[Wind days in Taranto (Southern Italy): a public health intervention between technical and social contradictions. Lessons learned]. / Wind days a Taranto: un intervento di sanità pubblica tra contraddizioni tecniche e sociali. Lezioni imparate.

Public health interventions in the context of environmental crisis are necessary and desirable for the protection of public health. This manuscript highlights the critical aspects and potentials of a public health intervention by reconstructing the most relevant stages of the case study called 'Precautionary measures during wind days in Taranto'. Under particular weather conditions, the 'wind days' intervention includes prescriptions to companies and recommendations to the public. The latter has been found to be scientifically inconsistent, as highlighted by studies published over the years. The case-study analysis showed that any public health measure must include: a timed evaluation of the measure effectiveness and consider the possibility of its revision; involvement of the population at all stages.

[Sex/gender differences in COVID-19 lethality: what the data say, and do not say]. / Differenze sesso/genere nella letalità COVID-19: cosa dicono e non dicono i dati.

BACKGROUND: scientific literature indicates that there are sex, and gender differences in the development, symptomatology and evolution of different diseases, in the response to drugs and in the therapeutic pathways. Even in the COVID-19 epidemic some sex/gender differences emerged. OBJECTIVES: to analyze COVID-19 epidemic data by gender and age in Italy, Germany, Spain, and Sweden, characterized by having implemented different pandemic containment policies, with the aim of observing any characteristics that can be interpreted with the lens of sex/gender differences. MATERIALS AND METHODS: we used confirmed cases and deaths associated with COVID-19 for Italy, Spain, Germany, and Sweden from respective national surveillance databases. Mortality data for Italy were also analysed. The period of investigation was March-May 2020. As indicators, we used the case fatality ratio adjusted for time delay and SMR for mortality. RESULTS: women are more vulnerable to COVID- 19 infection in the 30-60-year age group. Case fatality ratio is higher in men than women, with a ratio men/women equal to 1.7 in Italy, Spain, and Sweden and 1,4 in Germany. The ratio increases in the lower age groups. The analysis of the mortality data observed/expected in Italy in the same period with respect to 2015-2019 shows a comparable excess with SMR equal to 132 for men and 127 for women. CONCLUSIONS: COVID-19 affects both genders with some differences in the incidence, higher in women, and lethality, higher in men. These differences highlight the need to better understand the sex/gender and age interaction both for epidemiological surveillance and for a better gender-appropriateness of the ongoing prophylactic and therapeutic treatments. This would be possible if all health indicators (symptoms, past illnesses, primary and hospital-level health care, hospitalization, etc.) were provided by age and gender. Analysis of the causes of death could help to better understand the increase in mortality for both genders, in particular for women, for whom a lower lethality for COVID-19 appears from data.

[Follow-up of the cohort of workers exposed to arsenic in the Manfredonia petrochemical plant (Apulia Region, Southern Italy)]. / Follow-up della coorte dei lavoratori esposti ad arsenico nel petrolchimico di Manfredonia.

INTRODUCTION: in 1976, a major chemical accident occurred in Manfredonia (Apulia Region, Southern Italy) due to an explosion in the fertilizer area. More than 10 tons of arsenic were released into the atmosphere, contaminating the plant and the surrounding areas. At the end of the 90s, criminal proceedings were initiated and a cohort study was conducted within the trial. OBJECTIVES: to update the vital status of workers enrolled within the trial; some relevant results are also given. METHODS: two different approaches were used to update the vital status depending on the residence of the individuals in the cohort. We computed cause-specific standardised mortality ratios (SMRs), stratified according to the type of employment (urea sector, caprolactam sector, and contract workers), with 95% confidence intervals (95%CI). For internal comparison purpose, Cox regression models were used and hazard ratios (HRs) were calculated, considering workers from the caprolactam area as a reference category. RESULTS: the cohort consisted of 1,467 workers; 114 were dead at the end of the previous follow-up. Among 728 workers residing in Manfredonia, we identified 619 people still alive and 93 deceased. Among 625 not-residents, 508 were alive and 93 deceased. For 285 cases out of 306, cause of death was ascertained. Contract workers show a statistically significant SMR for lung cancer (SMR: 1.26; 95%CI 1.05-1.54) and an increased risk for overall mortality (HR: 2.3; 95%CI 1.1-4.9). Workers residing in Manfredonia show a higher risk of lung cancer mortality in comparison to not-residents (HR: 2.3; 95%CI 1.1-4.9). CONCLUSIONS: workers who were most exposed to arsenic during the site cleaning show an increased risk of overall mortality compared to the least exposed and an increased risk of lung cancer compared to the general population.

