Le disuguaglianze di accesso ai programmi di screening dei tumori della mammella, del colon retto e della cervice uterina sono aumentate durante il periodo pandemico. Risultati di un health equity audit condotto dall'Agenzia di Tutela della Salute d.

OBJECTIVES: to evaluate the disparities in access to cancer screening programmes in the Province of Pavia (Lombardy Region, Northern Italy), along with identifying the factors influencing these disparities; to assess the impact of the pandemic emergency on invitation and screening coverage in the three organized screening programmes, which are provided free of charge to the target population. DESIGN: observational retrospective study covering both the pre-pandemic and the pandemic periods. SETTING AND PARTICIPANTS: for breast cancer screening, the eligible population comprises women aged 45 to 74; colorectal cancer screening is offered to men and women aged 50 to 74; cervical cancer screening is tailored based on women age. The management of all three screening programmes is overseen by the Health Protection Agency of Pavia, which proactively invites the eligible population through invitation letters. MAIN OUTCOMES MEASURES: for each screening programme, the examination coverage (the number of screened individuals out of the total eligible population) was analysed considering its influencing factors, with a specific emphasis on equity-related factors such as demographics (sex, age), geographic factors (country and continent of birth, residential district), comorbidities. RESULTS: the SARS-CoV-2 pandemic has led to a reorganization of healthcare services and to a reduction of the offer, resulting in an overall reduction in test coverage for all three programmes (-16.3% for breast and colorectal cancer screening, -8.5% for cervical cancer screening). The disparities in coverage among various population groups, reflecting inequalities in access, further escalated from the pre-pandemic to the pandemic period. Noteworthy, equity-related predictors of reduced screening access were non-Italian nationality and residency in rural or mountainous districts. CONCLUSIONS: during periods of healthcare system strain, such as the pandemic, disparities in access can become more pronounced. It is crucial to implement measures for enhancing access to screening in a more equitable manner.

Population-based breast cancer screening in Pavia (northern Italy) in 2016-2018: Key performance indicators and sensitivity estimate.

BACKGROUND AND AIM: This study aims to assess the quality of the population-based breast cancer screening programme in Pavia, northern Italy computing its key performance indicators and estimating its sensitivity for the years 2016-2018. METHODS: Invitation and examination coverage, participation rate, recall rate, detection rate and positive predictive values were computed on the basis of data provided yearly to the Italian Ministry of Health. Sensitivity was estimated identifying interval cancers in the local Cancer Registry and computed with the proportional incidence method. RESULTS: In 2016-2018 the adjusted invitation coverage was 90%, and the adjusted participation rate was 62%. Recall rate was 8.4% for first screenings and 3.9% for subsequent ones. The number of screen-detected cases was 268, corresponding to a detection rate of 6.6‰ for first screenings and 4.6‰ for subsequent screenings. The number of interval cancers observed was 110 over the study period; the proportional incidence was 22% for the first interval year and 50% for the second interval. The overall sensitivity of the screening program was 64%. CONCLUSIONS: The analysis of performance indicators and sensitivity estimates for the Pavia programme indicates that the programme performance is in line with the quality standards set by the European Union and the Italian reference scientific society (GISMa).

Time-Trends in Air Pollution Impact on Health in Italy, 1990-2019: An Analysis From the Global Burden of Disease Study 2019.

Objectives: We explored temporal variations in disease burden of ambient particulate matter 2.5 µm or less in diameter (PM2.5) and ozone in Italy using estimates from the Global Burden of Disease Study 2019. Methods: We compared temporal changes and percent variations (95% Uncertainty Intervals [95% UI]) in rates of disability adjusted life years (DALYs), years of life lost, years lived with disability and mortality from 1990 to 2019, and variations in pollutant-attributable burden with those in the overall burden of each PM2.5- and ozone-related disease. Results: In 2019, 467,000 DALYs (95% UI: 371,000, 570,000) were attributable to PM2.5 and 39,600 (95% UI: 18,300, 61,500) to ozone. The crude DALY rate attributable to PM2.5 decreased by 47.9% (95% UI: 10.3, 65.4) from 1990 to 2019. For ozone, it declined by 37.0% (95% UI: 28.9, 44.5) during 1990-2010, but it increased by 44.8% (95% UI: 35.5, 56.3) during 2010-2019. Age-standardized rates declined more than crude ones. Conclusion: In Italy, the burden of ambient PM2.5 (but not of ozone) significantly decreased, even in concurrence with population ageing. Results suggest a positive impact of air quality regulations, fostering further regulatory efforts.

