A call from 40 public health scientists for an end to the continuing humanitarian and environmental catastrophe in Gaza.

An under-recognised aspect of the current humanitarian catastrophe in Gaza is the impact of the war on the environment and the associated risks for human health. This commentary contextualises these impacts against the background of human suffering produced by the overwhelming violence associated with the use of military force against the general population of Gaza. In calling for an immediate cessation to the violence, the authors draw attention to the urgent need to rebuild the health care system and restore the physical and human infrastructure that makes a liveable environment possible and promotes human health and well-being, especially for the most vulnerable in the population. Environmental remediation should therefore form one of the most important parts of international efforts to assist reconstruction, through which we hope Palestinians and Israelis will achieve lasting peace, health, and sustainable development, all as part of accepted international human rights obligations.

[Death certification of pleural malignant mesothelioma from the Italian National Institute of Statistics: a comparison on 269 clinical diagnosis confirmed at autopsy (1997-2016)]. / La certificazione Istat di decesso per mesotelioma maligno pleurico: comparazione con 269 diagnosi cliniche confermate all'autopsia (1997-2016).

OBJECTIVES: To evaluate the agreement between pleural malignant mesothelioma diagnosis in life, with diagnoses confirmed at autopsy, and the certification of the cause of death in the form of the Italian National Institute of Statistics (Istat). DESIGN: comparison between autopsic cases and cases from Istat. SETTING AND PARTICIPANTS: two series of autopsy diagnoses of pleural malignant mesothelioma placed from 1997 to 2016; 185 in shipyard workers and 90 in Brescia province inhabitants, for whom the Istat death form was acquired for 180 and 89 subjects, respectively. RESULTS: the general agreement between pleural malignant mesothelioma clinical diagnosis in life and death certification was about 91% for the first group and 92% for the second one. In the first group, the age at diagnosis does not affect the accuracy of the death certification, which instead increased over time to become total in the period 2010-2016. CONCLUSIONS: the study suggests that the agreement between pleural malignant mesothelioma clinical diagnosis and certification of the cause of death appears to be very high.

Where are the landfilled zones? Use of historical geographic information and local spatial knowledge to determine the location of underground asbestos contamination in Sibaté (Colombia).

INTRODUCTION: Sibaté is a municipality located in the central region of Colombia, where the first asbestos-cement facility of the country has been in operation since 1942. Both a malignant pleural mesothelioma cluster and landfilled zones with the presence of an underground friable asbestos layer have been identified in Sibaté. There is still limited knowledge regarding the history of the construction of landfilled zones, and what kinds of materials were deposited. The current study aims to improve our understanding of the history and characteristics of the landfilled zones present in Sibaté. METHODS: Two participatory workshops with inhabitants of Sibaté were conducted to determine when the landfilled zones were built and their location. Information collected in participatory workshops was crossed with both topographic maps and aerial photographs, giving special attention to zones within the urban area of the municipality that in the past were inundated with water from El Muña Reservoir. An opportunistic soil sampling campaign was conducted in suspected landfilled zones that had not been previously sampled, during the replacement of pipelines of the drainage system ordered by the municipality. RESULTS: The analysis of historical topographic maps, combined with the interpretation of aerial photographs, confirmed the disposal of residues in areas that were previously inundated with water from El Muña Reservoir, creating landfilled zones in the urban area of Sibaté. On top of these landfilled zones, a football stadium and a football field with an athletic track were built. The location of landfilled zones identified using geographic analysis was similar to the location identified analyzing maps constructed by inhabitants of Sibaté in participatory workshops. The four soil samples collected during an opportunistic sampling campaign confirmed the presence in new locations of the underground friable asbestos layer discovered in previous studies. DISCUSSION: Based on the extension of the landfilled zones, the presence of friable asbestos in these areas, and the close proximity to a school and residential dwellings, there could have been major dispersion events of asbestos fibers in the urban area of Sibaté during the disposal of residue materials and the construction of the landfilled zones. Thus, important asbestos exposures may have occurred among residents of Sibaté, which is aggravated by the fact that during those years, more than 50% of the population of Sibaté was 25 years old or younger. Although the results of the current study improved our understanding of the processes and chronology associated with the landfilled zones, the uncertainty regarding their exact location remains significant. It is important to continue investigating the adverse health effects resulting from this potential asbestos exposure source.

Residential proximity to an industrial incinerator and risk of soft-tissue sarcoma, 1999-2014.

