Socioeconomic inequalities in avoidable mortality in Italy: results from a nationwide longitudinal cohort.

BACKGROUND: Disparities in avoidable mortality have never been evaluated in Italy at the national level. The present study aimed to assess the association between socioeconomic status and avoidable mortality. METHODS: The nationwide closed cohort of the 2011 Census of Population and Housing was followed up for 2012-2019 mortality. Outcomes of preventable and of treatable mortality were separately evaluated among people aged 30-74. Education level (elementary school or less, middle school, high school diploma, university degree or more) and residence macro area (North-West, North-East, Center, South-Islands) were the exposures, for which adjusted mortality rate ratios (MRRs) were calculated through multivariate quasi-Poisson regression models, adjusted for age at death. Relative index of inequalities was estimated for preventable, treatable, and non-avoidable mortality and for some specific causes. RESULTS: The cohort consisted of 35,708,459 residents (48.8% men, 17.5% aged 65-74), 34% with a high school diploma, 33.5% living in the South-Islands; 1,127,760 deaths were observed, of which 65.2% for avoidable causes (40.4% preventable and 24.9% treatable). Inverse trends between education level and mortality were observed for all causes; comparing the least with the most educated groups, a strong association was observed for preventable (males MRR = 2.39; females MRR = 1.65) and for treatable causes of death (males MRR = 1.93; females MRR = 1.45). The greatest inequalities were observed for HIV/AIDS and alcohol-related diseases (both sexes), drug-related diseases and tuberculosis (males), and diabetes mellitus, cardiovascular diseases, and renal failure (females). Excess risk of preventable and of treatable mortality were observed for the South-Islands. CONCLUSIONS: Socioeconomic inequalities in mortality persist in Italy, with an extremely varied response to policies at the regional level, representing a possible missed gain in health and suggesting a reassessment of priorities and definition of health targets.

Epidemiologic transition of lung cancer mortality in Italy by sex, province of residence and birth cohort (1920-1929 to 1960-1969).

Space-time analysis of mortality risk is useful to evaluate the epidemiologic transitions at the subnational level. In our study, we analysed the death certificate records for lung cancer in Italy in 1995-2016, obtained from the Italian National Institute of Statistics. Our objective was to investigate the spatial-temporal evolution of lung cancer mortality by sex and province of residence (n = 107) using the birth cohort as relevant time axis. We built Bayesian space-time models with space-time interactions. Among males (n = 554 829), mortality peaked in the 1920-1929 cohort, followed by a generalised decline. Among females (n = 158 619), we found novel original evidence for a peak in the 1955-1964 cohort, equivalent to a 35-year delay, with a downward trend being observed thereafter. Over time, the documented north-south decreasing mortality gradient has been replaced by a west-east decreasing gradient. Naples has become the province at highest risk in Italy, both among males and females. This pattern is consistent with an epidemiologic transition of risk factors for lung cancer to the south-west of the country and raises concern, because 5-year age-standardised net survival from the disease in this geographic area is lower than in northern and central Italy. The variability of mortality rates among provinces has changed over time, with an increasing homogeneity for males and an opposite trend for females in the more recent birth cohorts. These unprecedented observations provide evidence for a profound spatio-temporal transition of lung cancer mortality in Italy.

Frailty at death: An examination of multiple causes of death in four low mortality countries in 2017.

BACKGROUND: The increasing prevalence of frailty in aging populations represents a major social and public health challenge which warrants a better understanding of the contribution of frailty to the morbid process. OBJECTIVE: To examine frailty-related mortality as reported on the death certificate in France, Italy, Spain and the United States in 2017. METHODS: We identify frailty at death for the population aged 50 years and over in France, Italy, Spain and the United States. We estimate the proportions of deaths by sex, age group and country with specific frailty-related ICD-codes on the death certificate 1) as the underlying cause of death (UC), 2) elsewhere in Part I (sequence of diseases or conditions or events leading directly to death), and 3) anywhere in Part II (conditions that do not belong in Part I but whose presence contributed to death). RESULTS: The age-standardized proportion of deaths with frailty at ages 50 and over is highest in Italy (25.0%), then in France (24.1%) and Spain (17.3%), and lowest in the United States (14.0%). Cross-country differences are smaller when frailty-related codes are either the underlying cause of the death or reported in Part II. Frailty-related mortality increases with age and is higher among females than males. Dementia is the most frequently reported frailty-related code. CONCLUSIONS: Notable cross-country differences were found in the prevalence and the type of frailty-related symptoms at death even after adjusting for differential age distributions.

