Equity in the recovery of elective and oncological surgery volumes after the COVID-19 lockdown: a multicentre cohort study in Italy.

BACKGROUND: The COVID-19 pandemic has had, and still has, a profound impact on national health systems, altering trajectories of care and exacerbating existing inequalities in health. Postponement of surgeries and cancellation of elective surgical procedures have been reported worldwide. In Italy, the lock-down measures following the COVID-19 pandemic caused cancellations of surgical procedures and important backlogs; little is known about potential social inequalities in the recovery process that occurred during the post-lockdown period. This study aims at evaluating whether all population social strata benefited equally from the surgical volumes' recovery in four large Italian regions. METHODS: This multicentre cohort study covers a population of approximately 11 million people. To assess if social inequalities exist in the recovery of eight indicators of elective and oncological surgery, we estimated Risk Ratios (RR) through Poisson models, comparing the incidence proportions of events recorded during COVID-19 (2020-21) with those in pre-pandemic years (2018-19) for each pandemic period and educational level. RESULTS: Compared to 2018-19, volumes of elective surgery showed a U-shape with the most significant drops during the second wave or the vaccination phase. The recovery was socially unequal. At the end of 2021, incidence proportions among highly educated people generally exceeded the expected ones; RRs were 1.31 (95%CI 1.21-1.42), 1.24 (95%CI 1.17-1.23), 1.17 (95%CI 1.08-1.26) for knee and hip replacement and prostatic surgery, respectively. Among low educated patients, RR remained always < 1. Oncological surgery indicators showed a similar social gradient. Whereas volumes were preserved among the highly educated, the low educated were still lagging behind at the end of 2021. CONCLUSIONS: Surgical procedures generally returned to pre-pandemic levels but the low educated experienced the slowest recovery. An equity-oriented appraisal of trends in healthcare provision should be included in pandemic preparedness plans, to ensure that social inequalities are promptly recognised and tackled.

[The mortality cost of carbon dioxide emissions from a steel plant in Southern Italy: a climate change health impact assessment]. / Il "mortality cost" delle emissioni di CO2 di uno stabilimento siderurgico nel Sud Italia: una valutazione degli impatti sanitari derivanti dal cambiamento climatico.

OBJECTIVES: to quantify the temperature-related global health impacts of the Taranto steel plant CO2e emissions. DESIGN: using the risk functions available in the literature, a prospective global health impact assessment of the marginal CO2e emissions declared by the steel plant for 2020 was conducted. SETTING AND PARTICIPANTS: world population in the period 2020-2100. MAIN OUTCOMES MEASURES: deaths in the period 2020-2100 attributable to the marginal CO2e emitted by the Taranto steel plant in 2020. RESULTS: considering the central estimates in the baseline emission scenario (4.1°C warming by 2100), the Taranto steel plant 2020 CO2e emissions will cause 1,876 deaths worldwide between 2020 and 2100. The largest part will be attributable to steelmaking processes, accounting for 1,093 deaths. The same emissions will cause 5.56 × 10-4 deaths worldwide between 2020 and 2100 per tonne of steel produced in 2020, i.e. one death for every 1,799 tonnes of steel. If the 2020 CO2e emissions of the steel plant had been reduced by 25%, 50% or 75%, the deaths avoided in the world in the period 2020-2100 would have been 469, 938 and 1,407 respectively. CONCLUSIONS: estimates predict a probably significant mortality impact worldwide by the end of the century associated with the greenhouse gases emissions of the Taranto steel plant. Just reducing emissions by 50% in a single year could maybe avoid over 900 deaths worldwide by the end of the century. This confirms the importance of implementing incisive policies to reduce greenhouse gases emissions in all sectors.

[Health impact: considering only a plant assessment is not enough, an area assessment is also needed]. / Impatto sanitario: la valutazione del singolo impianto non è sufficiente, occorre anche una valutazione di area.

