[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.

Cardiorespiratory diseases in an industrialized area: a retrospective population-based cohort study.

BACKGROUND: Atmospheric pollution has been recognized as the greatest environmental threat to human health. The population of the Venafro Valley, southern Italy, is exposed to emissions from a Waste-To-Energy (WTE) and a cement plant and potentially also to another WTE located in the neighboring region of Lazio; also, the vehicular atmospheric pollution situation is critical. In order to assess the environmental health risk of residents in eight municipalities of the Venafro Valley, a retrospective residential cohort study during 2006-2019 was carried out. METHODS: Four exposure classes were defined by natural-break method, using a dispersion map of nitrogen dioxides (chosen as proxy of industrial pollution). The association between the industrial pollution and cause-specific mortality/morbidity of the cohort was calculated using the Hazard Ratio (HR) through a multiple time-dependent and sex-specific Cox regression adjusting for age, proximity to main roads and socio-economic deprivation index. RESULTS: Results showed, for both sexes, mortality and morbidity excesses in the most exposed class for diseases of the circulatory system and some signals for respiratory diseases. Particularly, mortality excesses in both sexes in class 3 for diseases of the circulatory system [men: HR = 1.37 (1.04-1.79); women: HR = 1.27 (1.01-1.60)] and for cerebrovascular diseases [men: HR = 2.50 (1.44-4.35); women: HR = 1.41 (0.92-2.17)] were observed and confirmed by morbidity analyses. Mortality excesses for heart diseases for both sexes [men-class 3: HR = 1.32 (0.93-1.87); men-class 4: HR = 1.95 (0.99-3.85); women-class 3: HR = 1.49 (1.10-2.04)] and for acute respiratory diseases among women [HR = 2.31 (0.67-8.00)] were observed. Morbidity excesses in both sexes for ischemic heart diseases [men-class 3: HR = 1.24 (0.96-1.61); women-class 4: HR = 2.04 (1.04-4.02)] and in class 4 only among men for respiratory diseases [HR = 1.43 (0.88-2.31)] were also found. CONCLUSIONS: The present study provides several not-negligible signals indicating mitigation actions and deserve further investigations. For future studies, the authors recommend enriching the exposure and lifestyle profile using tools such as questionnaires and human biomonitoring.

[Participation and facilitation in environment and health contexts. The case study of San Donaci (Apu-lia Region, Southern Italy)]. / Partecipazione e facilitazione nei contesti ambientali e sanitari. L'esperienza di San Donaci (Brindisi).

On behalf of the municipal administration of San Donaci (Brindisi Province, Apulia Region, Southern Italy), the Italian National Research Council counducted a participatory epidemiology experience. The activity of participation and discussion between the research group, the public administration, and citizens involved an association with expertise in facilitation. The participation methodology, adapted to the context, was articulated in focus groups and circle time. In addition to expanding the environmental and health analyses by enriching the final report, facilitation supported the expression of the different points of view, restoring greater complexity to the discussion by rebuilding a partial climate of trust among the participants.

Environmental assessment of interventions to restrain the impact of industrial pollution using a quasi-experimental design: limitations of the interventions and recommendations for public health policy.

BACKGROUND: In an industrial area, the asymmetry between the weights of the economic interests compared to the public-health needs can determine which interests are represented in decision-making processes. This might lead to partial interventions, whose impacts are not always evaluated. This study focuses on two interventions implemented in Taranto, Italy, a city hosting one of the largest steel plants in Europe. The first intervention deals with measures industrial plants must implement by law to reduce emissions during so called "wind days" in order to reduce PM10 and benzo [a] pyrene concentrations. The second one is a warning to the population with recommendations to aerate indoor spaces from 12 pm to 6 pm, when pollutant concentrations are believed to be lower. METHODS: To analyse the impact of the first intervention, we analysed monthly PM10 data in the period 2009-2016 from two monitoring stations and conducted an interrupted-time-series analysis. Coefficients of time-based covariates are estimated in the regression model. To minimise potential confounding, monthly concentrations of PM10 in a neighbourhood 13 km away from the steel plant were used as a control series. To evaluate the second intervention, hourly concentrations of PM10, SO2 and polycyclic-aromatic-hydrocarbons (PAHs) were analysed. RESULTS: PM10 concentrations in the intervention neighbourhood showed a peak just a few months before the introduction of the law. When compared to the control series, PM10 concentrations were constantly higher throughout the entire study period. After the intervention, there was a reduction in the difference between the two time-series (- 25.6%). During "wind days" results suggested no reduction in concentrations of air pollutants from 12 pm to 18 pm. CONCLUSION: Results of our study suggest revising the warning to the population. Furthermore, they evidence that in complex highly industrialised areas, air quality interventions cannot focus on only a single pollutant, but rather should consider the complex relationships between the different contaminants. Environmental interventions should be reviewed periodically, particularly when they have implications for social constraints. While the results of our study can be related only to the specific situation reported in the article, the methodology applied might be useful for the environmental management in industrial areas with similar features.