Increased kidney disease mortality among people with AIDS versus the general population: a population-based cohort study in Italy, 2006-2018.

OBJECTIVES: This study aimed to assess whether an excess mortality related to kidney and other urinary tract diseases exists among Italian people with AIDS (PWA), as compared with the general population without AIDS (non-PWA). DESIGN: Population-based, retrospective cohort study. SETTING AND PARTICIPANTS: We conducted a nationwide study including 9481 Italian PWA, aged 15-74 years, reported to the National AIDS Registry between 2006 and 2018. METHODS: Vital status and causes of death were retrieved by record linkage with the National Register of Causes of Death up to 2018. Excess mortality for PWA versus non-PWA was estimated through sex-standardised and age-standardised mortality ratios (SMRs) with corresponding 95% CIs. RESULTS: Among 2613 deceased PWA, 262 (10.0%) reported at least one urinary tract disease at death, including 254 (9.7%) non-cancer diseases-mostly renal failures (225 cases, 8.6%)-and 9 cancers (0.3%). The overall SMR for non-cancer urinary tract diseases was 15.3 (95% CI 13.4 to 17.3) with statistically significant SMRs for acute (SMR=22.3, 95% CI 18.0 to 27.4), chronic (SMR=8.4, 95% CI 6.0 to 11.3), and unspecified renal failure (SMR=13.8, 95% CI 11.2 to 16.8). No statistically significant excess mortality was detected for urinary tract cancers (SMR=1.7, 95% CI 0.8 to 3.3). The SMRs were particularly elevated among PWA aged <50 years, injecting drug users, or those with the first HIV-positive test >6 months before AIDS diagnosis. CONCLUSIONS: The excess mortality related to non-cancer kidney and other urinary tract diseases reported among PWA highlights the importance of implementing the recommendation for screening, diagnosis and management of such conditions among this population.

Male and Female Differences in Homicide Mortality: Results of an Italian Longitudinal Study, 2012-2018.

Introduction: Italy has one of the lowest homicide rates in Europe. However, while it is decreasing overall, the proportion of murdered women is increasing. This study aimed to analyze the demographic and socioeconomic characteristics associated with homicide mortality in Italy, focusing specifically on male and female differences. Methods: Using a longitudinal design, the Italian 2011 General Census population was followed up to 2018. Deaths from homicide were retrieved by a record linkage with the Causes of Death Register. Age-standardized mortality rates, stratified by sex, citizenship, education, and geographic area of residence were calculated. The association between sociodemographic characteristics and homicide mortality was evaluated using quasi-Poisson regression models. Results: Between 2012 and 2018, 1,940 homicides were recorded in Italy: 53% were females over age 55, 10% were immigrant females, 34% were males aged 40-54 years, 76% had a medium-low education level, and 57% lived in the South and Islands. Foreign citizenship increased a female's risk of dying from homicide (adjusted rate ratio (RRadj): 1.85; 95% CI: 1.54-2.23), while no differences between Italian and immigrant males were found. An inverse association between education and mortality was observed for both sexes, stronger for males (RRadj: 3.68; 95% CI: 3.10-4.36, low vs. high) than for females (RRadj: 1.38; 95%CI: 1.17-1.62, low vs. high). Moreover, a male residing in the South or the Islands had almost 2.5 times the risk of dying from homicide than a resident in the North-West. Finally, old age (over 75) increased a female's risk of being murdered, whereas the highest risk for males was observed for those aged 25-54 years. Conclusions: Male and female differences in homicide mortality profiles by age were expected, but the results by residence, citizenship, and education highlight that living in disadvantaged socioeconomic contexts increases the risk of dying from homicide, suggesting the need to implement specific prevention and intervention strategies.