Environmental Impact Assessments (EIAs) often conclude with a "low" or at least "negligible" final health impact assessment (HIA) of the industrial plant under assessment. We explore the reasons for this - often simplistic - conclusion and offer suggestions on how to extend the assessment focus from just the plant to an appropriate impact area. For many assessments, the conclusions are easily predictable: the application of available risk functions to modest increases in pollution, in the presence of numerically small populations in the areas of greatest fallout and considering rather rare health outcomes, can only result in quantitatively modest health impacts. This is the classic situation of low sensitivity of the observation system due to the impossibility of containing the type II error (false negatives) since we cannot increase the exposed population at will. The risk is to give the green light to an industrial plant in which the apparently null or very limited damage is simply not properly detectable. There is hardly any trace of these elements in the HIA scoping phase. In environmental complex territories, the renewal or authorization of a new plant should consider not only the impact of the individual plant, but also the health profile of the population concerned and the context in which the industrial project is located. An 'HIA area' is therefore configured, aimed at the complex of environmental pressure factors that insist on the same area of impact of the plant. Epidemiology focuses on the exposed population, considers the 'current' state of health, hazard, and risk information from toxicology, and estimates individual exposure and the effects of exposure. The 'HIA area' can assess the impact of the complex of persistent emission sources, considering in the analysis the health status of the exposed population and the presence of specific vulnerabilities. The proposal is in line with what is already foreseen in the Essential levels of care and Environmental technical performance of the National Health Service.A basic condition is the establishment of functions dedicated to integrated environmental and health surveillance to update the health profile and carry out the 'HIA area' as an accompanying tool for local strategic planning. On these issues, the Italian Environment and Health Network (RIAS) has opened a discussion within the network and with any Italian regions.

[Rt or RDt, that is the question!] / Rt or RDt, that is the question!

The article compares two of the most followed indices in the monitoring of COVID-19 epidemic cases: the Rt and the RDt indices. The first was disseminated by the Italian National Institute of Health (ISS) and the second, which is more usable due to the lower difficulty of calculation and the availability of data, was adopted by various regional and local institutions.The rationale for the Rt index refers to that for the R0 index, the basic reproduction number, which is used by infectivologists as a measure of contagiousness of a given infectious agent in a completely susceptible population. The RDt index, on the other hand, is borrowed from the techniques of time series analysis for the trend of an event measurement that develops as a function of time. The RDt index does not take into account the time of infection, but the date of the diagnosis of positivity and for this reason it is defined as diagnostic replication index, as it aims to describe the intensity of the development of frequency for cases recognized as positive in the population.The comparison between different possible applications of the methods and the use of different types of monitoring data was limited to four areas for which complete individual data were available in March and April 2020. The main problems in the use of Rt, which is based on the date of symptoms onset, arise from the lack of completeness of this information due both to the difficulty in the recording and to the absence in asymptomatic subjects.The general trend of RDt, at least at an intermediate lag of 6 or 7 days, is very similar to that of Rt, as confirmed by the very high value of the correlation index between the two indices. The maximum correlation between Rt and RDt is reached at lag 7 with a value of R exceeding 0.97 (R2=0.944).The two indices, albeit formally distinct, are both valid; they show specific aspects of the phenomenon, but provide basically similar information to the public health decision-maker. Their distinction lies not so much in the method of calculation, rather in the use of different information, i.e., the beginning of symptoms and the swabs outcome.Therefore, it is not appropriate to make a judgment of preference for one of the two indices, but only to invite people to understand their different potentials so that they can choose the one they consider the most appropriate for the purpose they want to use it for.

[Environmental justice promotion in industrially contaminated sites]. / Promozione della giustizia ambientale nei siti industriali contaminati.