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.

[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.

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

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

[Residential cohort study on mortality and hospitalization in Viggiano and Grumento Nova Municipalities in the framework of HIA in Val d'Agri (Basilicata Region, Southern Italy)]. / Studio di coorte residenziale su mortalità e ricoveri nei Comuni di Viggiano e Grumento Nova nell'ambito della VIS in Val d'Agri (Basilicata).

OBJECTIVES: to evaluate the associations among the emissions produced by "Centro olio Val d'Agri" (COVA), with mortality and hospitalization of residents in the Viggiano and Grumento Nova Municipalities, located in Val d'Agri (Basilicata Region, Southern Italy). DESIGN: residential cohort study. SETTINGS AND PARTICIPANTS: Lagrangians dispersion models to estimate the level of exposure at the address of residence to NOX concentrations as tracers of COVA emissions. Based on the tertile of NOX distribution, individual exposure was classified and a Cox model analysis was performed (hazard ratio, HR, trend with relative 95%CI). The association among exposure to NOX and the cohort mortality/hospitalization was evaluated considering age, socioeconomic status, and distance from the high traffic density road. The cohort included 6,795 residents (73,270 person-years) in the period 2000-2014. MAIN OUTCOME MEASURES: causes of mortality and hospitalization due to cardio-respiratory diseases, recognised as associated to air pollution, with medium-short latency induction period, consistent with the period of operation at the COVA. RESULTS: increasing trends were observed on three exposure classes for mortality due to circulatory system diseases (HR trend: 1.19; 95%CI 1.02-1.39), stronger considering women (HR trend: 1.19; 95%CI 1.02-1.39). From hospitalizations results, an increased risk emerges for respiratory diseases (HR trend: 1.12; 95%CI 1.01-1.25) and, for women, for diseases of the circulatory system (HR trend: 1.19; 95%CI 1.03-1.38), for ischemic diseases (HR trend: 1.33; 95%CI 1.02-1.74) and respiratory diseases (HR trend: 1.22; 95%CI 1.03-1.46). CONCLUSIONS: the excesses of mortality and hospitalization emerged in areas most exposed to pollutants of industrial origin are relevant for preventive actions. It is recommended to define and implement a surveillance system for the entire resident population based on indicators of environmental pollution and related health outcomes on the basis of the scientific literature and the results achieved by the present study.

[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.

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.

Spatial variability of air pollutants in the city of Taranto, Italy and its potential impact on exposure assessment.

Epidemiological studies typically use monitored air pollution data from a single station or as averaged data from several stations to estimate population exposure. In industrialized urban areas, this approach may present critical issues due to the spatial complexities of air pollutants which are emitted by different sources. This study focused on the city of Taranto, which is one of the most highly industrialized cities in southern Italy. Epidemiological studies have revealed several critical situations in this area, in terms of mortality excess and short-term health effects of air pollution. The aims of this paper are to study the variability of air pollutants in the city of Taranto and to interpret the results in relation to the applicability of the data in assessing population exposure. Meteorological and pollution data (SO2, NO2, PM10), measured simultaneously and continuously during the period 2006-2010 in five air quality stations, were analyzed. Relative and absolute spatial concentration variations were investigated by means of statistical indexes. Results show significant differences among stations. The highest correlation between stations was observed for PM10 concentrations, while critical values were found for NO2. The worst values were observed for the SO2 series. The high values of 90th percentile of differences between pairs of monitoring sites for the three pollutants index suggest that mean concentrations differ by large amounts from site to site. The overall analysis supports the hypothesis that various parts of the city are differently affected by the different emission sources, depending on meteorological conditions. In particular, analysis revealed that the influence of the industrial site may be primarily identified with the series of SO2 data which exhibit higher mean concentration values and positive correlations with wind intensity when the monitoring station is downwind from the industrial site. Results suggest evaluating the population exposure to air pollutants in industrialized cities by taking into account the possible zones of influence of different emission sources. More research is needed to identify an indicator, which ought to be a synthesis of several pollutants, and take into account the meteorological variables.

Sixteen-year air quality data analysis of a high environmental risk area in Southern Italy.