[The Manfredonia case 40 years after: measurements and modelling of arsenic deposition]. / Il caso Manfredonia 40 anni dopo: misure e modellazione della deposizione di arsenico.

One of the main aim of the participate research carried out in Manfredonia (Apulia Region, Southern Italy) was to evaluate the exposure to the arsenic released during the industrial accident occurred in 1976, by reconstructing the event and the extent of contamination through an analysis of all the collected environmental data, the information issued from the participated research group, and the execution of meteo-dispersive simulation. The emission form the blown-out column consisted of two fractions. The first fraction was a mix of liquid and solid material fallen in the area of the plant, with peaks of deposition exceeded 1,500 mg/kg of arsenic, to which mainly workers are exposed. The second fraction was a cloud which was dispersed and carried by the wind beyond the plant area, towards the town. This second fraction was calculated using meteorological simulations and short-term dispersion simulations (a few hours). The map of ground deposition is in accordance with the maps created out of the first deposition measurement of the ground (correlation index: 0.67), although this map identifies a larger area of contamination. Both measured and modelled depositions show a maximum deposition 2 km away from the outburst site. The reconstructed deposition map gives a contamination value with a gradient in the populated area, that is a relevant instrument to evaluate citizens' exposition.

[Tobacco cultivationin Salento (Apulia Region, Southern Italy) from 1929 to 1993: possible health implications]. / La tabacchicoltura nel Salento dal 1929 al 1993: possibili implicazioni sanitarie.

The Province of Lecce (Apulia Region, Southern Italy) is one of the Italian areas where the prevalence of respiratory disease and cancer of the respitartory tract is very high. Through a descriptive analysis of the historical series of tobacco culture indicators, a historical reconstruction of the development of tobacco cultivation in Salento (the area where the Province of Lecce is located) is here presented, in order to provide an additional element of knowledge on potential risk factors for respiratory diseases and cancers. Data regarding extensions in hectares and crop productions in the province of Lecce, in Apulia, and in Italy are from the Chamber of commerce of Lecce province and from the Italian National Institute of Statistics (Istat). From 1929 to 1993, the province of Lecce provided between 75% and 94% of the tobacco cultivated in Apulia Region and 25% of the national tobacco until 1945. Since the late Sixties, a growing increase in annual average production was observed, reaching 21.5 quintals per hectare in 1991 in Salento. This large tobacco production, associated with intensive use of pesticides, could be an element to be observed in analytical studies as a determining potential for the high prevalence of respiratory diseases and pulmonary cancers in the male population of the province of Lecce.

Cancer mortality in the West Bank, Occupied Palestinian Territory.

