[The mortality cost of carbon dioxide emissions from a steel plant in Southern Italy: a climate change health impact assessment]. / Il "mortality cost" delle emissioni di CO2 di uno stabilimento siderurgico nel Sud Italia: una valutazione degli impatti sanitari derivanti dal cambiamento climatico.

OBJECTIVES: to quantify the temperature-related global health impacts of the Taranto steel plant CO2e emissions. DESIGN: using the risk functions available in the literature, a prospective global health impact assessment of the marginal CO2e emissions declared by the steel plant for 2020 was conducted. SETTING AND PARTICIPANTS: world population in the period 2020-2100. MAIN OUTCOMES MEASURES: deaths in the period 2020-2100 attributable to the marginal CO2e emitted by the Taranto steel plant in 2020. RESULTS: considering the central estimates in the baseline emission scenario (4.1°C warming by 2100), the Taranto steel plant 2020 CO2e emissions will cause 1,876 deaths worldwide between 2020 and 2100. The largest part will be attributable to steelmaking processes, accounting for 1,093 deaths. The same emissions will cause 5.56 × 10-4 deaths worldwide between 2020 and 2100 per tonne of steel produced in 2020, i.e. one death for every 1,799 tonnes of steel. If the 2020 CO2e emissions of the steel plant had been reduced by 25%, 50% or 75%, the deaths avoided in the world in the period 2020-2100 would have been 469, 938 and 1,407 respectively. CONCLUSIONS: estimates predict a probably significant mortality impact worldwide by the end of the century associated with the greenhouse gases emissions of the Taranto steel plant. Just reducing emissions by 50% in a single year could maybe avoid over 900 deaths worldwide by the end of the century. This confirms the importance of implementing incisive policies to reduce greenhouse gases emissions in all sectors.

The Impact of the COVID-19 Pandemic and Socioeconomic Deprivation on Admissions to the Emergency Department for Psychiatric Illness: An Observational Study in a Province of Southern Italy.

The restriction measures adopted to limit population movement in order to contain the COVID-19 pandemic contributed to a global public health system crisis. This retrospective study aimed at identifying changes in psychiatric admissions to Accident and Emergency Departments (A&Es) in a province in southern Italy during the first two years of the pandemic and was characterized by two different restriction levels (phases 2 and 3) compared to the pre-pandemic period (phase 1). We also investigated the role of socioeconomic deprivation (DI) on psychiatric admissions. The total number of patients admitted to the A&Es was 291,310. The incidence of admission for a psychiatric disorder (IPd) was 4.9 per 1000 admissions, with a significant younger median age of 42 [IQR 33-56] compared to non-psychiatric patients (54 [35-73]). The type of admission and type of discharge were factors related to the psychiatric admission to A&E, and their relationship was modified by the pandemic. In the first year of the pandemic, patients with psychomotor agitation increased compared to the pre-pandemic period (72.5% vs. 62.3%). In the period preceding the spread of SARS-CoV-2, the IPd was equal to 3.33 ± 0.19; after the pandemic started, there was an increase in the IPd: 4.74 ± 0.32 for phase 2 and 3.68 ± 0.25 for phase 3. The IPd was higher for psychiatric admissions from areas with a very low DI compared to areas with a low DI; however, during phase 2, this difference was reduced. In conclusion, an increase in admissions for psychiatric disease was observed during the initial spread of SARS-CoV-2. Patients who lived in the most deprived municipalities generally came to the A&Es less than others, probably because the patients and their families had less awareness of their mental health. Therefore, public health policies to address these issues are needed to reduce the pandemic's impact on these conditions.

No Excess of Mortality from Lung Cancer during the COVID-19 Pandemic in an Area at Environmental Risk: Results of an Explorative Analysis.