BACKGROUND: exposure to dioxins has been associated with an increased risk of soft-tissue sarcoma (STS). In a study relating to 1989-1998, a significant excess of STS was found in the population living within a 2-kilometre radius of an industrial incinerator located inside a Mantua industrial site. In the years 1974-1991, the incinerator burned hazardous chlorine-containing waste that resulted in the emission of dioxins. After 1991, it was exclusively fed with organic synthetic products not containing chlorine. OBJECTIVES: the aim of this case-control study was to estimate the STS risk, for 1999-2014, in the population living in four Mantua districts located in the proximity of the industrial incinerator, compared to subjects resident in the remaining parts of Mantua province, regarded as non-exposed. METHODS: the cases analysed were subjects with a first-incident diagnosis of STS between 1999 and 2014 resident at diagnosis in Mantua Province. Cases were selected using the 2013 criteria from the WHO classification. Cases of Kaposi sarcoma, PEComas and STS occurring in a previously irradiated field were excluded. For each case of soft-tissue sarcoma, four controls were randomly selected from all individuals resident in Mantua Province included in the Regional Health Service database in the years of incidence of each case (calendar year), and individually matched for gender and year of birth. Residential and occupational history (for employment in an oil refinery, and petrochemical and chemical plants) was reconstructed for all study subjects (cases and controls) since 1961. Subjects were considered exposed if they had lived in the four Mantua districts most affected by the incinerator emissions, on the basis of an atmospheric dispersion model and a dioxins biomonitoring survey. Four analyses were performed according to variously defined residential time windows. Odds ratios and corresponding 95% confidence intervals (95%CI) were calculated using conditional regression models adjusted for occupational history. RESULTS: 391 cases (203 males and 188 females) and 1,564 controls were included. The number of exposed cases and controls in the four analyses were 8 and 55, 8 and 60, 15 and 68, and 15 and 73, respectively. An increased STS risk was not observed in any of the analyses. CONCLUSIONS: in this study, no increased risk of STS was observed in subjects who had lived, in the study's time window, in the Mantua districts most affected by the incinerator emissions. The most likely interpretation of the present finding is a real STS risk reduction for subjects resident in the most recent decades in the Mantua districts most affected by the incinerator emissions, due to the cessation of burning chlorine-containing waste in the incinerator, development of some remediation plans, and implementation of new industrial procedures.

Occupational cohort study of asbestos-cement workers in a contaminated site in Sicily (Italy).

OBJECTIVES: to analyse the asbestos-related diseases risk among the former workers of Sacelit asbestos-cement plant, operating in San Filippo del Mela (Sicily: 1958- 1993). DESIGN: cohort study. SETTING AND PARTICIPANTS: 228 subjects were employed in Sacelit from 1958 to 1993. Due to the available observation periods, the analyses of the different outcomes were performed for the subjects alive at the beginning of the respective follow up periods: mortality (1986-2018) was analysed for 204 subjects (177 men, 27 women), hospitalization (2001-2016) for 164 workers (139 men, 25 women) and the incidence of mesothelioma (1998-2016) was estimated for 178 subjects (153 men, 25 women). MAIN OUTCOMES MEASURES: mortality (Standardized Mortality Ratio: SMR) and hospitalization (Standardized Hospitalization Ratio: SHR) from specific diseases were analysed. Incidence (Standardized Incidence Ratio: SIR) of mesothelioma cases was detected, also. SMR (1986-2014), SHR (2001-2016) and SIR (1998-2016), with 95% Confidence Intervals, were computed with respect to the regional rates, with STATA11. RESULTS: in the men cohort, mortality from lung (17 cases, SMR 2.83) and pleural cancers (5 cases, SMR 30) and from asbestosis (15 cases, SMR 1,930) was in excess. The risk of hospitalization was in excess, in both genders, from lung cancer (men: 6 cases, SHR 4.1; women: 2 cases, SHR 8.6) and asbestosis (men: 17 cases, SHR 1,304; women: 6 cases, SHR 2,455). The incidence of mesothelioma was in excess in men (5 cases, SIR 23.9); no female cases of mesothelioma were observed. CONCLUSIONS: a high occurrence of asbestos-related diseases in the cohort, particularly among men, was observed. The excess of hospitalization from asbestosis and lung cancer was highlighted also in women. The prosecution of the on-going health surveillance plan is particularly appropriated.

[Effects of Asbestos on Human Health. Document of the Italian Epidemiological Association (AIE)]. / Effetti dell'amianto sulla salute. Documento dell'Associazione Italiana di Epiemiologia (AIE).

