Institutionalizing Health Impact Assessment: A consultation with experts on the barriers and facilitators to implementing HIA in Italy.

A Health Impact Assessment (HIA) is an evidence-based methodology that includes health promotion and protection goals in decision-making. HIA has been introduced and/or institutionalized to various extents in different countries. In order to promote HIA and preventive health assessments in Italy, a research methodology was followed to identify specific obstacles or facilitators. The experiences of various countries reported in the literature were analyzed in terms of facilitating or hindering the introduction and institutionalization of HIA. A consultation with the proponents of projects and plans in Italy was carried out with a multi-approach methodology in order to characterize the national context. A general implementation plan was drawn up from the international experiences. In Italy this is not yet in place. Specific areas of intervention need to be addressed, including: 1) data availability; 2) tools and methods; 3) engagement of stakeholders; 4) capacity building. The research suggests that the institutionalization of HIA in Italy rests on the government's commitment to providing specific legislation regarding HIA so that skills, intersectoral coordination and dedicated budgets can be built and maintained.

[Recommendations from a health impact assessment in Viggiano and Grumento Nova (Basilicata Region, Southern Italy)]. / EPICHANGE/2. Indicazioni emerse dalla VIS a Viggiano e Grumento Nova (PZ).

In Europe, Health Impact Assessment (HIA) is a consolidated practice aimed at predicting health impacts supporting the predisposition of plans and projects subjected to authorization procedures. In Italy, further developments are needed to harmonize the practice and consolidate methodologies in order to extend the HIA application in different fields. The recent HIA conducted in Val d'Agri (Basilicata) on the impacts of a first crude oil treatment plant represents an opportunity to illustrate its tools, methods and fields of application. In this experience, participation methods in impact assessment have been adapted to the context, emphasizing aspects of ethics, equity and democracy. Environmental and epidemiological studies were included in the HIA Val d'Agri in order to characterize the environment and assess the health status of the resident population. On the basis of the results public health recommendations have been elaborated, shared with the stakeholders and shared with local and regional administrators. The experience in Val d'Agri introduces elements of reflection on the potential of HIA at local level in order to support the public health and the environmental control systems in the area, as well as planning based on preventive environment and HIA.

[Epidemiological population-based cohort study on mortality and hospitalization in the area near the waste incinerator plant of San Zeno, Arezzo (Tuscany Region, Central Italy)]. / Studio epidemiologico di coorte residenziale su mortalità e ricoveri ospedalieri nell'area intorno all'inceneritore di San Zeno, Arezzo.

OBJECTIVES: to evaluate whether exposure to an urban waste incinerator plant operating in Arezzo (Tuscany Region, Central Italy) since the 2000 is associated with mortality and morbidity. DESIGN: a population-based cohort study of inhabitants living close to the incinerator in the period 2001-2010 was conducted. The individual exposure histories to the incinerator and other sources in the area were estimated using a dispersion model producing PM10 concentration maps for each source (ADMS-URBAN model). Hazard Ratios (HR) with 95% Confidence Interval (95%CI) adjusted for the other environmental exposures, age and socioeconomic status were estimated for the highest class of exposure using the lowest one as reference. Trends of HR were evaluated too. MAIN OUTCOME MEASURES: mortality and hospitalization causes with induction-latent period overlapping the incinerator activity period were analysed. RESULTS: morbidity analysis showed an increased risk for cardiovascular diseases (No. 732; HR: 1.18; 95%CI 1.06-1.32; trend of HR: 1.08, p=0.006) and a trend of HRs for urinary diseases (trend: 1.13; p=0.063). Mortality analysis showed a trend of HRs for general mortality in males (trend: 1.10; p=0.014), for cardiovascular diseases in males (trend: 1.15; p=0.036), for respiratory diseases in females (trend: 1.30; p=0.098), and an excess of acute respiratory diseases in females with the highest exposure (No. 11; HR=2.54; 95%CI 0.84-7.68). CONCLUSIONS: the cohort study allowed to characterise the environmental exposures considering the most relevant pollution sources and providing estimation of individual environmental exposures. Residual confounding due to the overlapping of concentration maps cannot be excluded and further investigations are needed. However, the increased risks for cardiovascular and respiratory diseases reinforce the limited epidemiological evidence on health effects of incinerators.

