Availability of open data related to COVID-19 epidemic in Italy.

Background: Since the beginning of the COVID-19 outbreak in Italy, health authorities have released epidemiologic data about this disease. These data were the most important sources of information which were periodically updated and analyzed by researchers to predict the spread of the epidemic. However, comprehensive and timely data on the evolution of COVID-19 have not always been made available to researchers and physicians. Method: The aim of our work is to investigate quality, availability and format of epidemiologic data about COVID-19 in Italy in different territorial and temporal areas. We tried to access the online resources made available by each of the 19 Italian Regions and the two autonomous Provinces, and in more detail by the Local Health Authorities of one of them, the Emilia-Romagna Region. We analyzed the main sources and flows of data (namely new and cumulative cases of infection, total swabs, new and cumulative COVID-19 deaths, overall and divided by sex), describing their characteristics such as accessibility, format and completeness. We eventually reviewed the data published by the Italian Ministry of Health, the National Institute of Health (ISS) and the Civil Protection Department. The Tim Berners-Lee scale was used to evaluate the open data format. Results: The flow of COVID-19 epidemiologic data in Italy originated from the Local Health Authorities that transmitted the data - on a daily basis - to the regional authorities, which in turn transferred them to the national authorities. We found a rather high heterogeneity in both the content and the format of the released data, both at the local and the regional level. Few Regions were releasing data in open format. ISS was the only national source of data that provided the number of COVID-19 health outcomes divided by sex and age groups since Spring 2020. Conclusions: Despite multiple potential useful sources for COVID-19 epidemiology are present in Italy, very few open format data were available both at a macro geographical level (e.g. per Region) and at the provincial level. The access to open format epidemiologic data should be eased, to allow researchers to adequately assess future epidemics and therefore favor timely and effective public health interventions.

Impact of the environment on the health: From theory to practice.

The Erice 56 Charter titled "Impact of the environment on the health: from theory to practice" was unanimously approved at the end of the 56th course of the "International School of Epidemiology and Preventive Medicine G. D'Alessandro" held from 3rd to November 7, 2019 in Erice - Sicily (Italy) and promoted by the Study Group of "Environment and Health" of the Italian Society of Hygiene, Preventive Medicine and Public Health. The course, that included lectures, open discussions and guided working groups, was aimed to provide a general training on epidemiological and toxicological aspects of the environmental health impact, to be used by public health professionals for risk assessment, without forgetting the risk communications. At the end of the course 12 key points were agreed among teachers and students: they underlined the need of specific training and research, in the perspective of "One Health" and "Global Health", also facing emerging scientific and methodological issues and focusing on communication towards stakeholders. This Discussion highlight the need to improve knowledge of Health and Environment topic in all sectors of health and environmental prevention and management.

Blood pressure levels and hypertension prevalence in a high selenium environment: results from a cross-sectional study.

BACKGROUND AND AIMS: Recent human and laboratory studies have suggested the possibility that selenium overexposure may increase blood pressure. We sought to ascertain whether adults living in a seleniferous area exhibit an association between selenium exposure and both blood pressure levels as well as prevalence of hypertension. METHODS AND RESULTS: We measured selenium levels in blood (serum), hair and nail samples obtained from 680 adult volunteers (267 men and 413 women), living in seven Punjabi villages in a seleniferous area and related them to health outcomes, including systolic and diastolic blood pressure and presence of hypertension. In a multivariable restricted cubic spline regression model, adjusted for age, sex and history of hypertension, we found a positive association between systolic blood pressure and both serum (P = 0.004) and hair (P = 0.058) selenium levels, but not with nail selenium content. Little association emerged between the three selenium biomarkers and diastolic blood pressure. Hypertension prevalence was positively associated with the three exposure indicators (P < 0.001). The associations we found were generally stronger in women than in men. CONCLUSIONS: Overall, these findings suggest that chronic overexposure to environmental selenium may increase blood pressure, though there were inconsistencies for this association according to the choice of exposure indicator, the study endpoint and the sex.

Environmental risk factors for amyotrophic lateral sclerosis: methodological issues in epidemiologic studies.

The exact role of environmental risk factors in the etiology of the neurodegenerative disease amyotrophic lateral sclerosis (ALS) is still unknown. Their hypothetical contribution ranges from a minimal impact to a major role. Among the environmental factors strictu sensu (i.e., not life-style factors) suspected to play a role in ALS etiology, we consider pesticides, the metalloid selenium, some heavy metals, magnetic fields and cyanobacteria. However, the possibility exists that these factors exert their activity only in genetically susceptible persons and only after long-term exposures, thus further hampering epidemiologic studies. The recent availability of powerful tools such as population-based ALS registries for case ascertainment and clustering detection, and of environmental modeling techniques and of geographical information systems, may yield unique opportunities for offering insight into the etiology of the disease.