OBJECTIVES: the Italian Epidemiological Association (AIE) intends to formulate assessments and recommendations on the most relevant and critical aspects in the preparation, conduct, and interpretation of epidemiological investigations on the health effects of exposure to asbestos and asbestos-like fibres. DESIGN, SETTING, AND PARTICIPANTS: the document was prepared by a working group of AIE associates, with a broad curriculum of epidemiological investigations, starting from the evaluation of scientific evidence, and was subsequently evaluated by the AIE governing body. RESULTS: the topics covered included: • consumption and presence of asbestos; • association between asbestos exposure and disease; • epidemiological surveillance of asbestos related diseases in Italy; • risk function for asbestos related diseases; • increased risk and anticipation of the disease; • interaction between asbestos and other carcinogens; • diagnosis in epidemiological studies; • assessment of exposure to asbestos; • epidemiological evidence on asbestos related diseases. CONCLUSIONS: the document ends with a summary of the conclusions of scientific research shared by AIE, with reflection on the methodology to be followed for the application at individual level of the results of epidemiological studies, and the proposal of themes on which to direct research.

An asbestos contaminated town in the vicinity of an asbestos-cement facility: The case study of Sibaté, Colombia.

INTRODUCTION: The asbestos industry began operations in Colombia in 1942, with an asbestos-cement facility located in the municipality of Sibaté. In recent years residents from Sibaté have been complaining about what they consider is an unusually large number of people diagnosed with asbestos-related diseases in the town. A study to analyze the situation of Sibaté started in 2015, to verify if the number of asbestos related diseases being diagnosed were higher than expected, and to identify potential asbestos exposure sources in the town. METHODS: A health and socioeconomic survey was implemented door-to-door to identify potential asbestos-related diseases. Several self-reported mesothelioma cases were identified, and for confirmation purposes, copies of the medical record with the histopathology report were obtained. A panel of six physicians analyzed the medical records. Information of validated cases was used to estimate the male and female age-adjusted incidence rate for Sibaté. Based on reports of the existence of potential asbestos-contaminated landfills, topographic maps, a digital elevation model, and current satellite images were crossed using a geographic information system to identify potential landfilled areas, and soils samples were collected in some of these areas. RESULTS: A total of 355 surveys were completed, and 29 self-reported mesothelioma cases were identified. Twenty-five of these cases have been persons who had lived at some moment of their lives in Sibaté. It was possible to obtain copies of the medical diagnosis for 17 cases. Of these, the panel of physicians classified 15 cases as certain pleural mesothelioma, one as probable, and one as not mesothelioma. Based on this information, the estimated age-adjusted incidence rate of mesothelioma in Sibaté was 3.1 × 105 persons-year for males and 1.6 × 105 persons-year for females. These rates are high in comparison to those reported in other cities, regions, and countries of the world. Using geographic information systems, landfilled zones in the urban area of Sibaté were identified, on top of which a school and different sports facilities were built. The analysis of four soil samples collected in landfilled zones, confirmed the existence of an underground layer of friable and non-friable asbestos. CONCLUSION: The collected evidence suggests the presence of a malignant pleural mesothelioma cluster in Sibaté.

Mortality from liver angiosarcoma, hepatocellular carcinoma, and cirrhosis among vinyl chloride workers.

BACKGROUND: Occupational exposure to vinyl chloride monomer (VCM) has been established as a cause of hepatocellular carcinoma (HCC) and liver angiosarcoma (ASL). However, some controversy remains due to conflicting results on liver cirrhosis, and to evidence on HCC based on few confirmed cases. The aim of the study is to clarify the association between VCM exposure and mortality from liver diseases. METHODS: In a cohort of 1658 workers involved in VCM production and polymerization, Poisson regression was adopted to estimate rate ratios (RR) across categories of VCM exposure for mortality due to ASL (n = 9), HCC (n = 31) confirmed by histological/clinical records, and the combination of deaths from liver cirrhosis and from liver cancer with clinical/histological evidence of cirrhosis (n = 63). RESULTS: Cumulative VCM exposure was associated with study outcomes; RRs in the highest compared to the lowest exposure category were: ASL 91.1 (95%Confidence Interval 16.8-497), HCC 5.52 (2.03-15.0), liver cirrhosis 2.60 (1.19-5.67). CONCLUSIONS: The risk of death from liver cirrhosis, as well as from HCC in the largest available series of confirmed cases, increased with VCM exposure.

Long-term effect of arsenic exposure: Results from an occupational cohort study.

BACKGROUND: In 1976 in Manfredonia (Italy), arsenic was released into the atmosphere due to an accident in a petrochemical plant. We aimed to analyze the mortality of workers involved in the factory for the site cleaning activities. METHODS: The cohort consisted of 1467 workers grouped into contract, fertilizer, and plastic workers. The outcome of interest was mortality for specific causes. Standardized mortality ratios (SMR) and 95% confidence intervals (95%CI) were computed. RESULTS: For all workers and all causes of death combined, the SMR was less than 1.0. Mortality ratios were increased for malignant neoplasms of the pleura, bone and melanoma of the skin. Contract workers, the group mostly exposed to arsenic, showed statistically significant SMRs for several malignancies, in particular for lung cancer (SMR = 1.26; 95%CI: 1.05-1.54). CONCLUSIONS: Overall, the results reported here on mortality among persons occupationally exposed to arsenic are consistent with the literature and biologically plausible.