Pollutant exposure and myocardial injury: Protocol and progress report for a toxicological systematic mapping review.

An increasing body of evidence identifies pollutant exposure as a risk factor for cardiovascular disease (CVD), while CVD incidence rises steadily with the aging population. Although numerous experimental studies are now available, the mechanisms through which lifetime exposure to environmental pollutants can result in CVD are not fully understood. To comprehensively describe and understand the pathways through which pollutant exposure leads to cardiotoxicity, a systematic mapping review of the available toxicological evidence is needed. This protocol outlines a step-by-step framework for conducting this review. Using the National Toxicology Program (NTP) Health Assessment and Translation (HAT) approach for conducting toxicological systematic reviews, we selected 362 out of 8111 in vitro (17%), in vivo (67%), and combined (16%) studies for 129 potential cardiotoxic environmental pollutants, including heavy metals (29%), air pollutants (16%), pesticides (27%), and other chemicals (28%). The internal validity of included studies is being assessed with HAT and SYRCLE Risk of Bias tools. Tabular templates are being used to extract key study elements regarding study setup, methodology, techniques, and (qualitative and quantitative) outcomes. Subsequent synthesis will consist of an explorative meta-analysis of possible pollutant-related cardiotoxicity. Evidence maps and interactive knowledge graphs will illustrate evidence streams, cardiotoxic effects and associated quality of evidence, helping researchers and regulators to efficiently identify pollutants of interest. The evidence will be integrated in novel Adverse Outcome Pathways to facilitate regulatory acceptance of non-animal methods for cardiotoxicity testing. The current article describes the progress of the steps made in the systematic mapping review process.

Heart disease is a leading global cause of death. Recent research indicates that certain environmental chemicals can worsen heart problems. We're conducting a rigorous review of scientific studies to understand how these chemicals affect the heart. This will inform policymakers and promote non-animal testing methods for cardiotoxicity by providing a clear overview of the toxicological evidence. We have reviewed over 8,000 articles and focused on 362 studies about 129 chemicals, including heavy metals, air pollutants and pesticides, and their effects on the heart. The current manuscript describes the used methods and steps made in this process. The outcome of our systematic review of these 362 articles will be a comprehensive database that will aid the development of alternative testing methods for cardiotoxicity.

Protocol for a Systematic Review and Meta-Analysis of Observational Studies on the Association of Exposure to Toxic Environmental Pollutants and Left Ventricular Dysfunction.

The association between environmental exposure to toxic substances and cardiovascular diseases (CVDs) in humans is widely recognized. However, the analysis of underlying pathophysiological mechanisms is essential to target meaningful endpoints of cardiotoxicity and allow a close-to-real life understanding of the role of chronic and acute exposure to multiple toxicants. The aim of this study is to outline the process for a systematic review of the literature that investigates the relationship between environmental pollution and left ventricular dysfunction. This systematic review and meta-analysis protocol will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-P) statement. PubMed, Embase, and Web of Science databases will be searched without applying search filters. Two independent reviewers will screen all titles and abstracts and identify the articles to be included in the synthesis. The risk of bias (RoB) will be assessed using an instrument developed for non-randomized (i.e., observational) studies (NRS) of environmental exposures. The results of cohort, case-control, cross-sectional, time-series, and case-crossover studies will be extracted and presented in tables considering different population subgroups and length of exposure. This protocol will be expected to provide a sound basis for selecting toxic chemicals and pollutants to contribute with the epidemiological evidence to the in vitro testing protocol within the EU-funded ALTERNATIVE Project.

Risk Associations between Vehicular Traffic Noise Exposure and Cardiovascular Diseases: A Residential Retrospective Cohort Study.