Mortality of people with AIDS in Italy: comparison of AIDS surveillance and multiple cause-of-death registries.

AIMS: To assess whether the use of multiple cause-of-death data could improve reporting of AIDS mortality in Italy. METHOD: Population-based, record-linkage study, on 3,975,431 deaths recorded in the National Registry of Causes of Death (RCoD) and 4,530 deaths recorded in the National AIDS Registry (RAIDS), during 2006-2012. RESULTS: The record-linkage identified 3,646 AIDS-related deaths present in both registries, 884 deaths in the RAIDS without mention of HIV/AIDS in the RCoD, and 3,796 deaths in the RCoD with mention of HIV/AIDS that were not present in the RAIDS. In the latter, in-depth analysis of multiple cause-of-death allowed the identification of 1,484 deaths that were AIDS-related. On these results, we estimated 6,014 deceased people with AIDS. Of them, 14.7% (884) were not present in the RCoD and 24.7% (1,484) derived from the RCoD only. CONCLUSIONS: The integration of different nationwide registries allowed a more comprehensive estimate of the impact of AIDS-associated mortality in Italy.

Variation in Cause-Specific Mortality Rates in Italy during the First Wave of the COVID-19 Pandemic: A Study Based on Nationwide Data.

Italy was a country severely hit by the first coronavirus disease 2019 (COVID-19) pandemic wave in early 2020. Mortality studies have focused on the overall excess mortality observed during the pandemic. This paper investigates the cause-specific mortality in Italy from March 2020 to April 2020 and the variation in mortality rates compared with those in 2015-2019 regarding sex, age, and epidemic area. Causes of death were derived from the national cause-of-death register. COVID-19 was the leading cause of death among males and the second leading cause among females. Chronic diseases, such as diabetes and hypertensive, ischemic heart, and cerebrovascular diseases, with decreasing or stable mortality rates in 2015-2019, showed a reversal in the mortality trend. Moreover, mortality due to pneumonia and influenza increased. No increase in neoplasm mortality was observed. Among external causes of death, mortality increased for accidental falls but reduced for transport accidents and suicide. Mortality from causes other than COVID-19 increased similarly in both genders and more at ages 65 years or above. Compared with other areas in Italy, the Lombardy region showed the largest excess in mortality for all leading causes. Underdiagnosis of COVID-19 at the beginning of the pandemic may, to some extent, explain the mortality increase for some causes of death, especially pneumonia and other respiratory diseases.

Acute Effects of Particulate Matter on All-Cause Mortality in Urban, Rural, and Suburban Areas, Italy.

BACKGROUND: Short-term exposure to particulate matter (PM) has been related to mortality worldwide. Most evidence comes from studies conducted in major cities, while little is known on the effects of low concentrations of PM and in less urbanized areas. We aim to investigate the relationship between PM and all-cause mortality at national level in Italy. METHODS: Daily numbers of all-cause mortality were collected for all 8092 municipalities of Italy, from 2006 to 2015. A satellite-based spatiotemporal model was developed to estimate daily PM10 (inhalable particles) and PM2.5 (fine particles) concentrations at 1-km resolution. Multivariate Poisson regression models were fit to estimate the association between daily PM and mortality at province level, and then, results were pooled with a random-effects meta-analysis. Associations were estimated by combination of age and sex and degree of urbanization of the municipalities. Flexible functions were estimated to explore the shape of the associations at low PM concentrations. RESULTS: We analyzed 5,884,900 deaths (40% among subjects older than 85 years, 60% occurring outside the main urban areas). National daily mean (interquartile range) PM10 and PM2.5 concentrations were 23 (14) µg/m3 and 15 (11) µg/m3, respectively. Relative increases of mortality per 10 µg/m3 variation in lag 0-5 (average of last six days since death) PM10 and PM2.5 were 1.47% (95% Confidence Intervals (CI): 1.15%, 1.79%) and 1.96% (1.33%, 2.59%), respectively. Associations were highest among elderly and women for PM10 only, similar between rural and urbanized areas, and were present even at low concentrations, e.g., below WHO guidelines. CONCLUSIONS: Air pollution was robustly associated with peaks in daily all-cause mortality in Italy, both in large cities and in less urbanized areas of Italy. Current WHO Air Quality Guidelines (2021) for PM10 and PM2.5 are not sufficient to protect public health.