Health impact assessment should be based on correct methods.

The methodology of health impact assessment (HIA), originally proposed by WHO, is widely used to predict the potential health effects in a community living in a place in which a new project (e.g., an industrial plant) will be implemented. One of the key quantities to calculate the impact (i.e., the number of attributable cases) is the baseline (i.e., before the project implementation) rate of selected diseases in the community. In a recent paper on this journal, this methodology has been challenged. Specifically, the use of baseline rate has been questioned, proposing to use only the fraction of the baseline rate due to the exposures related to the project, and not the rate due to all risk factors for the disease. In this commentary, we argue that the proposal is logically and epidemiologically unsound, and devoid of scientific motivation. The conclusion that the traditional approach overestimates the health impact should be rejected as based on flawed assumptions. On the contrary, the proposal may produce a (seriously biased) underestimation of attributable cases.

[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.

[Covid-19 and clinical-epidemiological research in Italy: proposal of a research agenda on priority topics by the Italian association of epidemiology]. / Covid-19 e ricerca clinico-epidemiologica in Italia: proposta di un'agenda di ricerca su temi prioritari da parte dell'Associazione italiana di epidemiologia.

BACKGROUND: the Covid-19 pandemic has provoked a huge of clinical and epidemiological research initiatives, especially in the most involved countries. However, this very large effort was characterized by several methodological weaknesses, both in the field of discovering effective treatments (with too many small and uncontrolled trials) and in the field of identifying preventable risks and prognostic factors (with too few large, representative and well-designed cohorts or case-control studies). OBJECTIVES: in response to the fragmented and uncoordinated research production on Covid-19, the   italian Association of Epidemiology (AIE) stimulated the formation of a working group (WG) with the aims of identifying the most important gaps in knowledge and to propose a structured research agenda of clinical and epidemiological studies considered at high priority on Covid-19, including recommendations on the preferable methodology. METHODS: the WG was composed by 25 subjects, mainly epidemiologists, statisticians, and other experts in specific fields, who have voluntarily agreed to the proposal. The agreement on a list of main research questions and on the structure of the specific documents to be produced were defined through few meetings and cycles of document exchanges. RESULTS: twelve main research questions on Covid-19 were identified, covering aetiology, prognosis, interventions, follow-up and impact on general and specific populations (children, pregnant women). For each of them, a two-page form was developed, structured in: background, main topics, methods (with recommendations on preferred study design and warnings for bias prevention) and an essential bibliography. CONCLUSIONS: this research agenda represents an initial contribution to direct clinical and epidemiological research efforts on high priority topics with a focus on methodological aspects. Further development and refinements of this agenda by Public Health Authorities are encouraged.

Biomonitoring and exposure assessment of people living near or working at an Italian waste incinerator: methodology of the SPoTT study.

