risk among Radiation Workers in the Nuclear Industry: estimates of radiation-related cancer risks.

A 15-Country collaborative cohort study was conducted to provide direct estimates of cancer risk following protracted low doses of ionizing radiation. Analyses included 407,391 nuclear industry workers monitored individually for external radiation and 5.2 million person-years of follow-up. A significant association was seen between radiation dose and all-cause mortality [excess relative risk (ERR) 0.42 per Sv, 90% CI 0.07, 0.79; 18,993 deaths]. This was mainly attributable to a dose-related increase in all cancer mortality (ERR/Sv 0.97, 90% CI 0.28, 1.77; 5233 deaths). Among 31 specific types of malignancies studied, a significant association was found for lung cancer (ERR/Sv 1.86, 90% CI 0.49, 3.63; 1457 deaths) and a borderline significant (P = 0.06) association for multiple myeloma (ERR/Sv 6.15, 90% CI <0, 20.6; 83 deaths) and ill-defined and secondary cancers (ERR/Sv 1.96, 90% CI -0.26, 5.90; 328 deaths). Stratification on duration of employment had a large effect on the ERR/Sv, reflecting a strong healthy worker survivor effect in these cohorts. This is the largest analytical epidemiological study of the effects of low-dose protracted exposures to ionizing radiation to date. Further studies will be important to better assess the role of tobacco and other occupational exposures in our risk estimates.

Risk of congenital anomalies in the vicinity of waste landfills in Denmark; an epidemiological study using GIS.

Waste landfills are a potential hazard to health. Public concern exists about this potential hazard and researchers agree that further research is required on this field. The objective of the study was to investigate the association between waste landfill location and congenital anomalies risk in Denmark. The study was a multisided epidemiological geographical comparison study of risk of congenital anomalies combined and congenital anomalies of the cardiovascular and nervous systems with maternal residence in the vicinity of 48 Danish waste landfills compared with those living further away in the years 1997 to 2001. We used routine health and population data in Geographical Information System (GIS) to investigate the risk. The subjects were 2,477 live birth with congenital anomalies. All relative risks in the proximal zones of 0-2 km were set to 1 for comparison. For all anomalies combined relative risk in the middle zones of 2-4 km joint was 0.991 and in the distal zones of 4-6 km joint the relative risk was 1.013. For congenital anomalies of the nervous system, the relative risk in the middle zones was 1.226 and in the distal zones 1.113. For congenital anomalies of the cardiovascular system, the relative risk in the middle zones was 0.926 and in the distal zones 0.854. This result was not supported by the aggregated risk ratio mean. We found no association between waste landfill location and congenital anomalies combined or of the nervous system. However, we found small excess risk for congenital anomalies of the cardiovascular system. No causal mechanisms are available to explain these findings, but alternative explanations include approximated birth rates and residual confounding. It is our recommendation that more comprehensive multisided studies will be executed to examine the safety of waste landfills.

Cancer occurrence among radiation workers at Jaslovské Bohunice nuclear power plant.

The Public Health Institute in Trnava, Slovak Republic under coordination of the International Agency of Cancer Research (IARC) at Lyon, France, had completed a retrospective cohort study of cancer occurrence among nuclear workers at Jaslovské Bohunice, Slovak Republic, as part of a multicentric cohort study of 14 countries. The objective of the study was to assess an impact of a long-term low level ionising radiation on cancer occurrence. In summary, 2776 employees had been selected for the follow-up period, which lasted since January 1, 1973 till December 31, 1993, it means for 21 years. Mean age at beginning of follow-up was 28.9 years and at the end of follow-up 39.6 years. The total number of person years was 27,742.1 of males and 2,442.2 of females. Exposure was expressed as annual cumulative dose of each cohort member. The total cumulative external gamma dose over the follow-up time was 58,187.9 mSv. The average external gamma dose per person years was 2.06 mSv of males and 0.37 of females. Socio-economic status, described by the last job description and education were used as possible confounding variables. All cause mortality, cancer caused mortality and cancer incidence were assessed comparing with general Slovak population using indirect standardised mortality ratio or incidence ratio calculations. There were 47 deaths reported, 44 males and 3 females, over 21 years of follow-up. The most frequent causes of death were cancer (about 30%), accidents, suicides and other external causes (about 26%), cardiovascular diseases (23%). Standardised mortality ratios of 0.39 (0.386-0.392) and 0.46 (0.27-0.59) for males and females, respectively were found in case of all cause mortality. In case of cancer mortality the standardised mortality ratios (SMR) were 0.44 (0.42-0.47) and 1.35 (0.84-1.86) for males and females, respectively. There were 32 incident cases of cancer observed during follow-up. Standardised incidence ratios as 0.508 (0.49-0.52) and 0.905 (0.74-1.06) for males and females, respectively were found. Dose response relation was measured using Poisson regression and Cox proportional hazard model. The estimated excess risks in both approaches and both for mortality and morbidity study were rather anecdotal due to lack of statistical significance caused by small number of cases.