Evolution of Pathology Patterns in Persons Who Died From COVID-19 in Italy: A National Study Based on Death Certificates.

Background: In Italy, during the first epidemic wave of 2020, the peak of coronavirus disease 2019 (COVID-19) mortality was reached at the end of March. Afterward, a progressive reduction was observed until much lower figures were reached during the summer, resulting from the contained circulation of SARS-CoV-2. This study aimed to determine if and how the pathological patterns of the individuals deceased from COVID-19 changed during the phases of epidemic waves in terms of: (i) main cause of death, (ii) comorbidities, and (iii) complications related to death. Methods: Death certificates of persons who died and tested positive for SARS-CoV-2, provided by the National Surveillance system, were coded according to ICD rev10. Deaths due to COVID-19 were defined as those in which COVID-19 was the underlying cause of death. Results: The percentage of COVID-19 deaths varied over time. It decreased in the downward phase of the epidemic curve (76.6 vs. 88.7%). In February-April 2020, hypertensive heart disease was mentioned as a comorbidity in 18.5% of death certificates, followed by diabetes (15.9% of cases), ischemic heart disease (13.1%), and neoplasms (12.1%). In May-September, the most frequent comorbidity was neoplasms (17.3% of cases), followed by hypertensive heart disease (14.9%), diabetes (14.8%), and dementia/Alzheimer's disease (11.9%). The most mentioned complications in both periods were pneumonia and respiratory failure with a frequency far higher than any other condition (78.4% in February-April 2020 and 63.7% in May-September 2020). Discussion: The age of patients dying from COVID-19 and their disease burden increased in the May-September 2020 period. A more serious disease burden was observed in this period, with a significantly higher frequency of chronic pathologies. Our study suggests better control of the virus' lethality in the second phase of the epidemic, when the health system was less burdened. Moreover, COVID-19 care protocols had been created in hospitals, and knowledge about the diagnosis and treatment of COVID-19 had improved, potentially leading to more accurate diagnosis and better treatment. All these factors may have improved survival in patients with COVID-19 and led to a shift in mortality to older, more vulnerable, and complex patients.

Multi-morbidity and frailty at death: A new classification of death records for an ageing world.

Mortality statistics based on underlying cause of death are challenged by increased life expectancy and the growing share of population reaching ages associated with frequent multi-morbidity (with death likely resulting from interactions between multiple diseases). We provide a novel way of analysing causes of death: accounting for all causes mentioned on death certificates and summarizing this information along two dimensions emblematic of ageing populations-multi-morbidity and frailty. We implement this classification for all deaths at ages 50+ in Italy in 2014. Multi-morbid processes represent the majority of deaths, rising from 43 per cent at ages 50-54 to 63 per cent at ages 85-89. Multi-morbidity at death is more frequent among males, although age patterns are identical for both sexes. About one in four deaths involves frailty symptoms, rising to 45 per cent at ages 95+. Mortality rates involving frailty are very similar for both sexes. Supplementary material is available for this article at: https://doi.org/10.1080/00324728.2020.1820558.

The Role of COVID-19 in the Death of SARS-CoV-2-Positive Patients: A Study Based on Death Certificates.