BACKGROUND: The COVID-19 pandemic and the restrictive measures associated with it placed enormous pressure on health facilities and may have caused delays in the treatment of other diseases, leading to increases in mortality compared to the expected rates. Areas with high levels of air pollution already have a high risk of death from cancer, so we aimed to evaluate the possible indirect effects of the pandemic on mortality from lung cancer compared to the pre-pandemic period in the province of Taranto, a polluted site of national interest for environmental risk in the south of Italy. METHODS: We carried out a retrospective observational study on lung cancer data (ICD-10: C34) from the Registry of Mortality (ReMo) for municipalities in Taranto Province over the period of 1 January 2011 to 31 December 2021. Seasonal exponential smoothing, Holt-Winters additive, Holt-Winters multiplicative, and auto-regressive integrated moving average (ARIMA) models were used to forecast the number of deaths during the pandemic period. Data were standardized by sex and age via an indirect method and shown as monthly mortality rates (MRs), standardized mortality ratios (SMRs), and adjusted mortality rates (AMRs). RESULTS: In Taranto Province, 3108 deaths from lung cancer were recorded between 2011 and 2021. In the province of Taranto, almost all of the adjusted monthly mortality rates during the pandemic were within the confidence interval of the predicted rates, with the exception of significant excesses in March (+1.82, 95% CI 0.11-3.08) and August 2020 (+2.09, 95% CI 0.20-3.44). In the municipality of Taranto, the only significant excess rate was in August 2020 (+3.51, 95% CI 0.33-6.69). However, in total, in 2020 and 2021, the excess deaths from lung cancer were not significant both for the province of Taranto (+30 (95% CI -77; +106) for 2020 and +28 (95% CI -130; +133) for 2021) and for the municipality of Taranto alone (+14 (95% CI -47; +74) for 2020 and -2 (95% CI -86; +76) for 2021). CONCLUSIONS: This study shows that there was no excess mortality from lung cancer as a result of the COVID-19 pandemic in the province of Taranto. The strategies applied by the local oncological services during the pandemic were probably effective in minimizing the possible interruption of cancer treatment. Strategies for accessing care in future health emergencies should take into account the results of continuous monitoring of disease trends.

Gender differences, environmental pressures, tumor characteristics, and death rate in a lung cancer cohort: a seven-years Bayesian survival analysis using cancer registry data from a contaminated area in Italy.

Introduction: In Taranto, Southern Italy, adverse impacts on the environment and human health due to industrial installations have been studied. In the literature, associations have been reported between gender, environmental factors, and lung cancer mortality in women and men. The aim of this study was to investigate the relationships between gender, residence in areas with high environmental pressures, bronchus/lung cancer characteristics, and death rate. Methods: Data from the Taranto Cancer Registry were used, including all women and men with invasive bronchus/lung cancer diagnosed between 1 January 2016 and 31 December 2020 and with follow-up to 31 December 2022. Bayesian mixed effects logistic and Cox regression models were fitted with the approach of integrated nested Laplace approximation, adjusting for patients and disease characteristics. Results: A total of 2,535 person-years were observed. Male gender was associated with a higher prevalence of histological grade 3 (OR 2.45, 95% CrI 1.35-4.43) and lung squamous-cell carcinoma (OR 3.04, 95% CrI 1.97-4.69). Variables associated with higher death rate were male gender (HR 1.24, 95% CrI 1.07-1.43), pathological/clinical stage II (HR 2.49, 95% CrI 1.63-3.79), III (HR 3.40, 95% CrI 2.33-4.97), and IV (HR 8.21, 95% CrI 5.95-11.34), histological grade 3 (HR 1.80, 95% CrI 1.25-2.59), lung squamous-cell carcinoma (HR 1.18, 95% CrI 1.00-1.39), and small-cell lung cancer (HR 1.62, 95% CrI 1.31-1.99). Variables associated with lower death rate were other-type lung cancer (HR 0.65, 95% CrI 0.44-0.95), high immune checkpoint ligand expression (HR 0.75, 95% CrI 0.59-0.95), lung localization (HR 0.73, 95% CrI 0.62-0.86), and left localization (HR 0.85, 95% CrI 0.75-0.95). Discussion: The results among patients with lung cancer did not show an association between residence in the contaminated site of national interest (SIN) and the prevalence of the above mentioned prognostic factors, nor between residence in SIN and death rate. The findings confirmed the independent prognostic values of different lung cancer characteristics. Even after adjusting for patients and disease characteristics, male gender appeared to be associated with a higher prevalence of poorly differentiated cancer and squamous-cell carcinoma, and with an increased death rate.