The Brindisi area is characterized by the presence of industries with high environmental impact, located along its eastern border. Epidemiological studies have revealed several critical situations: two short-term (2003-2005) epidemiological studies have shown that PM(10) and NO(2) are adversely associated with daily hospital admissions: one of the two pointed to the associations with wind blowing from the southern, eastern and western sectors. This study aims to expand the time span of available air quality data in order to provide a more complete and extensive epidemiological study. Multi-year series (from 1992 to 2007) of SO(2), NO(2), and TSP concentration data are presented and analyzed. Data show a significant downward trend of SO(2) from 1992 to 2007, while for the TSP series, the downward trend is limited to the period 1992-1994. Marked seasonal trends are evident for all three pollutants, especially for NO(2) and TSP. The NO(2) series shows higher levels in winter. Inversely, the TSP series shows its maximum values during the summer months, associated with a moderate correlation with temperature and a poor correlation with other pollutants. Analysis of the series for wind sectors revealed the influence of the industrial site and of the harbor. The concentration series exhibit high concentration values and stronger correlations between them and with meteorology for wind blowing from the eastern sectors. Overall analysis supports the hypothesis of a different origin for TSP during the year and for different wind regimes and therefore possible size and chemical differences in TSP, which should be further investigated due to their health implications.

[Acute effects of air pollution in Brindisi (Italy): a case-crossover analysis]. / Effetti acuti dell'inquinamento a Brindisi: analisi case-crossover.

OBJECTIVE: To evaluate the association between daily air pollutant concentration and daily data regarding mortality and hospital admissions among residents of Brindisi (Southern Italy) in the years 2003-2006. DESIGN: The association between the time series of daily mortality (2003-2005) and hospital admissions (2003-2006) and the time series of daily pollutant concentration were analyzed using a case-crossover method and a conditional logistic regression. Bi-directional control periods were selected using a time-stratified approach. Models include mean temperature, relative humidity, influence of epidemics, summer decrease of resident population and holidays as confounders. Specific models with the following variables: cause of death or hospital admission, gender, age and season have been fitted. As hazard periods the following lags have been considered: single lag (from 0 to five) and cumulative lag (lag 0-1 for mortality and 0-3 for hospital admissions). MAIN OUTCOME MEASURES: A total of 1,792 subjects deceased of all natural causes (including cardiovascular and respiratory causes) and 6,925 hospital admissions for acute conditions (cardiac, cerebrovascular and respiratory diseases) were considered. PM10, NO2 and CO daily pollutant concentration series were examined. RESULTS: PM10 was associated with mortality from all natural causes (10.36%; 95% CI 1.83-19.61 at lag 0-1). The risk was more pronounced for cardiovascular mortality (14.35%; 95% CI 2.11; 28.07 at lag 1). The association with hospitalization for cerebrovascular diseases was statistically significant for PM10 among females (13.4%; 95% CI 1.7; 26.4 at lag 4) and elderly over 75 years old (13.6%; 95% CI 0.4; 28.6 at lag 4). In specific population groups, increased mortality and hospital admissions have been associated with NO2. CONCLUSION: This study found strong and consistent associations between outdoor air pollution (coming from both industrial emissions and urban traffic) and short-term increases in both mortality and morbidity. Precautionary measures should be taken.

Investigating mortality heterogeneity among neighbourhoods of a highly industrialised Italian city: a meta-regression approach.

OBJECTIVES: The purpose of this study was to investigate the role of various predictors to explain spatial mortality heterogeneity in Taranto. METHODS: Direct age-adjusted death rates (ADR) at a neighbourhood level for the period 1998-2010 were examined. SO2, PM10, distance from pollution sources, and socioeconomic status (SES) were tested as predictors within a meta-regression framework. We used τ (2) to quantify heterogeneity in ADR and I (2) statistic with 95 % confidence intervals to estimate the proportion of total variation across neighbourhoods attributable to the between-neighbourhood heterogeneity. RESULTS: High heterogeneity resulted for all and natural causes of death for both genders. One neighbourhood (Paolo VI) was detected as an outlier for all predictors except SO2, among males. After accounting for SES, moderate heterogeneity among residuals was observed for all-causes of death and was correlated with SO2. Higher concentrations of PM10 were observed in neighbourhoods close to the industrial site and higher concentrations of SO2 in neighbourhoods more distant from the industrial site. CONCLUSIONS: SES and air pollutants were predictors of spatial heterogeneity in ADR. Different distributions of SO2 and PM10 in the city suggested two exposure patterns.