Background: Death certificates are considered the most reliable source of information to compare cause-specific mortality across countries. The aim of the present study was to examine death certificates of persons who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to (a) quantify the number of deaths directly caused by coronavirus 2019 (COVID-19); (b) estimate the most common complications leading to death; and (c) identify the most common comorbidities. Methods: Death certificates of persons who tested positive for SARS-CoV-2 provided to the National Surveillance system were coded according to the 10th edition of the International Classification of Diseases. Deaths due to COVID-19 were defined as those in which COVID-19 was the underlying cause of death. Complications were defined as those conditions reported as originating from COVID-19, and comorbidities were conditions independent of COVID-19. Results: A total of 5311 death certificates of persons dying in March through May 2020 were analysed (16.7% of total deaths). COVID-19 was the underlying cause of death in 88% of cases. Pneumonia and respiratory failure were the most common complications, being identified in 78% and 54% of certificates, respectively. Other complications, including shock, respiratory distress and pulmonary oedema, and heart complications demonstrated a low prevalence, but they were more commonly observed in the 30-59 years age group. Comorbidities were reported in 72% of certificates, with little variation by age and gender. The most common comorbidities were hypertensive heart disease, diabetes, ischaemic heart disease, and neoplasms. Neoplasms and obesity were the main comorbidities among younger people. Discussion: In most persons dying after testing positive for SARS-CoV-2, COVID-19 was the cause directly leading to death. In a large proportion of death certificates, no comorbidities were reported, suggesting that this condition can be fatal in healthy persons. Respiratory complications were common, but non-respiratory complications were also observed.

[Impact of the implementation of ICD-10 2016 version and Iris software on mortality statistics in Italy]. / Impatto dell'implementazione della versione 2016 dell'ICD-10 e del software Iris sulle statistiche di mortalità in Italia.

OBJECTIVES: to assess the impact of coding causes of death with the ICD-10 2016 version and the software Iris on Italian official statistics on mortality. DESIGN: coding of a sample of death certificates with two different coding systems (bridge coding). SETTING AND PARTICIPANTS: a sample of 63,525 deaths occurred throughout 2015 among people aged over one year, already coded using the ICD-10 2009 version and the Mortality Medical Data System (MMDS) software, was re-coded through the ICD-10 2016 version and the Iris software. MAIN OUTCOME MEASURES: the transition matrix between the two coding systems was realized and the agreement percentages between the two coding systems, the comparability ratios, and the relative 95% confidence intervals were calculated. Comparability ratios have been calculated for both the underlying cause of death and the multiple causes. RESULTS: overall, 79% of deaths showed exactly the same underlying cause of death (ICD-10 code, 4 digits) in the two coding systems. On the three-digit level, the agreement was 89%; on ICD-10 chapter level, the agreement was 95%. At the chapter level, the most important changes were observed for: • certain infectious and parasitic diseases (-18% in ICD-10 2016/Iris); • diseases of the genitourinary system (-17%); • diseases of the respiratory system (+7%); • diseases of the nervous system and sense organs (+5%); • external causes of morbidity and mortality (+5%). Analyzing the multiple causes, the most important changes were observed for: • certain infectious and parasitic diseases (-19% in ICD-10 2016/Iris); • external causes of morbidity and mortality (+28%); • symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (+7%). CONCLUSION: the results are very useful to explain any change in the Italian statistics on mortality comparing 2015 with the following years.

Excess mortality related to circulatory system diseases and diabetes mellitus among Italian AIDS patients vs. non-AIDS population: a population-based cohort study using the multiple causes-of-death approach.