BACKGROUND: The burden of cancer is difficult to study in the context of the occupied Palestinian territory because of the limited data available. This study aims to evaluate the quality of mortality data and to investigate cancer mortality patterns in the occupied Palestinian territory's West Bank governorates from 1999 to 2009. METHODS: Death certificates collected by the Palestinian Ministry of Health for Palestinians living in the West Bank were used. Direct and indirect age-standardised mortality rates were computed and used to compare different governorates according to total and specific cancer mortality. Furthermore, standardised proportional mortality ratios were calculated to compare mortality by urban, rural and camp locales. RESULTS: The most common cause of death out of all cancer types was lung cancer among males (22.8 %) and breast cancer among females (21.5 %) followed by prostate cancer for males (9.5 %) and by colon cancer for females (11.4 %). Regional variations in cancer-specific causes of death were observed. The central- West Bank governorates had the lowest mortality for most cancer types among men and women. Mortality for lung cancer was highest in the north among men (SMR 109.6; 95%CI 99.5-120.4). For prostate cancer, mortality was highest in the north (SMR 103.6; 95%CI 88.5-120.5) and in the south (SMR 118.6; 95%CI 98.9-141.0). Breast cancer mortality was highest in the south (SMR 119.3; 95%CI 103.9-136.2). Similar mortality rate patterns were found in urban, rural and camp locales. CONCLUSION: The quality of the Palestinian mortality registry has improved over time. Results in the West Bank governorates present different mortality patterns. The differences might be explained by personal, contextual and environmental factors that need future in-depth investigations.

[Mortality from respiratory diseases in the provinces of Apulia Region (Southern Italy) from 1933 to 2010]. / La mortalità per patologie respiratorie nelle province pugliesi dal 1933 al 2010.

OBIETTIVI: valutare l'andamento temporale della mortalità per patologie respiratorie nelle province pugliesi utilizzando dati omogenei per fonte e metodologia di calcolo. DISEGNO: analisi ecologica storica degli andamenti temporali di mortalità per tumori e patologie dell'apparato respiratorio nelle province pugliesi, in Puglia e nelle ripartizioni geografiche italiane dal 1933 al 2010. SETTING E PARTECIPANTI: i dati di mortalità e le popolazioni residenti sono di fonte Istat. Sono state esaminate tutte le cause di decesso, il tumore della laringe, il tumore del polmone, l'insieme dei tumori respiratori, la bronchite, la polmonite e la broncopolmonite considerate congiuntamente, e l'insieme delle patologie respiratorie. Le analisi sono disaggregate per sesso dal 1969. PRINCIPALI MISURE DI OUTCOME: rapporti standardizzati di mortalità (SMR%) in riferimento all'Italia, con intervalli di confidenza al 95%, e tassi di mortalità standardizzati col metodo diretto (TSD ) in riferimento alla popolazione standard europea. RISULTATI: dal 1933 al 2010, i TSD per tumori respiratori e per bronchiti diminuiscono in tutte le aree analizzate. Tuttavia, nelle province di Taranto, Brindisi e Lecce, l'SMR% per tumori respiratori, inferiore al riferimento nazionale fino agli anni Sessanta, si allinea (a Brindisi) e supera (a Lecce e Taranto) il riferimento negli anni successivi. Nelle province di Foggia e Bari il numero dei decessi per tumore del polmone è costantemente inferiore all'atteso. CONCLUSIONI: la ricostruzione storica e l'analisi dei trend temporali di mortalità dal 1933 al 2010 mostrano alcune criticità sanitarie in periodi specifici. L'elaborazione dei dati di mortalità per un arco temporale di circa 80 anni ha messo in evidenza la maggiore rilevanza di queste criticità con l'avvio dello sviluppo industriale.

[Exposure to ionizing radiation from computed tomography (CT) in childhood and cancer risk]. / Esposizione a radiazioni ionizzanti da tomografia computerizzata (TC) in età infantile e rischio di tumore.

A recent US cohort study estimated 500 cancer cases attributable to exposure to CT out of 600,000 children aged <15 years who underwent a computed tomography (CT) to head or abdomen. This review synthetizes the evidence on the association between exposure to ionizing radiation through CT and cancer risk. Five cohort studies were identified. Three studies show clear increases in cancer risk among children and adolescents who underwent at least one CT. All studies had methodological limits, among which the lack of an individual level estimate of dose-organ specific absorbed by patient and problems of statistical power. Results from on-going large international studies will allow a more accurate risk estimation.

