[Solidarity, covid-19 and a lever without fulcrum.] / Solidarietà, covid-19 e una leva senza fulcro.

Herd, or collective, immunity has been a permanent reference all along the Covid-19 pandemic, often misunderstood as a technical synonym of "epidemic end" once a threshold value of immunized people is reached. The pandemic development has shown that with current variants transmissibility and current vaccines such critical threshold cannot be reached. An effective collective immunity is however attainable, the stronger the higher the population proportion of vaccinated people. This immunity, a powerful brake on the epidemic progression, depends on the degree of solidarity that society enacts as a whole via containment measures (physical distancing, masks) and vaccination. A clear solidarity deficit is manifest within countries in the form of repeatedly delayed adoption of correct interventions against the epidemic and between countries with the heavy shortage of vaccines in countries with low and middle-low income. The lever of counter epidemic actions by governments and health authorities cannot operate without the support of a fulcrum of civic solidarity: it depends only on citizens, individually and collectively, to build it small stone upon stone.

Strategy for primary prevention of non-communicable diseases (NCD) and mitigation of climate change in Italy.

This paper derives from a document commissioned in 2019 by the Italian Minister of Health, and outlines a general strategy for primary prevention of non-communicable diseases in Italy, with a special focus on cobenefits of climate change mitigation. Given that action against climate change is primarily taken via energy choices, limiting the use of fossil fuels and promoting renewable sources, an effective strategy is one in which interventions are designed to prevent diseases and jointly mitigate climate change, the so-called cobenefits. For policies capable of producing relevant co-benefits we focus on three categories of interventions, urban planning, diet and transport that are of special importance. For example, policies promoting active transport (cycling, walking) have the triple effect of mitigating greenhouse gas emissions, preventing diseases related to atmospheric pollution, and increasing physical activity, thus preventing obesity and diabetes.In particular, we propose that for 2025 the following goals are achieved: reduce the prevalence of smokers by 30%, with particular emphasis on young people; reduce the prevalence of childhood obesity by 20%; reduce the proportion of calories obtained from ultraprocessed foods by 20%; reduce the consumption of alcohol by 10%; reduce the consumption of salt by 30%; reduce the consumption of sugary drinks by 20%; reduce the average consumption of meat by 20%; increase the weekly hours of exercise by 10%. The aim is to complement individual health promotion with structural policies (such as urban planning, taxation and incentives) which render the former more effective and result in a reduction in inequality. We strongly encourage the inclusion of primary prevention in all policies, in light of the described cobenefits. Italy's role as the cohost of the 2020 (now 2021) UN climate negotiations (COP26) presents the opportunity for international leadership in addressing health as an integral component of the response to climate change.

Counterpoint: Epidemiology's Dual Social Commitment-Science and Health.

Matching epidemiology's aspirations to actual delivery of goods valuable for population health depends both on the scientific and operational capabilities of epidemiology and on the degree to which the goods meet its contract with society. Epidemiology's capabilities have advanced remarkably in recent decades, although research gaps have appeared during the current coronavirus disease 2019 (COVID-19) pandemic. Epidemiology's social contract reflecting a dual commitment to science and health could arguably be entirely met by producing research results under conditions variously described as objective, impartial, neutral, or independent and handing such results to decision makers and the public at large. However, a closer examination shows that those four terms address sharply distinct issues, with distinct practical implications, and that the epidemiologist responsibility is de facto involved beyond providing research results. Hence the epidemiologist's engagement should encompass arguing from a science-for-health viewpoint and proactively driving the results into decision processes on public health issues.

Integrating public health programs and research after the malaria vaccine implementation program (MVIP): Recommendations for next steps.