BACKGROUND: Chronic diseases, chiefly cancers and circulatory system diseases (CSDs), have become the leading non-AIDS-related causes of death among HIV-infected people, as in the general population. After our previous report of an excess mortality for several non-AIDS-defining cancers, we now aim to assess whether people with AIDS (PWA) experience also an increased mortality for CSDs and diabetes mellitus (DM), as compared to the non-AIDS general population (non-PWA). METHODS: A nationwide, population-based, retrospective cohort study was conducted including 5285 Italians, aged 15-74 years, who were diagnosed with AIDS between 2006 and 2011. Multiple cause-of-death (MCoD) data, i.e. all conditions reported in death certificates, were retrieved through record-linkage with the National Register of Causes of Death up to 2011. Using MCoD data, sex- and age-standardized mortality ratios (SMRs) with 95% confidence intervals (CIs) were calculated by dividing the observed number of PWA reporting a specific disease among MCoD to the expected number, estimated on the basis of mortality rates (based on MCoD) of non-PWA. RESULTS: Among 1229 deceased PWA, CSDs were mentioned in 201 (16.4%) certificates and DM in 46 (3.7%) certificates among the various causes of death. These values corresponded to a 13-fold higher mortality related to CSDs (95% CI 10.8-14.4) and DM (95% CI: 9.5-17.4) as compared to 952,019 deceased non-PWA. Among CSDs, statistically significant excess mortality emerged for hypertension (23 deaths, SMR = 6.3, 95% CI: 4.0-9.4), ischemic heart diseases (39 deaths, SMR = 6.1, 95% CI: 4.4-8.4), other forms of heart diseases (88 deaths, SMR = 13.4, 95% CI: 10.8-16.5), and cerebrovascular diseases (42 deaths, SMR = 13.4, 95% CI: 9.7-18.2). The SMRs were particularly elevated among PWA aged < 50 years and those infected through drug injection. CONCLUSIONS: The use of MCoD data disclosed the fairly high mortality excess related to several CSDs and DM among Italian PWA as compared to non-PWA. Study findings also indicate to start preventive strategies for such diseases at a younger age among AIDS patients than in the general population and with focus on drug users.

Multiple cause-of-death data among people with AIDS in Italy: a nationwide cross-sectional study.

BACKGROUND: Multiple cause-of-death (MCOD) data allow analyzing the contribution to mortality of conditions reported on the death certificate that are not selected as the underlying cause of death. Using MCOD data, this study aimed to fully describe the cause-specific mortality of people with AIDS (PWA) compared to people without AIDS. METHODS: We conducted a nationwide investigation based on death certificates of 2,515 Italian PWA and 123,224 people without AIDS who had died between 2006 and 2010. The conditions most frequently associated with PWA mortality, compared to people without AIDS, were identified using an age-standardized proportion ratio (ASPR) calculated as the ratio between the age-standardized proportion of a specific cause among PWA and the same proportion among people without AIDS. RESULTS: The most frequently reported conditions at death among PWA were infectious/parasitic diseases (52%), digestive (36%), respiratory (33%), and circulatory (32%) system diseases, and neoplasms (29%). All AIDS-defining conditions resulted highly associated (ASPR significantly greater than unity) with PWA deaths. Significant associations also emerged for leishmaniasis (ASPR = 188.0), encephalitis/myelitis/encephalomyelitis (ASPR = 14.3), dementia (ASPR = 13.1), chronic viral hepatitis (ASPR = 13.1), liver fibrosis/cirrhosis (ASPR = 4.4), pneumonia (ASPR = 4.4), anal (ASPR = 12.1) and liver (ASPR = 1.9) cancers, and Hodgkin's disease (ASPR = 3.1). CONCLUSIONS: Study findings identified the contribution of several non-AIDS-defining conditions on PWA mortality, emphasizing the need of preventive public health interventions targeting this population.

Obesity-related mortality in France, Italy, and the United States: a comparison using multiple cause-of-death analysis.

OBJECTIVES: We investigate the reporting of obesity on death certificates in three countries (France, Italy, and the United States) with different levels of prevalence, and we examine which causes are frequently associated with obesity. METHODS: We use cause-of-death data for all deaths at ages 50-89 in 2010-2011. Since obesity may not be the underlying cause (UC) of death, we compute age- and sex-standardized death rates considering all mentions of obesity (multiple causes or MC). We use cluster analyses to identify patterns of cause-of-death combinations. RESULTS: Obesity is selected as UC in no more than 20% of the deaths with a mention of obesity. Mortality levels, whether measured from the UC or the MC, are weakly related to levels of prevalence. Patterns of cause-of-death combinations are similar across the countries. In addition to strong links with cardiovascular diseases and diabetes, we identify several less familiar associations. CONCLUSIONS: Considering all mentions on the deaths certificates reduces the underestimation of obesity-related mortality based on the UC only. It also enables us to describe the various mortality patterns involving obesity.