[Ecological study on the mortality of residents in Manfredonia (Apulia Region, Southern Italy) from 1970 to 2013]. / Studio ecologico sulla mortalità dei residenti a Manfredonia dal 1970 al 2013.

OBIETTIVI: valutare lo stato di salute della popolazione residente nel comune di Manfredonia dal 1970 al 2013. DISEGNO: analisi descrittiva dell'andamento temporale della mortalità generale, per gruppi di cause, dal 1970 al 2013. SETTING E PARTECIPANTI: i dati di mortalità e le popolazioni residenti sono di fonte Istat. Sono state esaminate 55 cause di decesso. Le analisi sono disaggregate per sesso e periodo. PRINCIPALI MISURE DI OUTCOME: sono stati elaborati i rapporti standardizzati di mortalità (SMR%), con i rispettivi intervalli di confidenza al 90% (IC90%), e i tassi di mortalità standardizzati col metodo diretto (TSD ). RISULTATI: lo stato di salute misurato dal tasso di mortalità per tutte le cause migliora nel tempo: i TSD passano da 92 x10.000 negli anni 1970-1974 a 52 x10.000 nel biennio 2012-2013 negli uomini, da 70 x10.000 a 39 x10.000 nelle donne. Tuttavia, rispetto alla media regionale Manfredonia perde progressivamente il suo vantaggio, passando da -20% a -10% negli uomini, e da -20% a +1,5% nelle donne. Questo andamento è molto evidente per il complesso delle cause cardiovascolari, mentre i tumori maligni sono in generale nella media regionale. Nell'ultimo periodo disponibile per causa di decesso (2006-2011), la mortalità per infarto miocardico è stata più alta della media regionale (uomini: +35%; donne: +54%). I rapporti standardizzati di mortalità (SMR) mostrano tra gli uomini valori in crescita, in particolar modo rispetto al riferimento provinciale, con un eccesso a cominciare dal periodo 2006-2011 (22 decessi/anno e 19 attesi; SMR%: 117,2; IC90% 101,1-135,2; riferimento: provincia di Foggia). Anche tra le donne gli SMR% superano i riferimenti provinciali negli ultimi periodi esaminati (nel 2012-2013: 7 decessi/ anno e 4,2 attesi; SMR%: 116,4; IC90% 97,0-260,7; riferimento: provincia di Foggia). CONCLUSIONI: la mortalità a Manfredonia è diminuita in misura minore rispetto a quella osservata nei riferimenti provinciali e regionali. Il vantaggio che si osservava negli anni Sessanta si è, infatti, ridotto nel tempo, fino ad annullarsi negli ultimi anni. Dal 1970, Manfredonia ha progressivamente perso il vantaggio che aveva. Dagli anni Duemila, la mortalità per infarto del miocardio è in eccesso sulla media regionale e provinciale. Da casi documentati in letteratura si osserva che le popolazioni che sperimentano catastrofi di origine naturale o antropica possono fronteggiare un aumento di patologie cardiovascolari. La mortalità per tumore polmonare mostra un eccesso sulla media regionale, in particolare provinciale, a cominciare dal 2000, coerentemente con i tempi di latenza legati all'esposizione ad arsenico negli anni Settanta.

[A Parliament debate regarding a scientific study]. / Il dibattito in Parlamento su una ricerca scientifica.

Publishing studies on the relationship between health and pollution provokes reactions and interest in the public opinion involved, the highest national institutions included. This commentary, aroused by a parliamentary debate, which also concerned one of our recent scientific papers published on Environmental Research about the association between congenital anomalies and maternal exposure to atmospheric pollutants in Brindisi (Apulia Region, Southern Italy), aims at contributing to reply the following questions: the type and quality of the data used in the estimates of exposure must be certified by institutional bodies? Adverse health effects in people exposed to pollutants at levels below the law limits can be excluded? Finally, we draw some remarks on measures to protect public health and on the relationship between the work of the researchers of public institutes and administrations.