BACKGROUND: In February 2020, international controversy arose about the ethical acceptability of the WHO Malaria Vaccine Implementation Program (MVIP). Whereas some have argued that this program must be seen as research that is not in line with international ethical standards, notably regarding informed consent and local ethical review, some WHO representatives consider the MVIP as a public health implementation program that need not adhere to these standards. METHODS: We performed a case analysis in light of the 2016 CIOMS International Ethical Guidelines for Health-related Research involving Humans. FINDINGS: We argue that the MVIP has a substantial research component, and that it is prudent to therefore apply ethical norms for research involving humans, such as the CIOMS guidelines. Accordingly, we agree that the ethical requirements of informed consent and independent ethical review have not been met. In addition, we are concerned that the study might not meet CIOMS's social value requirement. RECOMMENDATIONS: We urge WHO to release more details about the process that led to the MVIP program and make the MVIP protocol publicly available. The full protocol should be assessed by the relevant ethics committees, new and already enrolled parents should be informed about the uncertainties under investigation and given a real opportunity to consent or refuse (continued) participation, communities should be engaged, and aspects of MVIP that require alteration in light of ethical review should be altered, if possible. Furthermore, in order to improve good ethical practices, it is necessary to engage in international debate regarding the integration of research and public health programs. Procedurally, vaccine implementation programs that combine both prevention and research should involve the wider international ethics community and ensure participation of the target populations in setting the proper conditions for launching such programs.

Prevention in COVID-19 time: from failure to future.

The COVID-19 pandemic has developed as a consequence of sheer prevention failures, leading in many countries to a sizeable number of deaths and over-saturation of intensive care units. This triggered the imposition of generalisd quarantine ('lockdown') of variable stringency in different countries: with the decrease of the epidemic, the lockdown is now gradually relaxed and replaced by tight tracing and isolation of new cases and their contacts. Prevention, however, remains not a constant priority, as the objective may be avoidance of saturation of intensive care beds or more generally of healthcare facilities rather than the minimisation of the disease incidence. This combined with the fact that notwithstanding repeated warnings in past years the epidemic occurred as a surprise denotes a way of thinking in which prevention is an important option but not a guiding principle of choice and action within the health system. To modify this way of thinking and place prevention at the core of the system, non-negligible changes are required: they may become possible in light of emerging hazards like new viruses and climate change, huge economic costs of failed prevention and initial changes in the health system already induced by the COVID-19 epidemic.

Effect of national and local lockdowns on the control of COVID-19 pandemic: a rapid review.

OBJECTIVES: to describe and compare the effectiveness of national and local lockdowns in controlling the spread of COVID-19. METHODS: a rapid review of published and grey literature on COVID-19 pandemic was conducted following predefined eligibility criteria by searching electronic databases, repositories of pre-print articles, websites and databases of international health, and research related institutions and organisations. RESULTS: of 584 initially identified records up to 5 July 2020, 19 articles met the inclusion criteria and were included in the review. Most of the studies (No. 11) used the reproduction  number (Rt) as a measure of effect and in all of them areduction of the estimated value at post-intervention period was found. The implementation of lockdown in 11 European countries was associated with an average 82% reduction of Rt, ranging from a  posterior Rt of 0.44 (95%CI 0.26-0.61) for Norway to a posterior Rt of 0.82 (95%CI 0.73- 0.93) for  Belgium. Changes in infection rates and transmission rates were estimated in 8 studies. Daily changes in infection rates ranged from -0.6% (Sweden) to -11.3% (Hubei and Guangdong provinces). Additionally, other studies reported a change in the trend of hospitalizations (Italy, Spain) and positive effects on the  doubling time of cases (Hubei, China) after lockdown. CONCLUSIONS: results of this rapid review suggest a positive effect of the containment measures on the spread of COVID-19 pandemic, with a major effect in  countries where lockdown started early and was more restrictive. Rigorous research is warranted to evaluate which approach is the most effective in each stage of the epidemic and in specific social contexts, in particular addressing if these approaches should be implemented on the whole population or target specific risk groups.

The IARC Monographs: Updated Procedures for Modern and Transparent Evidence Synthesis in Cancer Hazard Identification.

The Monographs produced by the International Agency for Research on Cancer (IARC) apply rigorous procedures for the scientific review and evaluation of carcinogenic hazards by independent experts. The Preamble to the IARC Monographs, which outlines these procedures, was updated in 2019, following recommendations of a 2018 expert advisory group. This article presents the key features of the updated Preamble, a major milestone that will enable IARC to take advantage of recent scientific and procedural advances made during the 12 years since the last Preamble amendments. The updated Preamble formalizes important developments already being pioneered in the Monographs program. These developments were taken forward in a clarified and strengthened process for identifying, reviewing, evaluating, and integrating evidence to identify causes of human cancer. The advancements adopted include the strengthening of systematic review methodologies; greater emphasis on mechanistic evidence, based on key characteristics of carcinogens; greater consideration of quality and informativeness in the critical evaluation of epidemiological studies, including their exposure assessment methods; improved harmonization of evaluation criteria for the different evidence streams; and a single-step process of integrating evidence on cancer in humans, cancer in experimental animals, and mechanisms for reaching overall evaluations. In all, the updated Preamble underpins a stronger and more transparent method for the identification of carcinogenic hazards, the essential first step in cancer prevention.