Environmental pressures, tumor characteristics, and death rate in a female breast cancer cohort: a seven-years Bayesian survival analysis using cancer registry data from a contaminated area in Italy.

Introduction: In Taranto, Southern Italy, adverse impacts on the environment and human health due to industrial installations have been studied. In the literature, few associations have been reported between environmental factors and breast cancer mortality in women. The aim of this study was to investigate the relationships between residence in areas with high environmental pressures, female breast cancer characteristics, and death rate. Methods: Data from the Taranto Cancer Registry were used, including all women with invasive breast cancer diagnosed between 01 January 2015 and 31 December 2020 and with follow-up to 31 December 2021. Bayesian mixed effects logistic and Cox regression models were fitted with the approach of integrated nested Laplace approximation, adjusting for patients and disease characteristics. Results: A total of 10,445 person-years were observed. Variables associated with higher death rate were residence in the contaminated site of national interest (SIN) (HR 1.22, 95% CrI 1.01-1.48), pathological/clinical stage III (HR 2.77, 95% CrI 1.93-3.97) and IV (HR 17.05, 95% CrI 11.94-24.34), histological grade 3 (HR 2.50, 95% CrI 1.20-5.23), Ki-67 proliferation index of 21-50% (HR 1.42, 95% CrI 1.10-1.83) and > 50% (HR 1.81, 95% CrI 1.29-2.55), and bilateral localization (HR 1.65, 95% CrI 1.01-2.68). Variables associated with lower death rate were estrogen and/or progesterone receptor positivity (HR 0.61, 95% CrI 0.45-0.81) and HER2/neu oncogene positivity (HR 0.59, 95% CrI 0.44-0.79). Discussion: The findings confirmed the independent prognostic values of different female breast cancer characteristics. Even after adjusting for patients and disease characteristics, residence in the SIN of Taranto appeared to be associated with an increased death rate.

Industrial air pollution and mortality in the Taranto area, Southern Italy: A difference-in-differences approach.

BACKGROUND: A large steel plant close to the urban area of Taranto (Italy) has been operating since the sixties. Several studies conducted in the past reported an excess of mortality and morbidity from various diseases at the town level, possibly due to air pollution from the plant. However, the relationship between air pollutants emitted from the industry and adverse health outcomes has been controversial. We applied a variant of the "difference-in-differences" (DID) approach to examine the relationship between temporal changes in exposure to industrial PM10 from the plant and changes in cause-specific mortality rates at area unit level. METHODS: We examined a dynamic cohort of all subjects (321,356 individuals) resident in the Taranto area in 1998-2010 and followed them up for mortality till 2014. In this work, we included only deaths occurring on 2008-2014. We observed a total of 15,303 natural deaths in the cohort and age-specific annual death rates were computed for each area unit (11 areas in total). PM10 and NO2 concentrations measured at air quality monitoring stations and the results of a dispersion model were used to estimate annual average population weighted exposures to PM10 of industrial origin for each year, area unit and age class. Changes in exposures and in mortality were analyzed using Poisson regression. RESULTS: We estimated an increased risk in natural mortality (1.86%, 95% confidence interval [CI]: -0.06, 3.83%) per 1 µg/m3 annual change of industrial PM10, mainly driven by respiratory causes (8.74%, 95% CI: 1.50, 16.51%). The associations were statistically significant only in the elderly (65+ years). CONCLUSIONS: The DID approach is intuitively simple and reduces confounding by design. Under the multiple assumptions of this approach, the study indicates an effect of industrial PM10 on natural mortality, especially in the elderly population.

[Intercensal reconstruction of population and descriptive epidemiological measures in Italy: what is the impact on the cancer incidence rates?]. / La ricostruzione intercensuaria della popolazione e le misure di epidemiologia descrittiva in Italia: qual è l'impatto sui tassi di incidenza dei tumori?