[SENTIERI: Epidemiological Study of Residents in National Priority Contaminated Sites. Fifth Report]. / SENTIERI: Studio epidemiologico nazionale dei territori e degli insediamenti esposti a rischio da inquinamento. Quinto Rapporto.

INTRODUCTION AND OBJECTIVES: This volume provides an update of the health status of the populations living in the National Priority Contaminated Sites (NPCSs) included in the SENTIERI Project. This update is part of an epidemiological surveillance programme carried out in NPCSs, promoted by the Italian Ministry of Health as a further step of a project started in 2006, when the health status of residents in contaminated sites was first addressed within the National Strategic Program "Environment and Health". The Report focuses on five health outcomes: mortality, cancer incidence, hospital discharges, congenital anomalies, and children, adolescents and young adults' health. A key element of SENTIERI project is the a priori evaluation of the epidemiological evidence of a causal association between the considered cause of disease and the exposure. When an a priori evidence is identified, it is given a greater importance in the comment of the study findings. METHODS: The present update of the SENTIERI Project concerns 45 NPCSs including in all 319 Italian Municipalities (out of over 8,000 Municipalities), with an overall population of 5,900,000 inhabitants at the 2011 Italian Census. Standardized Mortality Ratios (SMRs) and Standardized Hospitalization Ratios (SHRs), referring to a time window of 2006-2013, were computed for all the 45 NPCSs, using as a reference the corresponding mortality and hospitalization rates of the Regions where each NCPS is located. Standardized Incidence Ratios (SIRs) were computed by the Italian Association of Cancer Registries (AIRTUM) for the 22 NPCSs served by a Cancer Registry. AIRTUM covers about 56% of Italy, with partly different time-windows. SIRs have been estimated using as reference population the 4 macroareas in which Italy is divided (North-West, North-East, Centre, South). Prevalence of congenital anomalies was computed for 15 NPCSs. RESULTS: An all-cause excess of 5,267 and 6,725 deaths was observed, respectively, in men and women; the cancer death excess was of 3,375 in men and 1,910 in women. It was estimated an excess of cancer incidence of 1,220 case in men and 1,425 in women over a five-year time window. With regard to the diseases with an a priori environmental aetiological validity, an excess for malignant mesothelioma, lung, colon, and gastric cancer, and for non-malignant respiratory diseases was observed. Cancer excess mainly affected NPCSs with presence of chemical and petrochemical plants, oil refineries, and dumping hazardous wastes. An excess of non-malignant respiratory disease was also detected in NPCSs in which steel industries and thermoelectric plants were present. An excess of mesothelioma was observed in NPCSs characterized by presence of asbestos and fluoro-edenite; it was also observed where the presence of asbestos was not reported in the legislative national decrees which define the NPCS areas. It is worth noting that, even if the presence of asbestos is not reported in many NPCSs legislative decrees, petrochemical plants and steel industries, for instance, are often characterized by the presence of a large amount of this mineral that, in the past, was extensively used as an insulating material. For the first time, the present Report includes a focus on the health status of children and adolescents (1,160,000 subjects, aged 0-19 years), and young adults (660,000 subjects, aged 20-29 years). Among infants (0-1 year), an excess of 7,000 hospitalizations was observed, 2,000 of which due to conditions of perinatal origin. In the age class 0-14, an excess of 22,000 hospitalizations for all causes was observed; 4,000 of them were due to acute respiratory diseases, and 2,000 to asthma. Data on cancer incidence for subjects aged 0-24 years were derived from general population cancer registries for twenty NPCSs, and from children cancer registries (age group: 0-19 years) for six NPCSs; 666 cases where diagnosed in the age group 0-24 years, corresponding to an excess of 9%. The main contributions to this excess are from soft tissue sarcomas in children (aged 0-14 years), acute myeloid leukaemia in children (aged 0-14 years) and in the age group 0-29 years, non-Hodgkin lymphoma and testicular cancer in young adults (aged 20-29 years). In seven out of 15 NPCSs, an excess prevalence rate of overall congenital anomalies at birth was observed. Congenital anomalies excesses included the following sites: genital organs, heart, limbs, nervous system, digestive system, and urinary system. CONCLUSIONS: The main findings of SENTIERI Project have been the detection of excesses for the diseases which showed an a priori epidemiological evidence of a causal association with the environmental exposures specific for each considered NPCS. These observations are valuable within public health, because they contribute to priority health promotion activities. Looking ahead, the health benefits of an improved environmental quality might be appreciated in terms of reduction of the occurrence of adverse health effects attributable to each Site major pollutant agents. Due to the methodological approach of the present study, it was not possible to adjust for several confounding factors reported to be risk factors for the studied diseases (e.g., smoking, alcohol consumption, obesity). Even if excesses of mortality, hospitalization, cancer incidence, and prevalence of congenital anomalies were found in several NPCSs, the study design and the multifactorial aetiology of the considered diseases do not permit, for all of them, to draw conclusions in terms of causal links with environmental contamination. Moreover, it must be taken into consideration that economic factors and the availability of health services may also play a relevant role in a diseases outcome. A few observations regarding some methodological limitations of SENTIERI Project should be made. There is not a uniform environmental characterisation of the studied NPCSs in term of quality and detection of the pollutants, because this information is present in different databases which at present are not adequately connected. Moreover, the recognition of a contaminated site as a National Priority Site is based on soil and groundwater pollution, and the available information on air quality is currently sparse and not homogenous. Another limitation, in term of statistical power, is the small population size of many NPCSs and the low frequency of several health outcomes. A special caution must be paid in data interpretation when considering the correspondence between the contaminated areas and the municipality boundaries, as they do not always coincide perfectly: in some cases, a small municipality with a large industrial site, while in other settings only a part of the municipality is exposed to the sources of pollution. Furthermore, all available health information systems are currently accessible at municipality level. The real breakthrough is essentially comprised of the development and fostering of a networking system involving all local health authorities and regional environmental protection agencies operating in the areas under study. The possibility to integrate the geographic approach of SENTIERI Project with a set of ad hoc analytic epidemiological investigations, such as residential cohort studies, case control studies, children health surveys, biomonitoring surveys, and with socioepidemiological studies, might greatly contribute to the identification of health priorities for environmental remediation activities. Finally, as discussed in the last section of the report, there is a need to adopt, in each NPCS, a two-way oriented communication plan involving public health authorities, scientific community, and resident population, taking into account that the history, the cultural frame and the network of relationships specific of each local context play a major role in the risk perception perspective.

