The burden of heat-related mortality attributable to recent human-induced climate change.

Climate change affects human health; however, there have been no large-scale, systematic efforts to quantify the heat-related human health impacts that have already occurred due to climate change. Here, we use empirical data from 732 locations in 43 countries to estimate the mortality burdens associated with the additional heat exposure that has resulted from recent human-induced warming, during the period 1991-2018. Across all study countries, we find that 37.0% (range 20.5-76.3%) of warm-season heat-related deaths can be attributed to anthropogenic climate change and that increased mortality is evident on every continent. Burdens varied geographically but were of the order of dozens to hundreds of deaths per year in many locations. Our findings support the urgent need for more ambitious mitigation and adaptation strategies to minimize the public health impacts of climate change.

High level of TILs is an independent predictor of negative sentinel lymph node in women but not in men.

Factors that are most associated with positive lymph node status in melanoma are Breslow thickness and ulceration. However, there are other factors that have been little explored and could help in the identification of "at risk patients" harbouring occult metastasis. The objective of this study was to determine whether intensity of tumour-infiltrating lymphocytes (TILs) in a cohort study (N = 4133) is an independent predictor of sentinel lymph node (SLN) status in patients with primary cutaneous melanoma. Of the patients with cutaneous melanoma who resulted negative for nodal metastasis, 50.7% had moderate/marked TILs versus 27.7% among those patients who resulted positive for nodal metastasis. In the multivariate analysis, controlling for sex, age, mitotic rate, ulceration and Breslow, high levels of TILs in primary invasive melanoma was associated with a lower risk of developing SLN metastasis (OR 0.46; 95% CI 0.23-0.95, p = 0.037). When the analysis was stratified by sex, the protective effect of moderate/marked TIL remained only for women (OR 0.30; 95% CI 0.10-0.93, p = 0.037) but not for men (OR 0.51; 95% CI 0.19-1.34, p = 0.172). Other independent predictors of negative lymph node were low Breslow thickness (≤ 2.0 mm) and low mitotic rate. Besides predicting a negative lymph node response, TILs were also associated with a decreased risk of 10-year mortality among females with positive lymph node. Our findings suggest that high level of TILs is an independent predictor of negative SLN status among women. Further research is warranted to confirm our findings.

Predictors of Beta-Hexachlorocyclohexane blood levels among people living close to a chemical plant and an illegal dumping site.

BACKGROUND: Hexachlorocyclohexane is a synthetic chemical with several isomers, including ß-Hexachlorocyclohexane (ß-HCH). In 2005, a large contamination of crude milk from some bovine farms along the Sacco River (Central Italy) was detected; it was related to the illegal disposal of large quantities of processing waste by a chemical industry of the area. A biomonitoring study, conducted in 2007 on a sample of the residing population, found high values of ß-HCH in people living close to the river. These results led to the establishment of a clinical and epidemiological surveillance program on all the exposed population. The aim of the study was to evaluate the determinants of ß-HCH blood levels in people living within 1 Km of the Sacco River, focusing on the role of specific foods, body mass index and risk factors not yet identified. METHODS: The program involved all people living within 1 km of the river. A descriptive analysis of ß-HCH blood levels was done in relation to the potential determinants including specific foods. Regression analysis was used to study the association between potential determinants and (natural log) ß-HCH haematic concentration. The results were expressed as geometric mean ratios (GMR). To take into account similarities within the families we adjusted for family clustering. RESULTS: A total of 602 subjects (87.2%) agreed to participate in the surveillance. The ß-HCH geometric mean serum concentration was 72 ng/g lipid. The regression analysis showed that being female (GMR: 1.32, 95%CI: 1.14-1.53), elderly (GMR> 70yy: 10.04, 95%CI: 6.65-15.15), obese (GMR: 1.63, 95%CI: 1.28-2.08), eating food of local/own production (GMR 1.47, 95%CI: 1.15-1.88) and using water from private wells (GMRdrink:1.47, 95%CI: 1.00-2.14 and GMRwash: 1.48, 95%CI: 1.17-1.87) were associated with higher ß-HCH values. There was inverse association with breastfeeding (GMR: 0.64, 95%CI: 0.47-0.86). The focus on specific foods showed that the most important factors were eggs and beef. CONCLUSIONS: The study indicated a greater contamination for older people, and those drinking and washing with water from private wells and consuming locally produced food, especially eggs and beef.

Temporal variation in the effect of heat and the role of the Italian heat prevention plan.