Pooled analysis of recent studies on magnetic fields and childhood leukaemia.

BACKGROUND: Previous pooled analyses have reported an association between magnetic fields and childhood leukaemia. We present a pooled analysis based on primary data from studies on residential magnetic fields and childhood leukaemia published after 2000. METHODS: Seven studies with a total of 10,865 cases and 12,853 controls were included. The main analysis focused on 24-h magnetic field measurements or calculated fields in residences. RESULTS: In the combined results, risk increased with increase in exposure, but the estimates were imprecise. The odds ratios for exposure categories of 0.1-0.2 µT, 0.2-0.3 µT and ≥0.3 µT, compared with <0.1 µT, were 1.07 (95% CI 0.81-1.41), 1.16 (0.69-1.93) and 1.44 (0.88-2.36), respectively. Without the most influential study from Brazil, the odds ratios increased somewhat. An increasing trend was also suggested by a nonparametric analysis conducted using a generalised additive model. CONCLUSIONS: Our results are in line with previous pooled analyses showing an association between magnetic fields and childhood leukaemia. Overall, the association is weaker in the most recently conducted studies, but these studies are small and lack methodological improvements needed to resolve the apparent association. We conclude that recent studies on magnetic fields and childhood leukaemia do not alter the previous assessment that magnetic fields are possibly carcinogenic.

Food intake and risk of cutaneous melanoma in an Italian population.

We investigated the association of melanoma risk with food consumption in a northern Italian population in which disease risk was shown to correlate with linoleic acid and soluble carbohydrates intake. We collected information regarding the habitual consumption of 188 food items in 59 patients with newly diagnosed cutaneous melanoma and 59 sex- and age-matched population controls. In the unadjusted analyses, the intake of several foodstuffs directly or inversely correlated with melanoma risk. In multivariate analysis adjusting for several potential confounders, risk correlated directly with vegetable oil intake and inversely with consumption of crispbreads and rusks. Overall, most of the food items rich in linoleic acid and soluble carbohydrates were unrelated to disease risk. Despite the limited statistical precision of the point estimates, these findings seem to indicate that consumption of specific foods may influence melanoma risk.

Melanoma epidemic across the millennium: time trends of cutaneous melanoma in Emilia-Romagna (Italy) from 1997 to 2004.

BACKGROUND: After a rapid increase in malignant melanoma (MM) incidence in the last decades, trends of the melanoma epidemic in the recent years seemed not homogeneous. OBJECTIVE: This study aimed at the monitoring of some epidemiological data referring to melanoma in a region of the Northern Italy during the past 8-year period. METHODS: All cases of melanoma, including also in situ lesions, diagnosed in Emilia-Romagna and San Marino State, with the exclusion of Cesena province, from 1997 to 2004 were recorded and the incidence of melanoma, adjusted for the European standard population by the direct method, was calculated. RESULTS: Mean standardized incidence was 9.7 for invasive MMs and 11.9, considering also in situ ones, showing an ascending trend with an increment of 3.3 new incident cases in 2004 compared with 1997. No differences in age distribution, gender and site were reported. Concerning tumour thickness, although a general ascending trend in all subtypes, only thin melanoma incidence significantly increased over the study period. CONCLUSIONS: Contrary to data from Northern European countries, melanoma incidence still showed an ascending trend in the Italian population of Emilia Romagna.

[Waste incinerator and human health: a state-of-the-art review]. / Inceneritori e rischi per la salute umana: lo stato dell'arte.

Emissions of municipal solid waste incinerator plants consist as a suspected risk factor for the human health. Scientific literature about this theme appears contradictory: main sanitary outcomes actually evaluated, stating on geographic- or occupational-based epidemiologic approaches, produced inconsistent results. Research procedures applied, and effective quality of analyzed data, are the likely causes of such dissimilarities. Up to date, respiratory, cardiovascular renal, and hormonal pathologies, and also neoplasia, and developmental/reproductive disorders have been related to this kind of exposures: otherwise, an objective review of available data suggests a consistent relation only between residential or occupational exposure and the latter outcomes, always as a topic of multifactorial models. Finally, rigorous public health surveillance programs on exposed subjects appear mandatory steps to be established by Institutional Authorities. Also more accurate epidemiologic studies should be designed, eventually associating the retrieval of data relative to biomarkers of exposure or early health effect.