[EpiChange. Epidemiological study on the health status of residents in Manfredonia (Italy). Phase 2. Scenarios and implications]. / EpiChange. Studio epidemiologico sullo stato di salute dei residenti nel Comune di Manfredonia. Fase 2. Scenari e implicazioni.

This is the second paper on the Project Manfredonia Environment and Health launched on February 2015 and based on a participatory approach. After a serious industrial accident on 1976 with release of several tons of arsenic, the management of environmental issues produced distrust and suspicion towards institutions and these feelings are still alive in the civil society. The Project is therefore based on a strong public engagement on each phase of the epidemiological investigation. In this article we report the second phase in which all the stakeholders consider all possible analysis results and the implications in terms of public health action plans. This step is relevant in order to acknowledge the limitation of the epidemiologic study due to uncertainties and assure transparency to the decision processes.

Congenital anomalies among live births in a high environmental risk area--a case-control study in Brindisi (southern Italy).

Maternal exposure to ambient pollution has been increasingly linked to the risk of congenital anomalies (CAs) in the fetus and newborns. Recently, a descriptive study in the high environmental risk city of Brindisi (Italy) revealed an increased prevalence of total CAs, especially congenital heart disease (CHD) and ventricular septal defects (VSDs), both at the local level and in comparison with the pool of EUROCAT registries. This paper concerns a population-based case control study to investigate the association between maternal exposure to air pollutants - sulfur dioxide (SO2) and total suspended particulate (TSP) matter - and the risk of CA. Cases were newborns up to 28 days of age, born to mothers resident in Brindisi between 2001 and 2010, and discharged with a diagnosis of CA. Cases and controls were individually matched according to sex, socio-economic status of the census area of residence of the mother, and year of beginning of pregnancy. Up to four controls were extracted for each case. Concentration data from monitoring stations were used to estimate air pollution exposure. Each case and control was assigned pollutant concentration values as mean and 90th percentile of the daily average values during weeks 3-8 of pregnancy. Exposure as both continuous and categorical variables was considered and a conditional logistic regression model was constructed to quantify the odds ratios of exposure to air pollutants and the occurrence of total CAs, CHDs and VSDs. We found exposure to the 90th percentile of SO2 to be associated with CHDs (p for trend =0.01) and VSDs (p for trend <0.05). Findings for TSP were less consistent. In conclusion, in the studied area, maternal exposure to sulfur dioxide increased risk of CHD.

[Chronic obstructive pulmonary disease (COPD) prevalence in Brindisi Province (Southern Italy) for the years 2005-2009]. / Stima della prevalenza di broncopneumopatia cronica ostruttiva (BPCO) nella Provincia di Brindisi per gli anni 2005-2009.

OBJECTIVES: to estimate the prevalence of chronic obstructive pulmonary disease (COPD) in Brindisi Province (Southern Italy) during the period 2005-2009. DESIGN: longitudinal approach using electronic health data. SETTING AND PARTICIPANTS: prevalence of COPD cases where defined as: 35+ year-old residents in Brindisi Province discharged from hospital with a diagnosis of COPD, recorded in any of the diagnostic fields, during the period 2005-2009; residents discharged in the previous 4 years and still alive at the beginning of the year considered; residents who died of COPD without previous hospital admissions for the same disease. Diagnoses codes selected from discharge data and cause of mortality archive were 490-492, 494 and 496, of the International Classification of Diseases - IX Revision - Clinical Modification (ICD-9-CM). MAIN OUTCOME MEASURES: crude prevalence and age standardized prevalence (per 100 residents), with confidence intervals (95%CI), by gender. RESULTS: COPD prevalence rates did not change in Brindisi Province over the period of study and the rate was around 6.6%. Prevalence was higher in males and increased with age both among males and females. The rates were higher among the females resident in Brindisi town than those observed among females resident in the rest of the municipalities of the Province considered. Among males, prevalence rates were similar between males living in the selected areas. CONCLUSIONS: this study is the first to present COPD prevalence rates estimated for the Brindisi Province based on electronic health data. The results showed a higher COPD prevalence in Brindisi then in other Italian cities and spatial and temporal differences by gender among Brindisi and the rest of the municipalities considered. Results require additional investigations. In particular, the use of additional health data sources not considered in the present study might help in better explaining the differences observed.