OBJECTIVES: The aim of the article is to evaluate the temporal change in the effect of heat on mortality in Italy in the last 12 years after the introduction of the national heat plan. STUDY DESIGN: Time series analysis. METHODS: Distributed lag non-linear models were used to estimate the association between maximum apparent temperature and mortality in 23 Italian cities included in the national heat plan in four study periods (before the introduction of the heat plan and three periods after the plan was in place between 2005 and 2016). The effect (relative risks) and impact (attributable fraction [AF] and number of heat-related deaths) were estimated for mild summer temperatures (20th and 75th percentile maximum apparent temperature [Tappmax]) and extreme summer temperatures (75th and 99th percentile Tappmax) in each study period. A survey of the heat preventive measures adopted over time in the cities included in the Italian heat plan was carried out to better describe adaptation measures and response. RESULTS: Although heat still has an impact on mortality in Italian cities, a reduction in heat-related mortality is observed progressively over time. In terms of the impact, the heat AF related to extreme temperatures declined from 6.3% in the period 1999-2002 to 4.1% in 2013-2016. Considering the entire temperature range (20th vs 99th percentile), the total number of heat-related deaths spared over the entire study period was 1900. CONCLUSIONS: Considering future climate change and the health burden associated to heat waves, it is important to promote adaptation measures by showing the potential effectiveness of heat prevention plans.

Climate change, extreme weather events, air pollution and respiratory health in Europe.

Due to climate change and other factors, air pollution patterns are changing in several urbanised areas of the world, with a significant effect on respiratory health both independently and synergistically with weather conditions; climate scenarios show Europe as one of the most vulnerable regions. European studies on heatwave episodes have consistently shown a synergistic effect of air pollution and high temperatures, while the potential weather-air pollution interaction during wildfires and dust storms is unknown. Allergen patterns are also changing in response to climate change, and air pollution can modify the allergenic potential of pollens, especially in the presence of specific weather conditions. The underlying mechanisms of all these interactions are not well known; the health consequences vary from decreases in lung function to allergic diseases, new onset of diseases, exacerbation of chronic respiratory diseases, and premature death. These multidimensional climate-pollution-allergen effects need to be taken into account in estimating both climate and air pollution-related respiratory effects, in order to set up adequate policy and public health actions to face both the current and future climate and pollution challenges.

Impact of heat on mortality in 15 European cities: attributable deaths under different weather scenarios.

BACKGROUND: High ambient summer temperatures have been shown to influence daily mortality in cities across Europe. Quantification of the population mortality burden attributable to heat is crucial to the development of adaptive approaches. The impact of summer heat on mortality for 15 European cities during the 1990s was evaluated, under hypothetical temperature scenarios warmer and cooler than the mean and under future scenarios derived from the Intergovernmental Panel on Climate Change Special Report on Emission Scenarios (SRES). METHODS: A Monte Carlo approach was used to estimate the number of deaths attributable to heat for each city. These estimates rely on the results of a Bayesian random-effects meta-analysis that combines city-specific heat-mortality functions. RESULTS: The number of heat-attributable deaths per summer ranged from 0 in Dublin to 423 in Paris. The mean attributable fraction of deaths was around 2%. The highest impact was in three Mediterranean cities (Barcelona, Rome and Valencia) and in two continental cities (Paris and Budapest). The largest impact was on persons over 75 years; however, in some cities, important proportions of heat-attributable deaths were also found for younger adults. Heat-attributable deaths markedly increased under warming scenarios. The impact under SRES scenarios was slightly lower or comparable to the impact during the observed hottest year. CONCLUSIONS: Current high summer ambient temperatures have an important impact on European population health. This impact is expected to increase in the future, according to the projected increase of mean ambient temperatures and frequency, intensity and duration of heat waves.

Effects of cold weather on mortality: results from 15 European cities within the PHEWE project.

Weather-related health effects have attracted renewed interest because of the observed and predicted climate change. The authors studied the short-term effects of cold weather on mortality in 15 European cities. The effects of minimum apparent temperature on cause- and age-specific daily mortality were assessed for the cold season (October-March) by using data from 1990-2000. For city-specific analysis, the authors used Poisson regression and distributed lag models, controlling for potential confounders. Meta-regression models summarized the results and explored heterogeneity. A 1 degrees C decrease in temperature was associated with a 1.35% (95% confidence interval (CI): 1.16, 1.53) increase in the daily number of total natural deaths and a 1.72% (95% CI: 1.44, 2.01), 3.30% (95% CI: 2.61, 3.99), and 1.25% (95% CI: 0.77, 1.73) increase in cardiovascular, respiratory, and cerebrovascular deaths, respectively. The increase was greater for the older age groups. The cold effect was found to be greater in warmer (southern) cities and persisted up to 23 days, with no evidence of mortality displacement. Cold-related mortality is an important public health problem across Europe. It should not be underestimated by public health authorities because of the recent focus on heat-wave episodes.