[Sensitivity and accuracy of health databases in determining incidence of lymphoid malignancies in an Italian population]. / Sensibilità ed accuratezza diagnostica dei flussi informativi del Servizio Sanitario Nazionale nella rilevazione dell'incidenza delle patologie linfoproliferative in una popolazione italiana.

We examined the sensitivity and the accuracy of three health databases (hospital discharge data, death certificates and pathologic records) between 1997 and 2001 in an Italian community, to evaluate their accuracy for the diagnosis of lymphoid malignancies and their ability to detect newly diagnosed patients affected by these diseases. Hospital discharge data showed the best sensitivity among the examined databases, though they exhibited an unexpectedly high number of diagnostic errors, even when limiting the analysis to patients with repeated hospital admissions over time. Overall, the pathologic registry and the death certificate file showed a higher diagnostic accuracy, though their sensitivity was considerably lower than hospital discharge data.

An approach for manganese biomonitoring using a manganese carrier switch in serum from transferrin to citrate at slightly elevated manganese concentration.

After high-dose-short-term exposure (usually from occupational exposure) and even more under low-dose long term exposure (mainly environmental) manganese (Mn) biomonitoring is still problematic since these exposure scenarios are not necessarily reflected by a significant increase of total Mn in blood or serum. Usually, Mn concentrations of exposed and unexposed persons overlap and individual differentiation is often not possible. In this paper Mn speciation on a large sample size (n=180) was used in order to be able to differentiate between highly Mn-exposed or low or unexposed individuals at low total Mn concentration in serum (Mn(S)). The whole sample set consisted of three subsets from Munich, Emilia Romagna region in Italy and from Sweden. It turned out that also at low total Mn(S) concentrations a change in major Mn carriers in serum takes place from Mn-transferrin (Mn-Tf(S)) towards Mn-citrate (Mn-Cit(S)) with high statistical significance (p<0.000002). This carrier switch from Mn-Tf(S) to Mn-Cit(S) was observed between Mn(S) concentrations of 1.5µg/L to ca. 1.7µg/L. Parallel to this carrier change, for sample donors from Munich where serum and cerebrospinal fluid were available, the concentration of Mn beyond neural barriers - analysed as Mn in cerebrospinal fluid (Mn(C)) - positively correlates to Mn-Cit(S) when Mn(S) concentration was above 1.7µg/L. The correlation between Mn-Cit(S) and Mn(C) reflects the facilitated Mn transport through neural barrier by means of Mn-citrate. Regional differences in switch points from Mn-Tf(S) to Mn-Cit(S) were observed for the three sample subsets. It is currently unknown whether these differences are due to differences in location, occupation, health status or other aspects. Based on our results, Mn-Cit(S) determination was considered as a potential means for estimating the Mn load in brain and CSF, i.e., it could be used as a biomarker for Mn beyond neural barrier. For a simpler Mn-Cit(S) determination than size exclusion chromatography inductively coupled plasma mass spectrometry (SEC-ICP-MS), ultrafiltration (UF) of serum samples was tested for suitability, the latter possibly being a preferred choice for routine occupational medicine laboratories. Our results revealed that UF could be an alternative if methodical prerequisites and limitations are carefully considered. These prerequisites were determined to be a thorough cleaning procedure at a minimum Mn(S) concentration >1.5µg/L, as at lower concentrations a wide scattering of the measured concentrations in comparison to the standardized SEC-ICP-MS results were observed.

Excess melanoma incidence in a cohort exposed to high levels of environmental selenium.

Epidemiological studies on the relation between selenium and human cancer have yielded strongly conflicting results. Prompted by the observation of a positive association between selenium intake and site-specific cancers, including melanoma, in a large cohort of nurses, we studied the 11-year melanoma incidence in an Italian cohort that consumed unusually high levels of inorganic selenium in tap water from 1975 to 1985. The setting was Reggio Emilia, an Italian municipality that provided a natural experiment relating to intake of high levels of inorganic selenium. We identified 2,065 individuals with high selenium exposure, who contributed a total of 20,179 person-years of follow-up, and we compared their experience with the 1,384,386 person-years of follow-up in the remaining population of Reggio Emilia. We included all cases of pathologically confirmed malignant melanoma, including intraocular melanoma, identified from the Reggio Emilia Hospital, the Bologna regional registry of hospital discharges, and the Milan National Cancer Institute. Eight cases of malignant melanoma occurred in the exposed cohort during the follow-up. Melanoma incidence was 3.9 times greater in the exposed than in the unexposed cohort (95% exact confidence limits, 1.8-7.4).