[Reflections on time. From the clinic to climate change.] / Riflessioni sul tempo. Dalla clinica al cambiamento climatico.

The often heard 'time is money' formula is today generally applied to all human activities: it implies that a gain in time is a gain in money, with the consequence of introducing a generalized pressure to minimize the execution time of all and every human operation. There are however processes that are just destroyed when their execution speed becomes faster and faster: any music piece, whose time structure is essential, is a prototype of these phenomena. Two apparently remote phenomena as the doctor-patient interaction and the control of global climatic change belong for different reasons to the same category of phenomena the priority of which cannot be derived using the 'time is money' formula but requires - before any accounting calculation - considering their intrinsic value for health and medicine.

Cancer mortality in an international cohort of reinforced plastics workers exposed to styrene: a reanalysis.

OBJECTIVE: To investigate the carcinogenicity of styrene by reanalysing data from a previous international cohort study of workers in the reinforced plastics industry. METHODS: Mortality from cancers of prior interest was analysed with more detailed consideration of exposure-response relations and an updated classification of leukaemias and lymphomas in data from a previous international cohort study of 37 021 reinforced plastics workers exposed to airborne styrene. RESULTS: Increased mortality from non-Hodgkin's lymphoma (NHL) was associated with the mean level of exposure to styrene in air (relative risk (RR) 2.31, 95% CI 1.29 to 4.12 per 100 ppm), but not with cumulative styrene exposure. Similar associations with mean exposure were observed for the oesophagus (RR 2.44, 95% CI 1.11 to 5.36 per 100 ppm) and pancreas (RR 1.89, 95% CI 1.17 to 3.09). Oesophageal cancer mortality was also associated with cumulative styrene exposure lagged 20 years (RR 1.16, 95% CI 1.03 to 1.31). No other cancer, including lung cancer, was associated with any indicator of styrene exposure. CONCLUSION: This reanalysis does not substantially change the conclusions of the original study with respect to NHL or lung cancer but new evidence concerning cancers of the oesophagus and pancreas merits further investigation.

Exploring causality of the association between smoking and Parkinson's disease.

BACKGROUND: The aim of this paper is to investigate the causality of the inverse association between cigarette smoking and Parkinson's disease (PD). The main suggested alternatives include a delaying effect of smoking, reverse causality or an unmeasured confounding related to a low-risk-taking personality trait. METHODS: A total of 715 incident PD cases were ascertained in a cohort of 220 494 individuals from NeuroEPIC4PD, a prospective European population-based cohort study including 13 centres in eight countries. Smoking habits were recorded at recruitment. We analysed smoking status, duration, and intensity and exposure to passive smoking in relation to PD onset. RESULTS: Former smokers had a 20% decreased risk and current smokers a halved risk of developing PD compared with never smokers. Strong dose-response relationships with smoking intensity and duration were found. Hazard ratios (HRs) for smoking <20 years were 0.84 [95% confidence interval (CI) 0.67-1.07], 20-29 years 0.73 (95% CI 0.56-0.96) and >30 years 0.54 (95% CI 0.43-0.36) compared with never smokers. The proportional hazard assumption was verified, showing no change of risk over time, arguing against a delaying effect. Reverse causality was disproved by the consistency of dose-response relationships among former and current smokers. The inverse association between passive smoking and PD, HR 0.70 (95% CI 0.49-0.99) ruled out the effect of unmeasured confounding. CONCLUSIONS: These results are highly suggestive of a true causal link between smoking and PD, although it is not clear which is the chemical compound in cigarette smoking responsible for the biological effect.

[Insidious barbarism.] / Insidiosa barbarie.

The number of migrants to Italy by the Central Mediterranean route is decreasing while the risk of dying of those attempting the crossing is markedly increasing. It can be hypothesized that with reinforced barriers to migration only the most desperate, in poorest overall conditions (including those of their boats) dare to try the crossing. Whatever the explanation the raising death rates at sea point to the inadequacy of the salvage system, raising the question of whether the priority of the European Union is , as declared, "to save lives at sea" or, de facto, only to reduce the migrants' flow.