Factors affecting in-hospital heat-related mortality: a multi-city case-crossover analysis.

BACKGROUND: Several studies have identified strong effects of high temperatures on mortality at population level; however, individual vulnerability factors associated with heat-related in-hospital mortality are largely unknown. The objective of the study was to evaluate heat-related in-hospital mortality using a multi-city case-crossover analysis. METHODS: We studied residents of four Italian cities, aged 65+ years, who died during 1997-2004. For 94,944 individuals who died in hospital and were hospitalised two or more days before death, demographics, chronic conditions, primary diagnoses of last event and hospital wards were considered. A city-specific case-crossover analysis was performed to evaluate the association between apparent temperature and mortality. Pooled odds ratios (OR) of dying on a day with a temperature of 30 degrees C compared to a day with a temperature of 20 degrees C were estimated with a random-effects meta-analysis. RESULTS: We estimated an overall OR of 1.32 (95% confidence interval: 1.25, 1.39). Age, marital status and hospital ward were important risk indicators. Patients in general medicine were at higher risk than those in high and intensive care units. A history of psychiatric disorders and cerebrovascular diseases gave a higher vulnerability. Mortality was greater among patients hospitalised for heart failure, stroke and chronic pulmonary diseases. CONCLUSIONS: In-hospital mortality is strongly associated with high temperatures. A comfortable temperature in hospitals and increased attention to vulnerable patients during heatwaves, especially in general medicine, are necessary preventive measures.

Airport and city-centre temperatures in the evaluation of the association between heat and mortality.

A variety of ambient exposure indicators have been used to evaluate the impact of high temperature on mortality and in the identification of susceptible population sub-groups, but no study has evaluated how airport and city centre temperatures differ in their association with mortality during summer. This study considers the differences in temperatures measured at the airport and in the city centre of three Italian cities (Milan, Rome and Turin) and investigates the impact of these measures on daily mortality. The case-crossover design was applied to evaluate the association between daily mean apparent temperature (MAT) and daily total mortality. The analysis was conducted for the entire population and for subgroups defined by demographic characteristics, socioeconomic status and chronic comorbidity (based on hospitalisation during the preceding 2 years). The percentage risk of dying, with 95% confidence intervals (95% CI), on a day with MAT at the 95th percentile with respect to the 25th percentile of the June-September daily distribution was estimated. Airport and city-centre temperature distributions, which vary among cities and between stations, have a heterogeneous impact on mortality. Milan was the city with the greatest differences in mean MAT between airport and city stations, and the overall risk of dying was greater when airport MAT (+47% increase, 95%CI 38-57) was considered in comparison to city MAT (+37% increase, 95%CI 30-45). In Rome and Turin, the results were very similar for both apparent temperature measures. In all cities, the elderly, women and subjects with previous psychiatric conditions, depression, heart and circulation disorders and cerebrovascular disease were at higher risk of dying during hot days, and the degree of effect modification was similar using airport or city-centre MAT. Studies on the impact of meteorological variables on mortality, or other health indicators, need to account for the possible differences between airport and city centre meteorological variables in order to give more accurate estimates of health effects.

The impact of the summer 2003 heat waves on mortality in four Italian cities.

This study evaluates the impact of the 2003 heat wave on cause-specific mortality and the role of demographic characteristics and socioeconomic conditions that may have increased the risk of mortality in four Italian cities: Bologna, Milan, Rome and Turin. Daily mortality counts, for the resident population by age, sex and cause of death were considered. Daily excess mortality was calculated as the difference between the number of deaths observed and the smoothed average. The impact of heat on health is measured in terms of maximum apparent temperature. The greatest excess in mortality was observed in the north west of Italy (Turin, +23% and Milan, +23%). The old (75-84 years) and the very old (85+ years) were the age groups most affected, and when stratifying by sex, the increase in mortality seemed to be greater among females. The greatest excess in mortality was registered in those with low socioeconomic status in Rome (+17.8%) and in those with lower education levels in Turin (+43%). The analysis of cause-specific mortality not only confirms results from previous studies of an increase in heat-related mortality by respiratory and cardiovascular diseases, but also shows a significant excess in mortality for diseases of the central nervous system and for metabolic/endocrine disorders. Results from 2003 highlight the necessity of targeting future prevention programmes at the susceptible sub-groups identified. The introduction of warning systems alongside efficient preventive plans and the monitoring of mortality during heat waves may represent a valid tool for the reduction of heat-related deaths.