Cancer mortality in a residential cohort exposed to environmental selenium through drinking water.

Cancer mortality from 1986 to 1992 was examined in a cohort of 4419 individuals who had been residing in an area of the municipality of Reggio Emilia, northern Italy, where tap water with unusually high selenium content was accidentally supplied. Mortality for all cancers was not significantly different, both in males and in females, from that expected using death rates in the remaining municipal population as standard rates. No significant difference in mortality for site-specific cancers was observed in males, while in females a higher mortality for malignancies of the lymphatic-hematopoietic tissue overall considered and for non-Hodgkin's lymphoma was detected. Even if evaluation of the results is hampered by the low number of cancer deaths on which the analysis is based, findings of the study do not support the hypothesis of a strong inverse independent relationship between dietary intake of selenium and cancer mortality in humans.

Mortality in a population with long-term exposure to inorganic selenium via drinking water.

We analyzed the 1986-1997 mortality in a cohort of 2065 residents of an Italian municipality which had been exposed to drinking water with a high content of inorganic selenium over a long period of time, and compared it with mortality in the remainder of the municipal population. Mortality from malignant neoplasms increased [standardized mortality ratio (SMR) 1.17, 95% confidence interval (CI) 0.96-1.42], mainly due to an excess mortality from melanoma and colorectal cancer in both sexes, kidney cancer in men, and lymphoid malignancies in women. Overall cardiovascular mortality changed little (SMR 1.05, 95% CI 0.89-1.23), despite the higher cerebrovascular mortality (SMR 1.43, 95% CI 1.03-1.93). Coronary disease mortality slightly decreased (SMR 0.87, 95% CI 0.63-1.16), due to a low mortality among women. We also noted an excess mortality from Parkinson's disease in men and from motor neuron disease in women. Evaluation of these findings is, however, hampered by the lack of information about potential lifestyle confounders, the fact that the exposure could only be characterized by a simple dichotomization, and the inconsistencies of most estimates between the two sexes.

Hypertension in newly diagnosed non-insulin-dependent diabetic subjects.

Medical records of newly diagnosed non-insulin-dependent diabetic patients attending a Diabetic Centre in Modena, northern Italy, during the period 1985-88 were reviewed to analyze the prevalence of hypertension at age of diagnosis of diabetes and its association with selected risk factors. The prevalence of hypertension was also determined in a representative sample of control subjects. In the multivariate analysis, greater body mass index and older age, but not smoking, were strongly associated with increased rates of hypertension both in control and in diabetic subjects. In diabetic patients, family history of diabetes, defined as presence of diabetes in close relatives, was not significantly associated with hypertension, while rates of hypertension were significantly lower in patients who reported at least one parent affected by diabetes. After adjustment for age and body mass index, newly diagnosed non-insulin-dependent diabetes was not an independent risk factor for hypertension. These findings seem to be consistent with the hypothesis that diabetes and hypertension are not linked by a common genetic background.

Rising melanoma incidence in an Italian community from 1986 to 1997.

We examined the incidence of primary invasive melanoma in the municipality of Reggio Emilia, northern Italy, in the period from 1986 to 1997. We identified 169 cases, five of which were intraocular. After adjustment for confounders, the risk of having a thick melanoma (Breslow > or = 1 mm) did not decrease over time, except in older females. The age-standardized incidence of cutaneous melanoma during the entire study period was 7.57 in males and 11 in females; from 1986-1991 to 1992-1997, it rose from 5.04 to 10.04 cases/100,000 person-years in males and from 8.96 to 13.09 cases/100,000 person-years in females. In males, the increase in incidence was almost entirely confined to subjects aged 30 or more, suggesting a possible cohort effect. We noted rising age-standardized incidences over time both in males with thin tumours (Breslow < 1 mm) (from 2.05 to 4.38 cases/100,000 person-years) and thick tumours (from 2.73 to 5.51 cases/100,000 person-years), while in females the increase was limited to thin melanomas (from 3.14 to 6.93 cases/100,000 person-years), mainly due to an increase in the older age groups (50 69 years and > or =70 years). The increase in thick melanomas among males and the expected cohort effects suggests antecedent exposure to environmental risk factors.

Adverse health effects of selenium in humans.