Only few studies on the health effect of waste incinerators were focused on human biomonitoring (HBM). Our aim is to describe a protocol for assessing early variation of selected items in a population group living close to a waste incinerator in Turin, Italy. A cohort of 394 subjects was randomly selected, among residents near the incinerator and residents far from it. To achieve this sample size, 765 subjects were contacted. The cohort was monitored before the start-up of the plant and will be followed up 1 and 3 years after, with measurements of respiratory function, selected blood and urine parameters including 19 metals, 17 congeners of PCDDs/Fs, 12 congeners of DL-PCBs, 30 congeners of NDL-PCBs, 11 OH-PAHs, specific hormones (T3, T4, TSH, cortisol and ACTH) and common health parameters. The same protocol is applied for plant workers and breeders living near the plant. Individual exposure to urban pollution and waste incinerator fallout were assessed through the use of mathematical models. Information on individual habits was assessed using a specific questionnaire. SPoTT is the first Italian study that adopts a longitudinal design of appropriate statistical power to assess health impacts of waste incinerator plants' emission. The initial results comparing the baseline to the first follow-up are due at the end of 2016.

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.

[Health impact assessment of policies for municipal solid waste management: findings of the SESPIR Project]. / Impatto sulla salute delle politiche di gestione dei rifiuti solidi urbani: i risultati del Progetto SESPIR.

The SESPIR Project (Epidemiological Surveillance of Health Status of Resident Population Around the Waste Treatment Plants) assessed the impact on health of residents nearby incinerators, landfills and mechanical biological treatment plants in five Italian regions (Emilia-Romagna, Piedmont, Lazio, Campania, and Sicily). The assessment procedure took into account the available knowledge on health effects of waste disposal facilities. Analyses were related to three different scenarios: a Baseline scenario, referred to plants active in 2008-2009; the regional future scenario, with plants expected in the waste regional plans; a virtuous scenario (Green 2020), based on a policy management of municipal solid waste (MSW) through the reduction of production and an intense recovery policy. Facing with a total population of around 24 million for the 5 regions, the residents nearby the plants were more than 380,000 people at Baseline. Such a population is reduced to approximately 330.000 inhabitants and 170.000 inhabitants in the regional and Green 2020 scenarios, respectively. The health impact was assessed for the period 2008-2040. At Baseline, 1-2 cases per year of cancer attributable to MSW plants were estimated, as well as 26 cases per year of adverse pregnancy outcomes (including low birth weight and birth defects), 102 persons with respiratory symptoms, and about a thousand affected from annoyance caused by odours. These annual estimates are translated into 2,725 years of life with disability (DALYs) estimated for the entire period. The DALYs are reduced by approximately 20% and 80% in the two future scenarios. Even in these cases, health impact is given by the greater effects on pregnancy and the annoyance associated with the odours of plants. In spite of the limitations due to the inevitable assumptions required by the present exercise, the proposed methodology is suitable for a first approach to assess different policies that can be adopted in regional planning in the field of waste management. The greatest reduction in health impact is achieved with a virtuous policy of reducing waste production and a significant increase in the collection and recycling of waste.

[Methods for health impact assessment of policies for municipal solid waste management: the SESPIR Project]. / Metodologia di valutazione degli impatti sulla salute delle politiche di gestione dei rifiuti solidi urbani: il Progetto SESPIR.

The Project Epidemiological Surveillance of Health Status of Resident Population Around the Waste Treatment Plants (SESPIR) included five Italian regions (Emilia-Romagna, Piedmont, Lazio, Campania, and Sicily) and the National Institute of Health in the period 2010-2013. SESPIR was funded by the Ministry of Health as part of the National centre for diseases prevention and control (CCM) programme of 2010 with the general objective to provide methods and operational tools for the implementation of surveillance systems for waste and health, aimed at assessing the impact of the municipal solid waste (MSW) treatment cycle on the health of the population. The specific objective was to assess health impacts resulting from the presence of disposal facilities related to different regional scenarios of waste management. Suitable tools for analysis of integrated assessment of environmental and health impact were developed and applied, using current demographic, environmental and health data. In this article, the methodology used for the quantitative estimation of the impact on the health of populations living nearby incinerators, landfills and mechanical biological treatment plants is showed, as well as the analysis of three different temporal scenarios: the first related to the existing plants in the period 2008-2009 (baseline), the second based on regional plans, the latter referring to MSW virtuous policy management based on reduction of produced waste and an intense recovery policy.