Pre-diagnostic blood immune markers, incidence and progression of B-cell lymphoma and multiple myeloma: Univariate and functionally informed multivariate analyses.

Recent prospective studies have shown that dysregulation of the immune system may precede the development of B-cell lymphomas (BCL) in immunocompetent individuals. However, to date, the studies were restricted to a few immune markers, which were considered separately. Using a nested case-control study within two European prospective cohorts, we measured plasma levels of 28 immune markers in samples collected a median of 6 years before diagnosis (range 2.01-15.97) in 268 incident cases of BCL (including multiple myeloma [MM]) and matched controls. Linear mixed models and partial least square analyses were used to analyze the association between levels of immune marker and the incidence of BCL and its main histological subtypes and to investigate potential biomarkers predictive of the time to diagnosis. Linear mixed model analyses identified associations linking lower levels of fibroblast growth factor-2 (FGF-2 p = 7.2 × 10-4 ) and transforming growth factor alpha (TGF-α, p = 6.5 × 10-5 ) and BCL incidence. Analyses stratified by histological subtypes identified inverse associations for MM subtype including FGF-2 (p = 7.8 × 10-7 ), TGF-α (p = 4.08 × 10-5 ), fractalkine (p = 1.12 × 10-3 ), monocyte chemotactic protein-3 (p = 1.36 × 10-4 ), macrophage inflammatory protein 1-alpha (p = 4.6 × 10-4 ) and vascular endothelial growth factor (p = 4.23 × 10-5 ). Our results also provided marginal support for already reported associations between chemokines and diffuse large BCL (DLBCL) and cytokines and chronic lymphocytic leukemia (CLL). Case-only analyses showed that Granulocyte-macrophage colony stimulating factor levels were consistently higher closer to diagnosis, which provides further evidence of its role in tumor progression. In conclusion, our study suggests a role of growth-factors in the incidence of MM and of chemokine and cytokine regulation in DLBCL and CLL.

[Health impact of asbestos fibres naturally occurring in Mount Pollino area (Basilicata Region, Southern Italy)]. / Impatto sulla salute delle fibre di amianto presenti in affioramenti naturali nell'area del Pollino (Basilicata).