Cancer incidence around the Nuclear Power Plant Jaslovské Bohunice.

The total cancer incidence in our district has been increasing during years 1986-1995. Standardised cancer incidence in district Trnava in 1994 to European population was 278.12 per 100,000 inhabitants. Nuclear Power Plant (NPP) Jaslovské Bohunice is situated in the centre of the district of Trnava. From 1978 five reactors have started to operate and four still work. NPP produces approximately 40% of whole electrical energy consumption in Slovakia. There are approximately 250,000 people in the area of 30 km around the NPP. The main part of this area belongs to Trnava district. Objectives of work were to study the dependence of incidence with distance of the home from NPP. Time period for the study of cancer incidence was 1986-1995. Population which is relatively stable from migration point of view was divided into following subgroups by the distance of residence from NPP; less than 5 km, 5 to 10 km, 10 to 15 km, 15 to 20 km, more than 20 km. Data from district cancer registry were used for calculation of SIR including statistical parameters. Statistically significant differences between observed and expected number of cancer cases were found only in some circles, for female in leukaemia's, stomach, other skin, for males stomach, colon, other skin. Relationship between distance of residence and SIR was tested using linear regression model. Significant correlation was found for leukaemia's, corpus uteri, colon/rectum, stomach cancers for females and stomach cancer for male. The small number of detected cases decreases importance of our findings. Ecologic study design does not allow to study confounders as migration, occupation, nutrition and other environmental exposures, yet gives enough knowledge for evaluation of public health status in geographical area.

Drinking water, mortality, and life expectancy: an assessment of the east-west mortality gap in Europe.

The role of the drinking water in public health has been recognised for many years. Recent ecological studies of mortality rates in Slovakia when compared to indicators of environmental pollution have shown surprising results--areas with greater air pollution seem to have lower total mortality rates. This paradox may be explained by a number of other factors, including urban/rural occupational conditions, socio-economic status, access to health care, and perhaps drinking water. Overall population access to safe drinking water is about the same between East and West Europe, but more careful evaluation suggest at least one important difference. About 35.7% of the people in Central and Eastern European countries do not have 100% access to safe drinking water in their rural areas, compared to only 18.7% of the rural populations in Western Europe who do not have full access to safe drinking water. This study examines access to safe drinking water, assesses overall drinking water quality, and utilises an index of drinking water quality to perform correlation with total mortality, selected chronic diseases which have been associated with drinking water contamination, and life expectancy at birth. These methods are applied to data for East-West Europe, Slovakia, and detailed urban-rural comparisons for three areas of Slovakia (Trnava, Banská Bystrica, and Kosice).

Colorectal cancer and environmental pollution.

Monitoring of personal exposure of population from environmental pollution is a very complicated process. There are many different pollutants in environment in very low concentrations and their distribution is non-homogenous. To measure these pollutants is not often feasible or possible due to technical problems. On the other side these can influence the health status of inhabitants by the way of a long time exposition by low doses. In our work we studied an incidence of the cancer of colon and rectum in rural area of Trnava district during the years 1986-1995. These are the most frequent types of cancer in our district-13.4%, incidence rate is 27.5 per 100,000 inhabitants. The standardised incidence ratio (observed/expected cases) were calculated for all villages, including statistical parameters. The population in this small area (1390 km2) is relatively stabile from point of view of migration and nutritional habits. The urban area consisting from five towns was excluded from analysis because the life style and nutritional habits of people living in towns and villages are different. These suppositions enabled to concentrate our attention to the study of environmental factors which can influence development of the colorectal cancer. The SIR's were correlated with time of public drinking water supply, surface water quality, location of waste dumps, and time of gas heating using as kind of house heating. Positive and statistically significant correlation's were found between SIR of the colorectal cancer and waste dump location for females and weaker for surface water and SIR for males. Statistically significant elevation of SIR both for males and females were found in one village. Ecological design of study did not allow to study confounders, yet served enough information for preparation of analytical studies and public health decision-making process on local level.