Environmental noise can induce detrimental health effects such as cardiovascular disease (CVD). The relationship between vehicular traffic noise pollution and CVD was investigated through a retrospective residential cohort study in the city of Pisa. Four exposure classes were defined for noise pollution, using noise propagation maps. The association between noise exposures and cause-specific mortality or hospitalization of the subjects of the cohort was calculated using the hazard ratio (HR) for night and day through a multiple time-dependent and sex-specific Cox regression adjusting for age, the socio-economic deprivation index, and traffic air pollution. Mortality excess for CVD and risk trends for a 1 decibel noise increment were observed among the most exposed women (mortality: HRnightclass4 1.15 (1.03-1.28); Trendnight 1.007 (1.002-1.012); HRdayclass4 1.14 (1.02-1.27); Trendday 1.008 (1.003-1.013)), particularly for ischaemic disease (mortality: Trendnight 1.008 (0.999-1.017); Trendday 1.009 (0.999-1.018)) and cerebrovascular disease (mortality: HRnightclass3 1.23 (1.02-1.48), HRdayclass3 1.24 (1.03-1.49)). Hospitalization analyses confirm mortality results. A decreased risk for hospitalization was also observed among the most exposed men (HRdayclass4 0.94 (0.88-1.01), particularly for ischaemic disease (HRnightclass4 0.90 (0.80-1.02); HRdayclass4 0.86 (0.77-0.97)) and cerebrovascular disease (HRnightclass4 0.89 (0.78-1.01)). Authors recommend the adoption of prevention measures aimed at mitigating noise and the activation of a monitoring of the risk profile in the Pisa population updating both the residential cohort and health data.

[Moniter Project: a model of HIA for Incinerators]. / Progetto Moniter: un modello di VIS per gli impianti di incenerimento.

The Emilia-Romagna regional government decided to develop a monitoring and surveillance system, known as MonITER (Incineration Monitoring on the Emilia-Romagna Territory), in 8 areas characterized by the presence of municipal waste incinerating plants.The project was divided into 7 lines, among these the number 6 developed a procedure of Health Impact Assessments (HIA) to support the planning of new facilities for incineration or combustion. Line number 6 is divided into 3 actions n action 1 aimed to developing and validating a participative HIA methodology, as well tools for the impact assessment and recommendations for implementing HIA on future plants; n action 2 analysed connected issues on communication; n action 3 was focused to developing a methodology for integrating HIA models into existing tools for mandatory impact assessment.Tailoring the HIA model development to the waste management context has highlighted the fundamental differences of the HIA approach with the other mandatory assessment tools, being theoretically founded on the principles of public involvement, equity, sustainable development and ethical use of evidence.

Environment in Children's Health: A New Challenge for Risk Assessment.

In the last few years, many studies have focused on the effects of environmental contaminant exposure during the prenatal period or infancy as predictors of health outcomes in the future. In these time windows, due to their rapid growth, and physiologic and metabolic development, we can observe a higher vulnerability to the effects of environment, with respect to adulthood. The evidence of possible influences, partly mediated by epigenetic mechanisms, involve neurobehavioral responses and immune, endocrine, and respiratory systems, acting directly on the child or indirectly when mediated by placental transfer or breast feeding. In particular, due to a greater intake of air, food, and fluids relative to body weight, crawling behaviors and short stature, the risk of excessive exposure is greater in children. However, data on the long-term implications of early exposures are scarce. Additionally, so that physicians and institutions for child care and assistance of pregnant women can take actions to counteract the effects of chemical pollution (i.e., by educational opportunities), a risk assessment perspective that responds to the biocomplexity of the human being is needed. The present paper provides an overview of physiologic and behavioral characteristics during the perinatal period and in childhood, suggesting in a more integrated way, the need of a new risk-assessment approach to managing chronic disease in pediatric patients.

Participatory health impact assessment used to support decision-making in waste management planning: A replicable experience from Italy.

The lack of participatory tools in Health Impact Assessment (HIA) to support decision-makers is a critical factor that negatively affects the impacts of waste policies. This study describes the participatory HIA used in deciding on the possible doubling of the municipal solid waste incinerating plant located near the city of Arezzo, Italy. Within the framework of the new waste management plan, a methodology for the democratic participation of stakeholders was designed adopting the Local Agenda 21 methodology. Communication and participation events with the stakeholders were set up from the plan's development to its implementation. Eleven different categories of stakeholders including individual citizens were involved in 21 local events, reaching over 500 participants in three years. Actions were performed to build the commitment and ownership of the local administrators. Then, together with the environment and health agencies and a representative from the local committees, the local administrators collaborated with scientists and technicians in the knowledge-building and scoping stages. Focus groups of voluntary citizens worked together with the researchers to provide qualitative and quantitative evidence in the assessment stage. Periodic public forums were held to discuss processes, methods and findings. The local government authority considered the HIA results in the final decision and a new waste strategy was adopted both in the short term (increased curbside collection, waste sustainability program) and in the long term (limited repowering of the incinerator, new targets for separate collection). In conclusion, an effective participatory HIA was carried out at the municipal level to support decision makers in the waste management plan. The HIA21 study contributed to evidence-based decisions and to make a broadly participatory experience. The authors are confident that these achievements may improve the governance of the waste cycle and the trust in the public administration.