OBJECTIVES: to estimate the health impact of asbestos fibres naturally occurring in Mount Pollino area (Basilicata Region, Southern Italy). DESIGN: geographic mortality, hospitalization, and incidence study. Setting and participant s: population resident in 12 Municipalities of Mount Pollino area with naturally occurring asbestos fibres. MAIN OUTCOME MEASURES: standardized mortality ratio (SMR) and standardized hospitalization rate (SHR) for asbestos-related diseases; standardized incidence ratio (SIR) for mesotheliomas. Result s: in the area of Mount Pollino, where asbestos fibres naturally occur, especially in the sub-area in which fibres are close to dwellings and settlements, it was observed: • a significant excess of mesothelioma incidence (SIR: 208; CI95% 111-355; 13 observed); • a non-significant excess of hospitalization for malignant pleural neoplasms (SHR: 176; CI95% 93-335; 9 observed); • a significant excess for mortality and hospitalization for pneumoconiosis (SMR: 534; CI95% 345-824; 20 observed - SHR: 245; CI95% 149-405; 15 observed); • a significant excess for hospitalization (SHR: 852; CI95% 290-2,506; 3 observed) for asbestosis. CONCLUSION: it is necessary to continue environmental monitoring and environmental remediation in the area with higher asbestos exposure. It is suggested to implement a permanent process of epidemiological surveillance in this same area. A communication plan with local administrators, general practitioners, school teachers, media, and the resident population at large should be realized.

Spatial distribution of kidney disease in the contaminated site of Taranto (Italy).

BACKGROUND: Exposure to heavy metals has been associated with kidney disease. We investigated the spatial distribution of kidney disease in the industrially contaminated site of Taranto. METHODS: Cases were subjects with a first hospital discharge diagnosis of kidney disease. Cases affected by specific comorbidities were excluded. Standardized Hospitalization Ratios (SHRs) were computed for low/high exposure area and for modeled spatial distribution of cadmium and fine particulate matter. RESULT: Using the high/low exposure approach, in subjects aged 20-59 years residing in the high exposure area a significant excess of hospitalization was observed in males and a non-significant excess in females. No excesses were observed in subjects aged 60 years and over. The analysis by the modeling approach did not show a significant association with the greatest pollution impact area. CONCLUSION: Due to the excesses of hospitalization observed in the high/low exposure approach, a continuing epidemiological surveillance of residents and occupational groups is warranted.

[Environmental justice in the epidemiological surveillance system of residents in Italian National Priority Contaminated Sites (SENTIERI Project)]. / Environmental justice nel sistema di sorveglianza epidemiologica SENTIER.

OBJECTIVES: descriptive evaluation of distributional justice in the epidemiological surveillance system of populations residing in Italian National priority Contaminated Sites (NPCSs) of SENTIERI project. Analysis of the feasibility of monitoring different Environmental Justice dimensions in SENTIERI. DESIGN: descriptive study and ecological meta-analysis. SETTING AN PARTICIPANTS: residents in 298 municipalities included in 44 NPCSs in SENTIERI. Description of their level of deprivation and mortality analysis by deprivation level in the first period evaluated in SENTIERI, years 1995-2002. MAIN OUTCOME MEASURES: an index of multiple deprivation at municipality level DI-SENTIERI, built using 4 indicators based on variables from the Italian 2001 Census, was used to describe deprivation in communities living in NPCSs. The risk of mortality for all causes and all tumors in the pool of NPCSs municipalities by deprivation level was assessed using meta-Standardized Mortality Ratios (meta-SMRs). RESULTS: sixty percent of municipalities (No. 179) in NPCSs belong to the two more deprived quintiles. The socioeconomic disadvantage of communities resident in NPCS has a North-South gradient: the proportion of municipalities belonging to the two more deprived quintiles is 29% in the North, 68% in the Centre, 92% in the South. Meta-SMRs for all causes in less deprived municipalities were 98 (90%CI 95-100) in men e 101 (90%CI 97-104) in women, the values for all cancers were 99 (90%CI 94-103) in men and 100 (90%CI 95-105) in women. The corresponding estimates in more deprived municipalities were, respectively in men and women, 103 (90%CI 101- 104) and 102 (90%CI 100-104) for all causes, 104 (90%CI 102-106) and 102 (90%CI 100-104) for all cancers. CONCLUSIONS: residents in NPCSs are exposed to environmental stressors and are generally more deprived. The socioeconomic disadvantage is mostly affecting Central and Southern Italy populations. Furthermore, in these deprived communities the risk of mortality for all diseases and all cancers is higher. Populations living in NPCSs are affected by distributional injustice. To monitor the different dimensions of Environmental Justice, the DI-SENTIERI should be developed and other socioeconomic indicators implemented.

[Mortality study update of workers exposed to vinyl chloride in plants located in Ferrara and Ravenna (Emilia-Romagna Region, Northern Italy)]. / Aggiornamento dello studio di mortalità nelle coorti di lavoratori ex esposti a cloruro di vinile monomero a Ferrara e Ravenna.