The communities residing close to industrially contaminated sites are often affected by several fragilities, particularly of a socioeconomic nature. The disadvantaged conditions have often resulted from their marginalization in the decision-making related to the industrialization processes and may persist even when action is taken to limit the harmful consequences for the natural and social environment. Exposure to contaminants and the resulting health risks often regard socioeconomic deprived communities or the most disadvantaged subgroups, generating conditions of environmental injustice. This paper reports the results of a multidisciplinary reflection focusing on the Italian context. It describes how the national epidemiological surveillance system of communities residing close to industrially contaminated sites (named SENTIERI) and local epidemiological surveillance systems can be implemented to document local conditions of distributive injustice (inequalities in harmful exposures and consequent health risks). Furthermore, it analyses the mechanisms for generating and maintaining marginalities that prevent local communities from participating in decision-making processes (procedural injustice). Finally, after having identified and described the dimensions of community capacity, which concern both to the understanding of the adverse effects of environmental contamination and to the capability of promoting interventions against environmental injustices, it proposes an environmental justice promotion approach that starts from mapping the dimensions of community capacity as a premise to the identification of interventions for community empowerment.

The effects of the introduction of a chronic care model-based program on utilization of healthcare resources: the results of the Puglia care program.

BACKGROUND: Ageing is continuously increasing the prevalence of patients with chronic conditions, putting pressure on the sustainability of Healthcare Systems. Chronic Care Models (CCM) have been used to address the needs of frail people in the continuum of care, testifying to an improvement in health outcomes and more efficient access to healthcare services. The impact of CCM deployment has already been experienced in a selected cohort of patients affected by specific chronic illnesses. We have investigated its effects in a heterogeneous frail cohort included in a regional CCM-based program. METHODS: a retrospective population-based cohort study was carried out involving a non-oncological cohort of adult subjects with chronic diseases included in the CCM-oriented program (Puglia Care). Individuals in usual care with comparable demographic and clinical characteristics were selected for matched pair analysis. Study cohorts were defined by using a record linkage analysis of administrative databases and electronic medical records, including data on the adult population in the 6 local area health authorities of Puglia in Italy (approximately 2 million people). The effects of Puglia Care on the utilizations of healthcare resources were evaluated both in a before-after and in a case-control analysis. RESULTS: There were 1074 subjects included in Puglia Care and 2126 matched controls. In before-after analysis of the Puglia Care cohort, 240 unplanned hospitalizations occurred in the pre-inclusion period, while 239 were registered during follow-up. The incidence of unplanned hospitalization was 10.3 per 100 person/year (95% CI, 9.1-11.7) during follow-up and 12.1 per 100 person/year (95% CI, 10.7-13.8) in the pre-inclusion period (IRR, 0.84; 95% CI, 0.80-0.99). During follow-up a significant reduction in costs related to unplanned hospitalizations (IRR, 0.92; 95% CI, 0.91-0.92) was registered, while costs related to drugs (IRR, 1.14; p < 0.01), out-patient specialist visits (IRR, 1.19; p < 0.01), and planned hospitalization (IRR 1.03; p < 0.01) increased significantly. These modifications can be related to the aging of the population and modifications to healthcare delivery; for this reason, a case-control analysis was performed. The results testify to a significantly lower number (IRR, 0.79; 95% CI, 0.68-0.91), length of hospital stay (IRR, 0.80; 95% CI, 0.76-0.84), and costs related to unplanned hospitalizations (IRR, 0.80; 95% CI, 0.80-0.80) during follow-up in the intervention group. However, there was a higher increase in costs of hospitalizations, drugs and out-patients specialist visits during follow-up in Puglia Care when compared with patients in usual care. CONCLUSION: In a population-based cohort, inclusion of chronic patients in a CCM-based program was significantly associated with a lower recourse to unplanned hospital admissions when compared with patients in usual care with comparable clinical and demographic characteristics.

Estimates of cancer burden in Puglia.