The impact of the summer 2003 heat waves on mortality in four Italian cities.

This study evaluates the impact of the 2003 heat wave on cause-specific mortality and the role of demographic characteristics and socioeconomic conditions that may have increased the risk of mortality in four Italian cities: Bologna, Milan, Rome and Turin. Daily mortality counts, for the resident population by age, sex and cause of death were considered. Daily excess mortality was calculated as the difference between the number of deaths observed and the smoothed average. The impact of heat on health is measured in terms of maximum apparent temperature. The greatest excess in mortality was observed in the north west of Italy (Turin, +23% and Milan, +23%). The old (75-84 years) and the very old (85+ years) were the age groups most affected, and when stratifying by sex, the increase in mortality seemed to be greater among females. The greatest excess in mortality was registered in those with low socioeconomic status in Rome (+17.8%) and in those with lower education levels in Turin (+43%). The analysis of cause-specific mortality not only confirms results from previous studies of an increase in heat-related mortality by respiratory and cardiovascular diseases, but also shows a significant excess in mortality for diseases of the central nervous system and for metabolic/endocrine disorders. Results from 2003 highlight the necessity of targeting future prevention programmes at the susceptible sub-groups identified. The introduction of warning systems alongside efficient preventive plans and the monitoring of mortality during heat waves may represent a valid tool for the reduction of heat-related deaths.

Occupational and environmental exposures and lung cancer in an industrialised area in Italy.

AIMS: To investigate the effects of occupational exposures and residence near to industrial sites on lung cancer mortality in an area in Italy. METHODS: 234 cases of lung cancer and 729 controls matched by sex, age, and date of death were enrolled. Environmental exposure was evaluated using historical residence data. A geographical information system was used to compute distances from residence to pollution source (cement factory, power plants, harbour) and an average distance was computed for each subject. Odds ratios (OR) and 95% confidence intervals (CI) in a logistic regression model were used to estimate the relative risk of lung cancer associated with the risk factors (smoking habits and occupational exposure) collected by questionnaire; ORs for distances from pollution sources and from city centre were computed, adjusting for smoking habits, education, and occupation. RESULTS: Smoking habits (< or =10 cigarettes/day, OR = 2.28; 11-20, OR = 4.64; >20, OR = 6.61) and occupational exposure to asbestos (OR = 3.50) were significantly associated with lung cancer risk. Reported traffic level of area of residence and residence near the four sources were not associated with increased risk of lung cancer. There was a significantly increased risk for those residing outside the city centre, in the southern outskirts (OR = 1.51). CONCLUSIONS: The increased lung cancer risk observed in the area can partly be explained by occupational exposures. The increased risk in the outskirts of the city is consistent with the results of dispersion models that indicate high levels of pollutant deposition in the same area.

Short-term effects of particulate air pollution on cardiovascular diseases in eight European cities.

STUDY OBJECTIVE: As part of the APHEA project this study examined the association between airborne particles and hospital admissions for cardiac causes (ICD9 390-429) in eight European cities (Barcelona, Birmingham, London, Milan, the Netherlands, Paris, Rome, and Stockholm). All admissions were studied, as well as admissions stratified by age. The association for ischaemic heart disease (ICD9 410-413) and stroke (ICD9 430-438) was also studied, also stratified by age. DESIGN: Autoregressive Poisson models were used that controlled for long term trend, season, influenza epidemics, and meteorology to assess the short-term effects of particles in each city. The study also examined confounding by other pollutants. City specific results were pooled in a second stage regression to obtain more stable estimates and examine the sources of heterogeneity. MAIN RESULTS: The pooled percentage increases associated with a 10 micro g/m(3) increase in PM(10) and black smoke were respectively 0.5% (95% CI: 0.2 to 0.8) and 1.1% (95% CI: 0.4 to 1.8) for cardiac admissions of all ages, 0.7% (95% CI: 0.4 to 1.0) and 1.3% (95% CI: 0.4 to 2.2) for cardiac admissions over 65 years, and, 0.8% (95% CI: 0.3 to 1.2) and 1.1% (95% CI: 0.7 to 1.5) for ischaemic heart disease over 65 years. The effect of PM(10) was little changed by control for ozone or SO(2), but was substantially reduced (CO) or eliminated (NO(2)) by control for other traffic related pollutants. The effect of black smoke remained practically unchanged controlling for CO and only somewhat reduced controlling for NO(2). CONCLUSIONS: These effects of particulate air pollution on cardiac admissions suggest the primary effect is likely to be mainly attributable to diesel exhaust. Results for ischaemic heart disease below 65 years and for stroke over 65 years were inconclusive.