[Congenital malformations in newborns residing in the municipality of Gela (Sicily, Italy)]. / Malformazioni congenite nei nati residenti nel comune di Gela (Sicilia, Italia).

OBJECTIVE: to conduct an epidemiological descriptive study on malformed newborns residing in the Municipality of Gela during 1991-2002 to compare theprevalences observed with those reported by the registries operating in Sicily, in Italy and in the scientific literature. DESIGN AND SETTING: epidemiological descriptive study in the area of the Municipality of Gela, (Sicily, Italy). MATERIALS: information on congenital anomalies occurred in livebirths and stillbirths residing in the Municipality of Gela were obtained from different sources: local hospital statistics, general paediatricians list of patients, the Sicilian Registry of Congenital Malformations (ISMAC), hospital discharge records of Catania University Hospital, previous investigation data, the Gela Hospital Obstetrics Department archive. RESULTS: 520 malformed cases out of 13060 newborns were ascertained, accounting for a prevalence rate of 398/10000 total births, approximately 2 times significantly higher than those reported by the Sicilian Registry ISMAC (182/10000) and the Italian registries (205/10000). The annual distribution resulted significantly heterogeneous for all malformed cases and for cardiovascular, limb and external genitalia malformations. Significant excesses for anomalies of central nervous system, cardiovascular system, urinary tract, digestive, teguments and total malformations were found, with observed/expected ratios ranging from 1.5 to 6.0 or from 1.3 to 3.4 when compared with ISMAC or Italian registries respectively. When specific malformations where analysed, significant excesses for male hypospadias and diaphragmatic hernia were found. The occurrence of hypospadias, 56.7/10000 births, was 2.5 times significantly higher than the reference rates. CONCLUSION: the observed hypospadias birth rate is amongst the most elevated ever reported in literature. A low diagnostic specificity (many false positives) may explain the relevant increase of newborns diagnosed with microcephaly. Results reinforce the hypothesis ofa causal role of risk factors present in the Gela area on the etiology of malformations and address the need for further insights into the excesses found, for consolidation of the registration action andfor implementation of a health and environment local surveillance system able to monitor sensitive diseases in areas considered at environmental risk. A retrospective case-control study on disease excesses is being completed.

Adverse reproductive outcomes associated with exposure to a municipal solid waste incinerator.

INTRODUCTION: The association between reproductive health outcomes and exposure to municipal solid waste incinerators (MSWIs) is inconclusive. This study investigates the association between exposure to a MSWI and various reproductive outcomes (preterm birth, low birth weight, small for gestational age, and sex ratio), taking into account other sources of pollution (industrial plants, highway, major roads with high traffic flows) and maternal factors, including the socioeconomic status. METHODS: PM10 concentration maps were used for the exposure assessment to the MSWI and to other sources of pollution in the study area. Information on resident births and maternal covariates were selected from the delivery certificates referred to the period 2001-2010. Mothers' addresses were geocoded in order to attribute the individual level of exposure. Odds ratios (ORs) with a 95% confidence interval (CI) adjusted for maternal covariates and exposure to other pollution sources were calculated. RESULTS: A total of 3153 newborns to 2401 mothers residing in area during the study period were analyzed. A risk of preterm birth associated with increased exposure was detected (OR = 1.61; 95% CI: 0.88-2.94; p test for trend 0.098). When newborns to primiparous women were considered an OR of 2.18 (95% CI: 1.05-4.53) and a significant trend were observed (p = 0.033). No significant results for the other investigated outcomes were observed. CONCLUSIONS: The study detected a slight association between exposure at MSWI and preterm births. The results are in agreement with those of a previous multi-site study with similar design, and they strengthen the recommendation to consider gestational age in studies and surveillance in areas with MSWIs and similar sources of pollution.