AIMS AND BACKGROUND: A regional population-based cancer registry that provides incidence and survival data has become active only recently. Since it is important to know the time trends of basic epidemiological indicators to understand the cancer burden in the region, this paper will provide incidence, prevalence and mortality estimates in the region for seven major cancers for the period 1970-2015. METHODS: The estimates were obtained by applying the MIAMOD method, a statistical back-calculation approach to derive incidence and prevalence figures starting from mortality and relative survival data. Survival was modeled on the basis of published data from the Italian cancer registries. RESULTS: The incidence rates are estimated to be still increasing for female breast cancer, colorectal cancer in men and skin melanoma in both sexes. By contrast, the incidence rates indicate a decreasing trend for cervix uteri cancer and stomach cancer, the latter both in men and women. For these cancers an analogous trend is observed for mortality, confirming the reduction of the risk factors related to these cancer types. The incidence rates for lung cancer and prostate cancer in men were estimated to rise, reach a peak, and then decrease in the last part of the considered period. Prevalence increased for all the considered cancers except cervix cancer. The increase was striking for breast cancer and less pronounced for stomach cancer in both genders. CONCLUSION: This paper provides a description of the burden of the major cancers until 2015. The results highlight the need to reinforce effective preventive measures to contrast cancers related to an unhealthy lifestyle and to increase the compliance with organized screening programs to reduce the colorectal and breast cancer burden.

[Health impact assessment of pollution from incinerator in Modugno (Bari)]. / Valutazione ex-ante dell'impatto sulla salute attribuibile all'inquinamento da inceneritore a Modugno (Bari).

OBJECTIVES: the purpose of this study is to assess the potential health impact of the start-up of a new incinerator in general population living near the facility in Modugno, province of Bari (Puglia Region, Italy), in combination with the existent Combined-Cycle combustion Gas Turbine (CCGT) power generation facility. DESIGN: an algorithm was used to calculate the number of cases (deaths and hospital admissions) associated with a given concentrations of PM10, the exposed population, the specific mortality/morbidity rate. For every health end-point, an estimate of RR was obtained from the literature. Using PM10 as tracer, simulations were made of incinerator emissions fallout. Residents within 2 km radius from the plants were considered. RESULTS: with the reduction of the average concentration of PM10 to 40 µg/m(3), 0.12% of natural causes of death could be prevented. Proportionally, the increment in PM10 concentration of 1 µg/m(3) could be associated to 0.02% of deaths. CONCLUSIONS: the estimated health impact of the incinerator emissions doesn't modify the epidemiological profile for the population living nearby.

[Assessment of occupational exposure to PAH in coke-oven workers of Taranto steel plant through biological monitoring]. / Valutazione dell'esposizione professionale a IPA in lavoratori della cokeria dello stabilimento siderugico di Taranto mediante monitoraggio biologico.

OBJECTIVE: This study aims at evaluating the occupational exposure to polycyclic aromatic hydrocarbons (PAH) through biological monitoring and at investigating the influence of selected genetic polymorphisms on the levels of internal dose biomarker. DESIGN: A cross-sectional study has been conducted on the basis of biological measurements in order to evaluate the levels of PAH exposure. SETTING: PAH exposure assessment has been carried out in a coke-oven of one of the largest European steel plants (ILVA, Taranto), in the context of the program of medical surveillance carried in collaboration with the ILVA Occupational Health Service. PARTICIPANTS: 355 coke-oven workers exposed to PAH were enrolled from the 3 batteries of the coke oven plant. Maintenance workers and industrial cleaners were included. MAIN OUTCOME MEASURES: The measurement of urinary levels of 1-hydroxypyrene (1-OHP) as biomarker of internal dose has been carried out, as well as the evaluation of metabolic polymorphisms of the cytochrome P450 1A1 (CYP1A1), glutathione S-transferases mu (GSTM1) and theta (GSTT1) as biomarkers of susceptibility. RESULTS: The median value of urinary 1-OHP was 1,05 microMol/Molcreat. The difference between the groups was statistically significant, with the highest value observed in the maintenance group (median 1,71, range 0,06-14,69 microMol/Molcreat). It is remarkable that 25% of the workers exceeded the proposed benchmark guideline value of2,3 microMol/Molcreat. No statistical difference was found in relation to smoking habits. Workers with GSTT1 null genotype had higher 1-OHP levels than those with wild type (p = 0,06). CONCLUSIONS: The levels of biomarker of internal dose reflect a critical exposure to PAH in the coke-oven plant. Further observations are needed to better investigate the role of GSTT1 on the 1-OHP levels.