OBJECTIVES: to update the mortality study of subjects exposed to vinyl chloride in the phases of synthesis of the monomer and polymerization in the plants of Ferrara and Ravenna (Emilia-Romagna Region, Northern Italy). DESIGN: both for the whole cohort and for the two plants, standardized mortality ratios (SMRs), with 95% confidence intervals (95%CI), were calculated for different death causes, then stratified by duration and latency, periods of the beginning of work and cumulative exposure (ppm-years). SETTING AND PARTICIPANTS: the cohort includes 1,540 subjects (469 in Ferrara hired from 1953 to 1999; 1,071 in Ravenna hired from 1959 to 2000), with at least six months of work. RESULTS: by the end of the follow-up (31.12.2013), 348 deaths occurred. Overall observed mortality, contrasted to that expected based on Emilia-Romagna Region mortality rates, appeared to be lower than expected in the whole cohort (348 cases, SMR: 0.85; 95%CI 0.77-0.95) and in Ravenna (173 cases, SMR: 0.71; 95%CI 0.61-0.83). Mortality for all neoplasms was in excess in Ferrara (79 cases, SMR: 1.27; 95%CI 1.02-1.58), but lower than expected in Ravenna (83 cases, SMR: 0.80; 95%CI 0.64-0.99). An excess in mortality was observed in the whole cohort (16 cases, SMR: 1.74; 95%CI 1.07-2.85) and in Ferrara for liver cancer (7 cases, SMR: 2.12; 95%CI 1.02-4.46), and only in Ferrara for respiratory tract cancer (30 cases, SMR: 1.45; 95%CI 1.02-2.07) and larynx cancer (4 cases, SMR: 3.35; 95%CI 1.26-8.92). In the whole cohort, SMR for liver cancer was in excess since a cumulative exposure of 5,000 ppm-year and 12 cases belong to the job title of autoclave workers (12 cases, SMR 4.6; 95%CI 2.6-8.0), duration of work higher than 20 years (8 cases, SMR 2.4; 95%CI 1.2-4.9), and latency higher than 40 years (7 cases, SMR 2.5; 95%CI 1.2-5.2). The excess in mortality for lung cancer is statistically significant for and with cumulative exposure higher than 7,330 ppm-years (6 cases, SMR 3.2 95%CI 1.4-7.0). There are not excesses among subjects hired after 1971. CONCLUSIONS: the study findings confirm and expand the ones of previous studies. It was not possible to apply a best evidence approach to the study of liver cancer, and consequently it is not possible to distinguish between hepatic angiosarcoma and hepatocellular carcinoma. The evidence of a causal link between vinyl chloride exposure and liver cancer is anyhow confirmed. The causal link between vinyl chloride exposure and lung cancer must be further investigated.

[SENTIERI-ReNaM: Rationale and objectives]. / SENTIERI-ReNaM: Razionale e obiettivi.

The purpose of the SENTIERI-ReNaM Project is to analyse the incidence of mesothelioma in Italian National Priority Contaminated Sites (NPCSs) in order to estimate the health impact of asbestos on resident populations, disentangling the role of occupational and environmental exposures. SENTIERI Project has provided the relevant information on geographic and demographic structure of NPCSs and on existing sources of contamination. The Italian National Mesothelioma Registry (ReNaM), that covers the whole country through its Regional Operational Centres (CORs), has made available the procedures for estimating the incidence of mesothelioma in NPCSs and for assessing occupational and environmental asbestos exposure of the individual cases. The synergy between these two epidemiological surveillance systems lay also the ground for communication programmes with the affected communities.

[SENTIERI-ReNaM: Materials and methods]. / SENTIERI-ReNaM: Materiali e metodi.

In the framework of SENTIERI Project, this study is aimed to identify excess risks of malignant mesothelioma (MM) in Italian National Priority Contaminated Sites (NPCSs) included in the national environmental remediation programme and to discuss the results by means of data available from the Italian National Mesothelioma Registry (ReNaM). Re- NaM has a regional structure with Regional Operational Centres (CORs) in charge of identifying mesothelioma incident cases and defining the asbestos exposure modalities thought an individual questionnaire. Starting from the 44 NPCSs selected in SENTIERI Project, we excluded Calabria and Sardinia Regions from the analyses (3 NPCSs). Furthermore, for 2 sites (Emarese in Valle d'Aosta and Tito in Basilicata) no incident MM cases have been detected in the considered period. Incident cases of MM and Standardized Incidence Ratios (SIR), with corresponding 90% confidence intervals, have been estimated in each NPCS, for both gender, in the period 2000-2011. Age-standardized rates of Italian geographical macro-areas (North- East, North-West, Centre, South and Islands) have been used to estimate expected cases. For every analyzed site, the occupational and non-occupational asbestos exposure modalities are discussed.