Introducing Health Impact Assessment: an analysis of political and administrative intersectoral working methods.

BACKGROUND: Intersectoral Action for Health (IAH) and its Health Impact Assessment (HIA) tool are built on collaboration between actors and sectors, requiring multidimensional and horizontal way of working. The study aims to analyse the enablers and barriers when such a new way of working and tool have been initiated to replace a traditional, vertical operation at the local level in Slovakia-a country in transition-in 2004. METHODS: Up to date, there are few studies that have analysed intersectoral initiatives in relation to politics. In this study the conceptual framework of Kingdon has been used by which the actual problems, the governmental actions (or non-actions) (politics) and the understanding, implementation and evaluation of the initiative (policy) could be analysed. All actors involved, civil servants, politicians, representatives of the local public health institute and researchers, were interviewed and made to answer a questionnaire. RESULTS: The results showed that there were a number of factors behind the initiation of HIA, which either delayed or accelerated the process. The problems identified were e.g. the prevailing traditional health care focus and the deteriorating health status of the population. There was a lack of multi-intersectoral knowledge, co-operation and function between sectors and actors. Enablers on the other hand were the membership of international organizations which called for new solutions, and the strong political commitment and belief that intersectorality would have a positive effect on health. CONCLUSION: The actors on the local level would have the capacity to work intersectorally to bring about policy change if HIA was to be more supported/institutionalized.

Risk of cancer after low doses of ionising radiation: retrospective cohort study in 15 countries.

OBJECTIVES: To provide direct estimates of risk of cancer after protracted low doses of ionising radiation and to strengthen the scientific basis of radiation protection standards for environmental, occupational, and medical diagnostic exposures. DESIGN: Multinational retrospective cohort study of cancer mortality. SETTING: Cohorts of workers in the nuclear industry in 15 countries. PARTICIPANTS: 407 391 workers individually monitored for external radiation with a total follow-up of 5.2 million person years. MAIN OUTCOME MEASUREMENTS: Estimates of excess relative risks per sievert (Sv) of radiation dose for mortality from cancers other than leukaemia and from leukaemia excluding chronic lymphocytic leukaemia, the main causes of death considered by radiation protection authorities. RESULTS: The excess relative risk for cancers other than leukaemia was 0.97 per Sv, 95% confidence interval 0.14 to 1.97. Analyses of causes of death related or unrelated to smoking indicate that, although confounding by smoking may be present, it is unlikely to explain all of this increased risk. The excess relative risk for leukaemia excluding chronic lymphocytic leukaemia was 1.93 per Sv (< 0 to 8.47). On the basis of these estimates, 1-2% of deaths from cancer among workers in this cohort may be attributable to radiation. CONCLUSIONS: These estimates, from the largest study of nuclear workers ever conducted, are higher than, but statistically compatible with, the risk estimates used for current radiation protection standards. The results suggest that there is a small excess risk of cancer, even at the low doses and dose rates typically received by nuclear workers in this study.

Life expectancy as an indicator of environmental health.

Whether or not life expectancy at birth is related to the quality of life as expressed by global economical, environmental and nutritional measures is the primarily studied question in this article. Two models, set of independent variables and multivariate analysis was performed. An attempt to estimate the role of studied variables in overall life expectancy was done, too. A descriptive, ecological study design was used. The population of 156 countries have been taken into account, using data from published databases [7, 9]. Access to safe drinking water, per capita gross domestic product, literacy, calories available as percentage of needs and per capita public health expenditures were taken as exposure, and compared with life expectancy at birth. A linear regression model was used to estimate the role of different exposures on life expectancy at birth. A correlation matrix for all variables and life expectancy at birth is presented in the article. Literacy and access to safe drinking water are statistically significant variables (p < 0.001) also after fitting a linear regression model. The correlation coefficient for the linear model was 0.8823 (R2 = 0.7784). Shares of years of life from overall life expectancy attributed to studied variables were 28.06, 9.42, 2.04 and 1.93% for literacy, access to safe drinking water, GDP and calories available as percentage of needs, respectively.