Non-AIDS-Defining Cancer Mortality: Emerging Patterns in the Late HAART Era.

BACKGROUND: Non-AIDS-defining cancers (non-ADCs) have become the leading non-AIDS-related cause of death among people with HIV/AIDS. We aimed to quantify the excess risk of cancer-related deaths among Italian people with AIDS (PWA), as compared with people without AIDS (non-PWA). METHODS: A nationwide, population-based, retrospective cohort study was carried out among 5285 Italian PWA, aged 15-74 years, diagnosed between 2006 and 2011. Date of death and multiple-cause-of-death data were retrieved up to December 2011. Excess mortality, as compared with non-PWA, was estimated using sex- and age-standardized mortality ratios (SMRs) and the corresponding 95% confidence intervals (CIs). RESULTS: Among 1229 deceased PWA, 10.3% reported non-ADCs in the death certificate, including lung (3.1%), and liver (1.4%), cancers. A 7.3-fold (95% CI: 6.1 to 8.7) excess mortality was observed for all non-ADCs combined. Statistically significant SMRs emerged for specific non-ADCs, ie, anus (5 deaths, SMR = 227.6, 95% CI: 73.9 to 531.0), Hodgkin lymphoma (12 deaths, SMR = 122.0, 95% CI: 63.0 to 213.0), unspecified uterus (4 deaths, SMR = 52.5, 95% CI: 14.3 to 134.5), liver (17 deaths, SMR = 13.2, 95% CI: 7.7 to 21.1), skin melanoma (4 deaths, SMR = 10.9, 95% CI: 3.0 to 27.8), lung (38 deaths, SMR = 8.0, 95% CI: 5.7 to 11.0), head and neck (9 deaths, SMR = 7.8, 95% CI: 3.6 to 14.9), leukemia (5 deaths, SMR = 7.6, 95% CI: 2.4 to 17.7), and colon-rectum (10 deaths, SMR = 5.4, 95% CI: 2.6 to 10.0). SMRs for non-ADCs were particularly elevated among PWA infected through injecting drug use. CONCLUSION: This population-based study documented extremely elevated risks of death for non-ADCs among PWA. These findings stress the need of preventive interventions for both virus-related and non-virus-related cancers among HIV-infected individuals.

Residential Proximity to Major Roadways and Lung Cancer Mortality. Italy, 1990-2010: An Observational Study.

BACKGROUND: Air pollution from road traffic has been associated to an increased risk of lung cancer. Herein, we investigated the association between lung cancer mortality and residence near Italian highways or national major roads. METHODS: Information on deaths for lung cancer registered from 1990 to 2010 and stratified by age, gender, and urban or rural municipality of residence at death were obtained from the National Institute of Statistics. Distance between the centroid of the municipality of residence and closest major roadways was considered as a proxy of pollution exposure. Relative Risks (RR) and 95% confidence intervals (CI) were computed using Poisson log-linear models adjusted for age, calendar period, deprivation index, North/South gradient, and urban/rural status. RESULTS: A gradient in risk for lung cancer mortality was seen for residents within 50 meters (m) of national major roads. In particular, in rural municipalities a statistically significant increased risk for lung cancer death was observed in both sexes (RR = 1.27 for distance <25 m vs. 500-1999 m, 95% CI 1.17-1.42, in men; RR = 1.97, 95% CI 1.64-2.39, in women). In urban municipalities, weak risks of borderline significance were documented in both sexes (RR = 1.06, 95% CI 0.99-1.15 in men; and RR = 1.09, 95% CI 0.97-1.22 in women). No statistically significant association emerged between residence within 100 to 500 m from highways and RRs of death for lung cancer. CONCLUSIONS: In Italy, residing near national major roads, in particular in rural municipalities, was related to elevated risks of death for lung cancer.

After the epidemiologic transition: a reassessment of mortality from infectious diseases among over-65s in France and Italy.