OBJECTIVES: to test the effect on cancer incidence rates when using precensal computation (computed population) or intercensal reconstruction of population (reconstructed population). DESIGN: comparison between computed and reconstructed population by area and period in 2002-2011; evaluation of the effect on cancer rates using Italian cancer registries data. Setting e participants: population data from the Italian National Institute for Statistics, cancer data from Italian cancer registries; specific analysis involves data from Parma (Emilia-Romagna Region, Northern Italy) and Taranto (Apulia Region, Southern Italy) cancer registries. MAIN OUTCOME MEASURES: ratio between computed and reconstructed population by area, gender, age, and period; ratio between corresponding age-standardized incidence rates. RESULTS: Italian population estimates by precensal computation for years 2002-2011 was generally higher than that obtained by intercensal reconstruction especially in 2011, when this has been found in more than 86% of Italian Municipalities. In the same year a smaller proportion of Municipalities (11%) showed an inverse population ratio. Among the most populated Municipalities, the City of Milan showed the higher precensal to intercensal population ratio (1.076), while the City of Taranto showed the lower precensal to intercensal population ratio (0.956). The ratios between age standardized rates obtained with precensal population to those obtained with intercensal population show similar differences; in particular, for all cancer in males and females they were, respectively, 0.985 and 0.982 in the Province of Parma, 0.974 and 0.968 in the City of Parma, 1.023 and 1.013 in the Province of Taranto, and 1.08 and 1.051 in the City of Taranto. CONCLUSION: using precensal population as denominator for the year 2002- 2011 produces a remarkable distortion of both temporal trend and geographical comparisons. It is, therefore, necessary that researchers take into account this possible distortion when reporting descriptive measures in the years between the last two censuses in Italy.

Estimates of cancer burden in Puglia.

AIMS AND BACKGROUND: A regional population-based cancer registry that provides incidence and survival data has become active only recently. Since it is important to know the time trends of basic epidemiological indicators to understand the cancer burden in the region, this paper will provide incidence, prevalence and mortality estimates in the region for seven major cancers for the period 1970-2015. METHODS: The estimates were obtained by applying the MIAMOD method, a statistical back-calculation approach to derive incidence and prevalence figures starting from mortality and relative survival data. Survival was modeled on the basis of published data from the Italian cancer registries. RESULTS: The incidence rates are estimated to be still increasing for female breast cancer, colorectal cancer in men and skin melanoma in both sexes. By contrast, the incidence rates indicate a decreasing trend for cervix uteri cancer and stomach cancer, the latter both in men and women. For these cancers an analogous trend is observed for mortality, confirming the reduction of the risk factors related to these cancer types. The incidence rates for lung cancer and prostate cancer in men were estimated to rise, reach a peak, and then decrease in the last part of the considered period. Prevalence increased for all the considered cancers except cervix cancer. The increase was striking for breast cancer and less pronounced for stomach cancer in both genders. CONCLUSION: This paper provides a description of the burden of the major cancers until 2015. The results highlight the need to reinforce effective preventive measures to contrast cancers related to an unhealthy lifestyle and to increase the compliance with organized screening programs to reduce the colorectal and breast cancer burden.

Environment and health in contaminated sites: the case of Taranto, Italy.

The National Environmental Remediation programme in Italy includes sites with documented contamination and associated potential health impacts (National Priority Contaminated Sites-NPCSs). SENTIERI Project, an extensive investigation of mortality in 44 NPCSs, considered the area of Taranto, a NPCS where a number of polluting sources are present. Health indicators available at municipality level were analyzed, that is, mortality (2003-2009), mortality time trend (1980-2008), and cancer incidence (2006-2007). In addition, the cohort of individuals living in the area was followed up to evaluate mortality (1998-2008) and morbidity (1998-2010) by district of residence. The results of the study consistently showed excess risks for a number of causes of death in both genders, among them: all causes, all cancers, lung cancer, and cardiovascular and respiratory diseases, both acute and chronic. An increased infant mortality was also observed from the time trends analysis. Mortality/morbidity excesses were detected in residents living in districts near the industrial area, for several disorders including cancer, cardiovascular, and respiratory diseases. These coherent findings from different epidemiological approaches corroborate the need to promptly proceed with environmental cleanup interventions. Most diseases showing an increase in Taranto NPCS have a multifactorial etiology, and preventive measures of proven efficacy (e.g., smoking cessation and cardiovascular risk reduction programs, breast cancer screening) should be planned. The study results and public health actions are to be communicated objectively and transparently so that a climate of confidence and trust between citizens and public institutions is maintained.