[SENTIERI KIDS: monitoring children's health in Italian polluted sites]. / SENTIERI KIDS: monitorare lo stato di salute infantile nei siti inquinati in Italia.

Protecting children's health from the effects of environmental contamination is a public health priority. In recent years, particular care has been devoted in Italy to the study of the relationship between environmental pollutants and health during infancy. The SENTIERI Project has called attention to increases in infant mortality in National Priority Contaminated Sites (NPCSs). SENTIERI KIDS provides a blueprint for the establishment of a task force charged with establishing multi and inter-disciplinary cooperation between central and regional institutions on the subject of children's health in contaminated sites. SENTIERI KIDS introduces a multiple outcome analytical model based on updated health outcomes (mortality, cancer incidence, hospital discharges) in order to establish a permanent observation system to monitor the state of health of infants residing in contaminated areas. This will pave the way for more in-depth epidemiological enquiries on an individual basis, and support the establishment and continued monitoring of primary prevention projects. Particular attention is devoted to issues of information and communication.

[Policies for the promotion of sustainable mobility and the reduction of traffic-related air pollution in the cities participating in the EpiAir2 project]. / Le politiche per la promozione della mobilità sostenibile e la riduzione dell'inquinamento atmosferico causato dal traffico veicolare nelle città partecipanti allo studio EpiAir2.

OBJECTIVE: to describe transport policies adopted in recent years (2006-2010) by some Italian municipalities and their effectiveness. DESIGN AND SETTING: survey data refer to fifteen cities participating in the EpiAir2 project: Torino, Milano, Venezia, Bologna, Firenze, Pisa, Roma, Taranto, Palermo, Cagliari, Trieste, Genova, Ancona, Napoli, and Bari. RESULTS: this survey revealed strengths and weaknesses of the way in which these Italian cities address the promotion of sustainable mobility. As a general rule, the vehicle fleets have been renewed with a reduction of old-emission-standard vehicles. Italian cities reported a considerable delay in the development of underground and tram systems, and suburban rail networks, compared to other European urban areas. Regarding other aspects of urban mobility (supply/demand for public transport, low traffic and pedestrian zones, bike paths, car and bike sharing), this survey highlighted a great heterogeneity among Italian cities. CONCLUSION: differences between Italian cities are partly explained by structural and cultural features and also by local governance, specifically the political capability to design and adopt effective policies concerning urban transportation systems and their environmental impact. Various and fragmented initiatives are signs that Italy has not formulated a comprehensive and integrated strategy about sustainable mobility in urban areas yet.

Hypertension and Exposure to Noise near Airports (HYENA): study design and noise exposure assessment.

An increasing number of people live near airports with considerable noise and air pollution. The Hypertension and Exposure to Noise near Airports (HYENA) project aims to assess the impact of airport-related noise exposure on blood pressure (BP) and cardiovascular disease using a cross-sectional study design. We selected 6,000 persons (45-70 years of age) who had lived at least 5 years near one of six major European airports. We used modeled aircraft noise contours, aiming to maximize exposure contrast. Automated BP instruments are used to reduce observer error. We designed a standardized questionnaire to collect data on annoyance, noise disturbance, and major confounders. Cortisol in saliva was collected in a subsample of the study population (n = 500) stratified by noise exposure level. To investigate short-term noise effects on BP and possible effects on nighttime BP dipping, we measured 24-hr BP and assessed continuous night noise in another subsample (n = 200). To ensure comparability between countries, we used common noise models to assess individual noise exposure, with a resolution of 1 dB(A). Modifiers of individual exposure, such as the orientation of living and bedroom toward roads, window-opening habits, and sound insulation, were assessed by the questionnaire. For four airports, we estimated exposure to air pollution to explore modifying effects of air pollution on cardiovascular disease. The project assesses exposure to traffic-related air pollutants, primarily using data from another project funded by the European Union (APMoSPHERE, Air Pollution Modelling for Support to Policy on Health and Environmental Risks in Europe).