Air pollution and hospital admissions for respiratory conditions in Rome, Italy.

Most of the evidence regarding the association between particulate air pollution and emergency room visits or hospital admissions for respiratory conditions and asthma comes from the USA. European time-series analyses have suggested that gaseous air pollutants are important determinants of acute hospitalization for respiratory conditions, at least as important as particulate mass. The association between daily mean levels of suspended particles and gaseous pollutants (sulphur dioxide, nitrogen dioxide, carbon monoxide, ozone) was examined. The daily emergency hospital admissions for respiratory conditions in the metropolitan area of Rome during 1995-1997 were also recorded. Daily counts of hospital admissions for total respiratory conditions (43 admissions day(-1)), acute respiratory infections including pneumonia (18 day(-1)), chronic obstructive pulmonary disease (COPD) (13 day(-1)), and asthma (4.5 day(-1)) among residents of all ages and among children (0-14 yrs) were analysed. The generalized additive models included spline smooth functions of the day of study, mean temperature, mean humidity, influenza epidemics, and indicator variables for day of the week and holidays. Total respiratory admissions were significantly associated with same-day level of NO2 (2.5% increase per interquartile range (IQR) change, 22.3 microg x m(-3)) and CO (2.8% increase per IQR, 1.5 mg x m(-3)). No effect was found for particulate matter and SO2, whereas O3 was associated with admissions only among children (lag 1, 5.5% increase per IQR, 23.9 microg x m3). The effect of NO2 was stronger on acute respiratory infections (lag 0, 4.0% increase) and on asthma among children (lag 1, 10.7% increase). The admissions for all ages for asthma and COPD were associated only with same-day level of CO (5.5% and 4.3% increase, respectively). Multipollutant models confirmed the role of CO on all respiratory admissions, including asthma and COPD, and that of NO2 on acute respiratory infections. Among children, O3 remained a strong indicator of acute respiratory infections. Carbon monoxide and photochemical pollutants (nitrogen dioxide, ozone) appear to be determinants of acute respiratory conditions in Rome. Since carbon monoxide and nitrogen dioxide are good indicators of combustion products from traffic related sources, the detected effect may be due to unmeasured fine and ultrafine particles.

[Leukemia mortality and incidence of infantile leukemia near the Vatican Radio Station of Rome]. / Mortalità per leucemia e incidenza di leucemia infantile in prossimità della stazione di Radio Vaticana di Roma.

Some recent epidemiological studies suggest an association between lymphatic and haematopoietic cancers and residential exposure to high frequency electromagnetic fields (100 kHz-300 GHz) generated by radio and television transmitters. Vatican Radio, a very powerful radio station transmitting all over the world (up to 600 kW) is located in Santa Maria di Galeria, in the northern suburbs of the city of Rome. Electric field measurements in the proximity of the radio station ranged between 1.5 and 25 V/m. In the 10 km area around the station, with 60.182 residents (1999), leukaemia mortality among adults (> 14 years, 40 cases) in the period 1987-98 and childhood leukaemia incidence in the period 1987-99 (8 cases) were evaluated. The analysis (Stone's conditional test) was performed computing observed and expected cases (reference: population of Rome) in 5 bands of increasing radius (2 km width). The risk of childhood leukaemia was higher than expected within 6 km from the station (Standardized Incidence Ratio = 217; 95% Confidence Interval 99-405). Stone's test showed a significant decrease in risk with increasing distance both for male adult mortality (p-value = 0.03) and for childhood incidence (p-value = 0.04). A Score test, showed a significant decrease in risk of childhood incidence as function of the distance. The main limitations of this study are the small number of observed cases and the use of distance as a proxy for RF exposure. Further research will require a systematic campaign of electromagnetic field measurements to allow better assessment of the population exposure.