Maternal environmental exposure, infant GSTP1 polymorphism, and risk of isolated congenital heart disease.

The GSTP1 gene, highly expressed early in fetal life, is the most abundant phase 2 xenobiotic metabolism enzyme in a human placenta. Fetal inherited GSTP1 Ile105Val polymorphism may modify the metabolism and excretion of xenobiotics from fetal tissue and increase the risk of congenital heart disease (CHD). This study aimed to analyze the joint effects of GSTP1 genetic polymorphism (Ile105Val) and maternal environmental exposure on CHD risk. Within a case-control design, a total of 190 children with CHD (104 boys age 4 ± 5.6 years) and 190 healthy children (114 newborn boys) were genotyped for the GSTP1 Ile105Val polymorphism. Mothers completed a structured questionnaire on the demographics as well as the preconceptional and lifestyle exposures. A higher frequency of mothers of children with CHD (38 %) reported a positive history of exposure to toxicants (occupational and environmental) than mothers of healthy children (23 %) (p = 0.0013). Logistic regression analysis showed that maternal occupational and environmental exposures increased the risk of CHD (odds ratio, 2.6; 95 % confidence interval, 1.6-4.2; p < 0.0001). No significant differences in Ile105Val genotype frequencies were observed between the children with CHD and the healthy children (p = 0.9). Furthermore, case-control analysis showed no evidence of significant interaction between the maternal exposures and GSTP1 polymorphism. Maternal exposure to toxicants increased the risk of children with CHD. However, fetal GSTP1 Ile105Val polymorphism did not increase the risk of CHD.

Acute effects of urban and industrial pollution in a government-designated "Environmental risk area": the case of Brindisi, Italy.

Exposure to air pollutants has been associated with increased hospital admissions (HAs) for respiratory and cardiovascular diseases. This work describes a short-term epidemiological study in Brindisi, a highly industrialized town in Southern Italy. The effects of daily exposure to PM10 and NO2 on daily HAs for cardiac, respiratory, and cerebrovascular diseases were investigated by means of a case-crossover design in the period 2001-2007. Results showed positive associations between PM10 and HAs for cardiac and respiratory diseases and between NO2 and HAs for all the categories of diseases considered, particularly among females. Although not statistically significant, increased risk was observed for wind blowing from the port and the industrial area. Findings confirm the health risks associated with ambient air pollution exposure, even though NO2 and PM10 concentrations were below the legal limits. This may be due to the complex scenario of emissions in the area, which should be better investigated.

[Air pollution and urgent hospital admissions in 25 Italian cities: results from the EpiAir2 project]. / Inquinamento atmosferico e ricoveri ospedalieri urgenti in 25 città italiane: risultati del progetto EpiAir2.