[SENTIERI-ReNaM: Integration of incidence, mortality, and hospitalization: general remarks and a focus on mesothelioma]. / SENTIERI-ReNaM: Integrazione di incidenza, mortalità e ospedalizzazione: considerazioni generali e applicazione al mesotelioma.

The integration of current data sources is now a practice widely used in epidemiology, especially in the environmental field. To better describe the health profile of populations residing in proximity to areas characterized by a "strong environmental pressure", the combined use of multiple indicators (i.e., mortality, hospitalization, cancer incidence) is recommended. To choose an indicator is complex, as indicators should be contextualized and they need to be related to the several issues involved in the studied pathology. This chapter explores the general considerations that are to be addressed both at the time of the study design, during the selection of outcomes and of the proper data sources, and at the time of the discussion of the results, when different and complementary data are compared. A special focus is devoted to the case of mesothelioma.

[SENTIERI-ReNaM: Burden of disease from mesothelioma in national priority contaminated sites in Italy]. / SENTIERI-ReNaM: Valutazione globale del carico di mesotelioma.

BACKGROUND: in Italy, National Priority Contaminated Sites (NPCSs) are defined as of concern for remediation; most of them are sites with a long-lasting industrial activity. OBJECTIVE: the study aims to estimate the burden of disease from mesothelioma in NPCSs. DESIGN: mesothelioma incidence in the period 2000-2011 was estimated for the populations residing in the 39 Italian NPCSs. Data were taken from the Italian National Mesothelioma Registry (ReNaM). NPCSs were ranked into risk groups (RGs) on the basis of the presence of the following asbestos-exposing activities: 1. asbestos-cement plants; 2. asbestos mines; 3. harbours with shipyards; 4. illegal dumping sites containing asbestos; 5. petrochemicals and/or refineries, and/or steel plants; 6. chemical plants and/or landfills without explicit mention of asbestos. For the population residing in each NPCS, crude rates per 100,000 per year and number of observed minus expected cases (Obs-Exp) by gender were computed. Expected cases were calculated using the age-class rates of a reference population (the geographical macroarea of every NPCS). For every RG, the meta-analytic estimate of the attributable proportion (AP), i.e., the proportion of cases attributable to the local context, was computed, being the AP for each NPCS expressed as (Obs-Exp/Obs) x100. RESULTS: the total number of mesothelioma cases estimated in the considered period of 12 years is 2,741 (2,048 males, 693 females). The total number of Obs-Exp cases was 1,531 (1,178 in males, 353 in females). In males, crude rate ranges from 71.5 in the RG1 to 3.0 in RG4, while in females it ranges from 48.4 in RG1 to 0.6 in RG4. In males, AP in RGs from 1 to 3 is over 65%, in RG4 is 59%, in RG5 is 30%, in RG6 is -14%. AP in females gradually drops from 95% in RG1 to -64% in RG6. CONCLUSIONS: the burden of mesothelioma in populations residing in NPCSs is high, with an AP gradient consistent with the a priori RG. This burden impacts on females in a different way: rates are lower than male ones; AP is similar to male ones in the RGs 1 and 3.

[SENTIERI-ReNaM: Results]. / SENTIERI-ReNaM: Risultati.

Mesothelioma incidence has been analyzed in National Priority Contaminated Sites (NPCSs) to estimate the health impact of asbestos exposure on resident people. The burden of professional and environmental exposures has been identified through data of the Regional Operational Centres (CORs), made available by the Italian National Mesothelioma Registry (ReNaM). An excess of mesothelioma incidence is confirmed in sites with a known past history of direct use of asbestos, such as Balangero, Casale Monferrato, Broni, Bari-Fibronit, and in coastal areas, where shipyards, harbours and other industries that involved a wide use of asbestos are represented (e.g., Trieste, La Spezia, Venice, and Leghorn). An excess of mesothelioma has been observed in settings where the asbestos is not mentioned as contaminant in the decree that included these sites among NPCSs, such as Cengio and Saliceto in Northern Italy; Falconara Marittima and the Bacino Idrografico Fiume Sacco in the Central Italy; the Litorale Domizio Flegreo and Agro Aversano, Milazzo, and Gela in the Southern Italy. Observed excess in the various NPCSs confirms the large-scale occurrence in contaminated Italian sites of a significant amount of total mesothelioma cases observed at national level. The analysis of occupational risk in epidemiological studies with an ecological design helps in defining the contribution of different factors to the overall risk.