[Acute effects of air pollution in Rome]. / Studi sugli effetti acuti dell'inquinamento atmosferico a Roma.

Two time-series studies, aimed at evaluating the acute health effect of air pollution among Rome inhabitants, were carried out. In the first study the correlation between daily mortality (1992 to 1995) and daily concentrations of five air pollutants (particles, SO2, NO2, CO, O3) was analyzed. In the second study the association between daily levels of the same pollutants and hospital admissions for respiratory and cardiovascular disease (1995-97) was evaluated. Poisson regression models were used to estimate the association between pollutant levels and health effect variables; the models included smooth functions of day of study, mean temperature, mean humidity and indicator variables for day of the week and holidays. Daily total mortality was associated with particle average concentration on that day and with NO2 levels of one or two days before. Hospital admissions for cardiovascular disease were positively correlated to particles, SO2, NO2, e CO. Hospital admissions for respiratory disease were associated with NO2 and CO levels of the same day and of two days before among children (0-14 years) and among adults (15-64 years). Increments of ozone were associated with increments of total respiratory and of acute respiratory diseases in children (0-14 years).

[Socioeconomic differences in mortality in Rome, 1990-1995]. / Differenze sociali nella mortalità a Roma negli anni 1990-1995.

Population groups with a lower socioeconomic status (SES) have a greater risk of disease and mortality. The aim of this study was to investigate the relationship between SES and mortality in the metropolitan area of Rome during the six-year period 1990-1995, and to examine variations in mortality differentials between 1990-92 and 1993-95. Rome has a population of approximately 2,800,000, with 6,100 census tracts (CTs). During the study period, 149,002 deaths occurred among residents. We compared cause-specific mortality rates among four socioeconomic categories (SES) defined by a socioeconomic index, derived from characteristics of the CT of residence. Among men, total mortality and mortality for the major causes of death showed an inverse association with SES. Among 15-44 year old men, the strong positive association between total mortality and low SES was due to AIDS and overdose mortality. Among women, a positive association with lower SES was observed for stomach cancer, uterus cancer and cardiovascular disease, whereas mortality for breast cancer was higher in the groups with higher SES. Comparing the periods 1990-92 and 1993-95, differences in total mortality between socioeconomic groups widened in both sexes. Increasing differences were observed for tuberculosis and lung cancer among men, and for uterus cancer, traffic accidents, and overdose mortality among women. The use of an area-based indicator of SES limits the interpretations of the findings. However, despite the possible limitations, these results suggest that social class differences in mortality in Rome are increasing. Time changes in life style and in the prevalence of risk behaviors may produce differences in disease incidence. Moreover inequalities in the access to medical care and in the quality of care may contribute to an increasing differentials in mortality.

Inequality in health: socioeconomic differentials in mortality in Rome, 1990-95.

STUDY OBJECTIVE: Population groups with a lower socioeconomic status (SES) have a greater risk of disease and mortality. The aim of this study was to investigate the relation between SES and mortality in the metropolitan area of Rome during the six year period 1990-1995, and to examine variations in mortality differentials between 1990-92 and 1993-95. DESIGN: Rome has a population of approximately 2,800,000, with 6100 census tracts (CTs). During the study period, 149,002 deaths occurred among residents. The cause-specific mortality rates were compared among four socioeconomic categories defined by a socioeconomic index, derived from characteristics of the CT of residence. MAIN RESULTS: Among men, total mortality and mortality for the major causes of death showed an inverse association with SES. Among 15-44 year old men, the strong positive association between total mortality and low SES was attributable to AIDS and overdose mortality. Among women, a positive association with lower SES was observed for stomach cancer, uterus cancer and cardiovascular disease, whereas mortality for lung and breast cancers was higher in the groups with higher SES. Comparing the periods 1990-92 and 1993-95, differences in total mortality between socioeconomic groups widened in both sexes. Increasing differences were observed for tuberculosis and lung cancer among men, and for uterus cancer, traffic accidents, and overdose mortality among women. CONCLUSIONS: The use of an area-based indicator of SES limits the interpretations of the findings. However, despite the possible limitations, these results suggest that social class differences in mortality in Rome are increasing. Time changes in lifestyle and in the prevalence of risk behaviours may produce differences in disease incidence. Moreover, inequalities in the access to medical care and in the quality of care may contribute to an increasing differentials in mortality.