[Studying risks of waste landfill sites on human health: updates and perspectives]. / Studi sul rischio per la salute umana in prossimità di discariche di rifiuti: aggiornamento e prospettive.

OBJECTIVE: Updating current reviews on epidiomiological studies on health effects of waste landfill sites. MATERIALS: Seven ecological studies, two health monitoring investigations and two environmental investigations performed between 2000 and 2004 are discussed. RESULTS: Excesses of risk for cancer incidence, mortality and congenital malformations or no excesses were reported Increasing of low birth weight and different types of symptoms were consistently found. None or very poor environmental data and individual measurements of exposure were available in the majority of the studies. The use of biomarkers and environmental monitoring data to define individual exposure was suggested by some studies. CONCLUSIONS: The development of new and advanced environmental epidemiology studies on health effects of waste sites exposure is now recommended by the scientific community.

[Surveillance of congenital malformations in Italy: an investigation in the province of Siracusa]. / Sorveglianza delle malformazioni congenite in Italia: un approfondimento nella provincia di Siracusa.

OBJECTIVE: The study describes briefly the current situation of the surveillance of congenital anomalies in Italy and gives an insight into the province of Siracusa in order to better characterise health status of populations residing in an area at high environmental risk. PARTICIPANTS: The authors, who coordinate the Italian registries of congenital malformations, have collaborated with the Eastern Sicily Registry of congenital malformations (ISMAC) and the registry of diseases of the Siracusa province. DESIGN AND SETTING: Data collected by the ISMAC Registry were used to calculate the prevalence of malformed newborns, resident in the municipalities of the province of Siracusa between 1991-2000. This prevalence was compared to that observed in the rest of the Siracusa province (RSP), in the whole area covered by the ISMAC Registry (ESR) and to the mean prevalence at birth of the North-East, Emilia Romagna, Toscana and Campania Registries (IR). Comparisons were made for all malformations and for groups of malformations (with the exclusion of groups with a 10 year frequence <10 cases in the province of Siracusa). In addition, heterogeneity among the municipalities of the province and temporal trends were statistically tested. MAIN OUTCOME MEASURES: Total, groups and specific congenital malformations. RESULTS: Results were statistically borderline considering all malformations when the Priolo-Augusta-Melilli area was compared to IR and ESR (standardized morbidity ratio SMR(IR)=1.1, SMR(ESR)=1.2) and statistically significant when compared to RSP (prevalences ratio PR(RSP)=1.9). Significant excesses resulted in this area also for hypospadias (SMR(IR)=1.9, SMR(ESR)=2.4, PR(RSP)=2.5) and anomalies of the digestive system (SMR(IR)=2.1, SMR(ESR)=1.9, PR(RSP)=2.6). CONCLUSION: Following these results a case-control study on malformations observed in excess has been activated and a protocol for the surveillance of sensitive diseases in areas at environmental risk is being elaborated.

Health Impact Assessment practice and potential for integration within Environmental Impact and Strategic Environmental Assessments in Italy.

Avoiding or minimizing potential environmental impact is the driving idea behind protecting a population's health via Environmental Impact Assessments (EIAs) and Strategic Environmental Assessments (SEAs). However, both are often carried out without any systematic approach. This paper describes the findings of a review of HIA, EIA andSEA experiences carried out by the authors, who act as institutional competent subjects at the national and regional levels in Italy. The analysis of how health is tackled in EIA and SEA procedures could support the definition of a protocol for the integration of HIA with EIA and SEA. Although EIA and SEA approaches include the aim of protecting health,significant technical and methodological gaps are present when assessing health systematically, and their basic principles regarding assessment are unsatisfactory for promoting and addressing healthcare concepts stated by the WHO. HIA is still poorly integrated into the decision-making process, screening and monitoring phases are only occasionally implemented, and operational details are not well-defined. The collaborative approach of institutions involved in environment and health is a core element in a systematic advancement toward supporting effective decisions and effective protection ofthe environment and health. At the Italian national level, the definition of guidelines and tools for HIA, also in relation with EIA and SEA, is of great interest.