Epidemiologic studies and case reports have shown that chronic exposure to selenium compounds is associated with several adverse health effects in humans. An early toxic effect of selenium is on endocrine function, particularly on the synthesis of thyroid hormones following dietary exposure of around 300 micrograms Se/d, and on the metabolism of growth hormone and insulin-like growth factor-1. Other adverse effects of selenium exposure can be the impairment of natural killer cells activity and at higher levels, hepatotoxicity and gastrointestinal disturbances. Dermatologic effects, such as nail and hair loss and dermatitis, occur after exposure to high levels of environmental selenium. Assessing the toxicity and morbidity after long-term exposure to environmental selenium is difficult: neurotoxicity, particularly the degeneration of motor neurons leading to increased risk of amyotrophic lateral sclerosis, might occur after chronic exposure to both organic and inorganic selenium compounds. The results of laboratory investigations and cohort studies suggest that selenium species exhibit a bivalent effect in cancer, either increasing or decreasing risk. Current environmental selenium exposure limits appear to be inadequate for averting adverse health effects.

Zinc and copper status and blood pressure.

In order to elucidate the relationships between Zn and Cu and blood pressure, the present case-control study was carried out. Zn and Cu status was evaluated in 60 subjects, pharmacologically untreated, affected by mild stable hypertension and in 60 normotensives matched for sex, age and smoking habits. Different markers of Zn and Cu status, including serum, erythrocyte and urine levels of the two trace elements and activities of some Zn- or Cu-dependent enzymes (alkaline phosphatase, lactic dehydrogenase, superoxide dismutase and lysyl oxidase) were evaluated. No significant difference between hypertensives and normotensives was observed in the mean levels of Zn and Cu as well as in Zn- or Cu-dependent enzymes, though higher levels of serum copper were associated with increased risk of hypertension. Interesting relationships between the biological parameters investigated were observed in the hypertensive subjects. Inverse correlations between blood pressures and serum Zn were observed. Furthermore, blood pressure was inversely related to lysyl oxidase activity. These findings give further support to the hypothesis that an imbalance of Zn and Cu bioavailability may be associated to hypertensive condition.

Reproductive outcomes in a population exposed long-term to inorganic selenium via drinking water.

Despite being an essential element in mammals and lower animals at very low doses, selenium is recognized as a teratogen and a growth-inhibiting substance in several animal species. Some inorganic selenium compounds have also been shown to be mutagenic and pro-oxidant: however, very little is known about their effects on human reproduction. Between 1972 and 1988, a few thousand residents in the municipality of Reggio Emilia, northern Italy, were accidentally exposed to drinking water with unusually high levels of inorganic selenium (selenate), range 7-9 microg/l, through a local public water supply system. We found no deleterious effect on overall body weight and length of newborns and stillborns delivered by 18 women previously exposed to high-selenium tapwater. Rates of spontaneous abortions, however, were increased slightly (RR = 1.73; 95% CI = 0.62-4.80), compared with rates among unexposed women from the same municipality. From 1980 through 1988 the prevalence of congenital malformations at birth among the exposed population was similar to that expected, but estimates were imprecise owing to small numbers. Results do not suggest marked effects on human reproduction from chronic exposure to selenate in drinking water at < 10 microg/l.

Risk of birth defects in a population exposed to environmental lead pollution.

To investigate the relation between environmental lead and risk of birth defects in humans, we examined the prevalence at birth of congenital anomalies in an industrial area of northern Italy heavily polluted with lead. Through a population-based registry of birth defects, we identified anomalies diagnosed during three consecutive periods characterized by decreasing environmental lead exposure, 1982-1986, 1987-1990 and 1991-1995. In the lead-polluted area, we observed an excess risk of cardiovascular defects which decreased from 2.59 [95% confidence interval (CI) 1.68-3.82] in the first period to 1.18 (95% CI 0.62-2.06) and 0.97 (95% CI 0.57-1.54) in the subsequent periods. We also found an excess risk of oral clefts and musculoskeletal anomalies, with decreasing trends over time. We could not identify homogeneous patterns of temporal variation for other congenital anomalies, neither did we detect cases of neural tube defects. These results appear to support an association between severe parental lead exposure and specific birth defects.

The epidemiology of selenium and human cancer.

The relation between the trace element selenium and the etiology of cancer in humans remains elusive and intriguing, despite the number of epidemiologic studies published on the topic. We address some methodologic issues, such as misclassification of exposure, particularly to single selenium compounds, effect modification, confounding, and other sources of bias, which may explain the inconsistencies in the literature. We also review the results of cohort studies, which have yielded either inverse or null or direct associations between selenium exposure and subsequent cancer risk. To date, no beneficial effect on cancer incidence at major sites, including prostate cancer, has emerged from the Finnish program begun in 1984 to increase the average selenium intake in its population. Populations exposed to unusually high or low levels of environmental selenium might offer unique opportunities to investigate if selenium exposure is related to the etiology of human cancer.