OBJECTIVES: To assess more accurately the contribution of infectious diseases (IDs) to mortality at age 65+. METHODS: We use cause-of-death data for France and Italy in 2009. In addition to chapter I of the 10th International Classification of Diseases (ICD-10), our list of IDs includes numerous diseases classified in other chapters. We compute mortality rates considering all death certificate entries (underlying and contributing causes). RESULTS: Mortality rates at age 65+ based on our extended list are more than three times higher than rates based solely on ICD-10 chapter I. IDs are frequently contributing causes of death. In France, the share of deaths at age 65+ involving an ID as underlying cause increases from 2.1 to 7.3 % with the extended list, and to 20.8 % when contributing causes are also considered. For Italy, these percentages are 1.4, 4.2 and 18.7 %, respectively. CONCLUSIONS: Publicly available statistics underestimate the contribution of IDs to the over-65s' mortality. Old age is a risk factor for IDs, and these diseases are more difficult to treat at advanced ages. Health policies should develop targeted actions for that population.

Risk factors for early mortality after AIDS in the cART era: A population-based cohort study in Italy.

BACKGROUND: Despite the dramatically improved survival due to combination antiretroviral therapies (cART), life expectancy of people with HIV/AIDS remains lower than that of the general population. This study aimed to estimate, at a population level, the survival experience of Italian people with AIDS (PWA) and to quantify the prognostic role of selected factors at diagnosis in the risk of early mortality (i.e., within six months from AIDS diagnosis). METHODS: A population-based, retrospective-cohort study was conducted among Italian PWA diagnosed between 1999 and 2009 and recorded in the national AIDS registry. The vital status, up to December 2010, of 14,552 PWA was ascertained through a record linkage procedure with the Italian mortality database. Survival probabilities were estimated through Kaplan-Meier method. To identify risk factors for early mortality from any cause, odds ratios (ORs) and corresponding 95% confidence intervals (CIs), adjusted for major confounders, were computed using multivariate logistic regression models. RESULTS: Of the 5,706 deaths registered among the 14,552 PWA included in the study, 2,757 (18.9%) occurred within six months from AIDS diagnosis. The probability of surviving six months increased from 81.2% in PWA diagnosed in 1999-2000 to 82.9% in 2009, while the 5-year survival augmented from 60.7% in PWA diagnosed in 1999-2000 to 65.4% for PWA diagnosed in 2005-2006. Elevated risks of early mortality were associated to older age (OR = 5.28; 95% CI: 4.41-6.32 for age ≥60 vs. <35 years), injecting drug use (OR = 1.71; 95% CI: 1.53-1.91 vs. heterosexual intercourse), and CD4 count <50 cells/mm(3) at AIDS diagnosis (OR = 1.87, 95% CI: 1.55-2.27 vs. ≥350). Elevated ORs for early mortality also emerged for PWA diagnosed with primary brain lymphoma (OR = 11.66, 95% CI: 7.32-18.57), or progressive multifocal leukoencephalopathy (OR = 4.21, 95% CI: 3.37-5.27). CONCLUSIONS: Our study documented, among Italian PWA, the high - though slightly decreasing - frequency of early mortality in the full cART era. These findings indicate the need for enduring and ameliorating preventive actions aimed at timely HIV testing among all individuals at risk for HIV infection and/or those who present diseases known to be related with HIV infection.

Mortality from Alzheimer's disease, Parkinson's disease, and dementias in France and Italy: a comparison using the multiple cause-of-death approach.

OBJECTIVE: We perform an in-depth analysis of all death certificates collected in France and Italy with an entry of Parkinson's disease (PD), Alzheimer's disease (AD), or another dementia. METHOD: Data are for 2008. We measure how frequently these conditions are the underlying cause of death. We then examine what other causes are reported on the certificates. RESULTS: In both countries, AD is the underlying cause for about 6 in 10 certificates with an AD entry. The proportion is lower for PD and dementia, but higher in France than in Italy. Many contributing causes reflect the circumstances surrounding the end of life in AD, PD, and dementia, often characterized by bed confinement and frailty. DISCUSSION: Our research highlights several consequences of the conditions under study that could be targeted by public health policy. It also speaks to the existence of differences in diagnosis/certification practices that may explain differences in mortality levels.