[Environment and health in Taranto, southern Italy: epidemiological studies and public health recommendations]. / Ambiente e salute a Taranto: studi epidemiologici e indicazioni di sanità pubblica.

INTRODUCTION: in Taranto IPS (Italian polluted site, made up of 2 municipalities) the Decree defining site boundaries lists the presence of a refinery, a steel plant, a harbour area and waste landfills together with illegal dumping sites. Previous environmental and epidemiological investigations in the area documented the presence of environmental contamination and increased mortality from respiratory and cardiovascular diseases as well as a number of cancer sites; for these same health outcomes the cohort study of residents showed increased risk both in terms of mortality and morbidity. OBJECTIVE: to describe the health status of residents in Taranto IPS analyzing different health indicators available at municipal level, i.e. mortality (2003-2009), mortality time trend (1980-2008) and cancer incidence (2006-2007). METHODS: the analyses were carried out for residents in Taranto IPS. Mortality update (SENTIERI Project, 2003-2009) regards 63 single or grouped causes (all ages, both genders); for a selection of causes 0-1 and 0-14 age classes were analyzed (both genders combined). Standardized mortality ratio crude (SMR) and deprivation adjusted together with 90% confidence intervals (90%CI) were computed using regional rates for comparison. Mortality time trend (1980-2008, triennial intervals) were analyzed calculating standardized rates (0-99 years, both genders, per 100,000, Italian population at 2001 Census as reference) and 90%CI. Time trends were computed for all causes, all neoplasms (and lung cancer), cardiovascular diseases (and ischemic heart diseases), respiratory diseases (also acute and chronic) and all causes infant mortality (both genders combined). For cancer incidence (2006-2007) Standardized incidence ratio (SIR) and 90%CI were calculated for both genders; incidence rates of cancer registries of the macroarea South and Islands (2005-2007) and rates of Taranto Province excluding SIN municipalities (2006-2007) were used for comparison. RESULTS: in Taranto IPS mortality among men is in excess in both periods (SENTIERI Project 1995-2002 and 2003-2009) for all causes, all neoplasms (including lung and pleural cancer), dementia, cardiovascular diseases (including hypertension and ischemic heart diseases), respiratory diseases (including the acute ones) and digestive diseases (including liver cirrhosis). All causes infant mortality is in excess in both periods. Time trends show that Taranto IPS rates are higher than regional average in the majority of time intervals for most causes in both genders. Rates are often higher than national average form any triennial intervals. Among males, over the whole period, mortality in Taranto IPS is higher than regional and national average for causes as lung cancer, diseases of the respiratory system, including the chronic ones. Among females, since the early Nineties, lung cancer and ischemic heart diseases are in excess in Taranto IPS. Also infant mortality is higher for the whole period in Taranto IPS than regional and national averages. Cancer incidence results show excesses for cancer sites already indicated by mortality data. CONCLUSIONS: mortality analyzed in the context of SENTIERI Project (1995-2002 and 2003-2009), time trend mortality (1980-2008) and cancer incidence (2006- 2007) show, in both genders, excesses for causes for which an etiologic role of environmental exposure present in Taranto IPS are either ascertained or suspected on the basis of a priori evaluation of the epidemiological evidence. The finding of excess infant mortality is of the utmost importance in public health terms. Most diseases showing an increased risk have multifactorial etiology, therefore interventions of proven efficacy, such as smoking cessation, food education, measures for cardiovascular risk reduction and breast cancer and colon screening programmes should be planned. To build a climate of confidence and trust between citizens and public institutions study results and public health actions are to be communicated objectively and transparently.