OBJECTIVE: to evaluate the relationship between air pollution and hospital admissions in 25 Italian cities that took part in the EpiAir (Epidemiological surveillance of air pollution effects among Italian cities) project. DESIGN: study of time series with case-crossover methodology, with adjustment for meteorological and time-dependent variables. The association air pollution hospitalisation was analyzed in each of the 25 cities involved in the study; the overall estimates of effect were obtained subsequently by means of a meta-analysis. The pollutants considered were PM10, PM2.5 (in 13 cities only), NO2 and ozone (O3); this last pollutant restricted to the summer season (April-September). SETTING AND PARTICIPANTS: the study has analyzed 2,246,448 urgent hospital admissions for non-accidental diseases in 25 Italian cities during the period 2006- 2010; 10 out of 25 cities took part also in the first phase of the project (2001-2005). MAIN OUTCOME MEASURES: urgent hospital admissions for cardiac, cerebrovascular and respiratory diseases, for all age groups, were considered. The respiratory hospital admissions were analysed also for the 0-14-year subgroup. Percentage increases risk of hospitalization associated with increments of 10 µg/m(3) and interquartile range (IQR) of the concentration of each pollutant were calculated. RESULTS: reported results were related to an increment of 10 µg/m(3) of air pollutant. The percent increase for PM10 for cardiac causes was 0.34% at lag 0 (95%CI 0.04-0.63), for respiratory causes 0.75% at lag 0-5 (95%CI 0.25-1.25). For PM2.5, the percent increase for respiratory causes was 1.23% at lag 0- 5 (95%CI 0.58-1.88). For NO2, the percent increase for cardiac causes was 0.57% at lag 0 (95%CI 0.13-1.02); 1.29% at lag 0-5 (95%CI 0.52-2.06) for respiratory causes. Ozone (O3) did not turned out to be positively associated neither with cardiac nor with respiratory causes as noted in the previous period (2001-2005). CONCLUSION: the results of the study confirm an association between PM10, PM2.5, and NO2 on hospital admissions among 25 Italian cities. No positive associations for ozone was noted in this period.

[Air pollution and mortality in twenty-five Italian cities: results of the EpiAir2 Project]. / Inquinamento atmosferico e mortalità in venticinque città italiane: risultati del progetto EpiAir2.

OBJECTIVES: this study aims at presenting the results from the Italian EpiaAir2 Project on the short-term effects of air pollution on adult population (35+ years old) in 25 Italian cities. DESIGN: the short-term effects of air pollution on resident people died in their city were analysed adopting the time series approach. The association between increases in 10µg/m(3) in PM10, PM2.5, NO2 and O3 air concentration and natural, cardiac, cerebrovascular and respiratory mortality was studied. City-specific Poisson models were fitted to estimate the association of daily concentrations of pollutants with daily counts of deaths. The analysis took into account temporal and meteorological factors to control for potential confounding effect. Pooled estimates have been derived from random effects meta-analysis, evaluating the presence of heterogeneity in the city specific results. SETTING AND PARTICIPANTS: it was analysed 422,723 deaths in the 25 cities of the project among people aged 35 years or more, resident in each city during the period 2006-2010. MAIN OUTCOME MEASURES: daily counts of natural, cardiac, cerebrovascular, and respiratory mortality, obtained from the registries of each city. Demographic information were obtained by record linkage procedure with the civil registry of each city. RESULTS: mean number of deaths for natural causes ranged from 513 in Rovigo to 20,959 in Rome. About 25% of deaths are due to cardiac diseases, 10% to cerebrovascular diseases, and 7% to respiratory diseases. It was found an immediate effect of PM10 on natural mortality (0.51%; 95%CI 0.16-0.86; lag 0-1). More relevant and prolonged effects (lag 0-5) have been found for PM2.5 (0.78%; 95%CI 0.12-1.46) and NO2 (1.10%; 95%CI 0.63-1.58). Increases in cardiac mortality are associated with PM10 (0.93%; 95%CI 0.16-1.70) and PM2.5 (1.25%; 95%CI 0.17-2.34), while for respiratory mortality exposure to NO2 has an important role (1.67%; 95%CI 0.23-3.13; lag 2-5), as well as PM10 (1.41%; 95%CI - 0.23;+3.08). Results are strongly homogeneous among cities, except for respiratory mortality. No effect has been found for cerebrovascular mortality and weak evidence of association has been observed between ozone and mortality. CONCLUSIONS: a clear increase in mortality associated to air pollutants was observed. More important are the effects of NO2 (on natural mortality), mostly associated with traffic emissions, and of PM2.5 (on cardiac and respiratory mortality). Nitrogen dioxide shows an independent effect from the particulate matter, as observed in the bi-pollutant models.