Population-based breast cancer screening in Pavia (northern Italy) in 2016-2018: Key performance indicators and sensitivity estimate.

BACKGROUND AND AIM: This study aims to assess the quality of the population-based breast cancer screening programme in Pavia, northern Italy computing its key performance indicators and estimating its sensitivity for the years 2016-2018. METHODS: Invitation and examination coverage, participation rate, recall rate, detection rate and positive predictive values were computed on the basis of data provided yearly to the Italian Ministry of Health. Sensitivity was estimated identifying interval cancers in the local Cancer Registry and computed with the proportional incidence method. RESULTS: In 2016-2018 the adjusted invitation coverage was 90%, and the adjusted participation rate was 62%. Recall rate was 8.4% for first screenings and 3.9% for subsequent ones. The number of screen-detected cases was 268, corresponding to a detection rate of 6.6‰ for first screenings and 4.6‰ for subsequent screenings. The number of interval cancers observed was 110 over the study period; the proportional incidence was 22% for the first interval year and 50% for the second interval. The overall sensitivity of the screening program was 64%. CONCLUSIONS: The analysis of performance indicators and sensitivity estimates for the Pavia programme indicates that the programme performance is in line with the quality standards set by the European Union and the Italian reference scientific society (GISMa).

Participants' satisfaction with colorectal cancer screening programs: A systematic review.

INTRODUCTION: Since satisfaction with cancer screening experience can increase adherence to programs and contribute to reduce morbidity and mortality, its assessment is crucial for programs´ effectiveness. Our aim was to conduct a systematic review about satisfaction of participants with organized colorectal cancer screening. METHODS: We searched relevant scientific databases (MEDLINE, EMBASE, PsycINFO, and CINAHL) from inception to May 2022. We selected cross-sectional studies and clinical trials reporting a quantitative survey-based measure of satisfaction towards CRC screening. RESULTS: A total of 15 studies were included, being published from 1992 to 2019 for an overall number of 21 surveys. Of those, 16 (76%) investigated satisfaction with screening tests (fecal occult blood test, fecal immunochemical test, sigmoidoscopy, colonoscopy, computed tomographic colonography), 4 (19%) with colonoscopy as assessment test after suspicious findings, and 2 (10%) with both the screening and assessment phase. None of the included surveys used a validated questionnaire. Most surveys reported a high level of satisfaction for both screening and further assessment phases. Temporary pain, discomfort, embarrassment, and anxiety while waiting for results were the commonest negative aspects perceived, with some variability across studies and considered procedures. CONCLUSIONS: Satisfaction with the information and communication about screening was generally good, but some authors reported participants' sub-optimal understanding of informative material. Satisfaction with CRC screening is generally high, but its evaluation is performed using non-validated instruments, which limits the interpretation of results and prevents comparability of the current body of evidence.

Time-Trends in Air Pollution Impact on Health in Italy, 1990-2019: An Analysis From the Global Burden of Disease Study 2019.

Objectives: We explored temporal variations in disease burden of ambient particulate matter 2.5 µm or less in diameter (PM2.5) and ozone in Italy using estimates from the Global Burden of Disease Study 2019. Methods: We compared temporal changes and percent variations (95% Uncertainty Intervals [95% UI]) in rates of disability adjusted life years (DALYs), years of life lost, years lived with disability and mortality from 1990 to 2019, and variations in pollutant-attributable burden with those in the overall burden of each PM2.5- and ozone-related disease. Results: In 2019, 467,000 DALYs (95% UI: 371,000, 570,000) were attributable to PM2.5 and 39,600 (95% UI: 18,300, 61,500) to ozone. The crude DALY rate attributable to PM2.5 decreased by 47.9% (95% UI: 10.3, 65.4) from 1990 to 2019. For ozone, it declined by 37.0% (95% UI: 28.9, 44.5) during 1990-2010, but it increased by 44.8% (95% UI: 35.5, 56.3) during 2010-2019. Age-standardized rates declined more than crude ones. Conclusion: In Italy, the burden of ambient PM2.5 (but not of ozone) significantly decreased, even in concurrence with population ageing. Results suggest a positive impact of air quality regulations, fostering further regulatory efforts.

Asthma, COPD, Respiratory, and Allergic Health Effects in an Adult Population Living near an Italian Refinery: A Cross-Sectional Study.

BACKGROUND AND AIM: Asthma and chronic obstructive pulmonary disease (COPD) are leading causes of morbidity and mortality worldwide. Globally, 545 million people suffer from chronic respiratory diseases with a wide geographical variability. Risk factors for asthma are both genetic and related to several environmental factors (internal and external pollutants); these also have an important role in the occurrence of COPD. The aim of this study was to describe the prevalence of asthma, COPD, and asthma/COPD overlap (ACO) in an adult population living in two municipalities located in the Po Valley. METHODS: A standardized questionnaire on respiratory symptoms and sociodemographic characteristics was self-administered to a random sample of the adult population aged 20-64 years, living near a refinery in Northern Italy during the period between 2016 and 2019. Logistic and multinomial regression were implemented to explore factors associated with asthma, COPD, and ACO. RESULTS: In total, 1108 subjects filled out the questionnaire, the mean age was 48.02 ± 12.34 years (range 21-68), and 53% of the respondents/participants were female. Half of the responders were non-smokers, but the frequency of current and former smokers was significantly greater in men than in women (p < 0.001). The likelihood of being a probable case of asthma decreased with increasing age and increased for smokers. Tobacco smoke was associated with the presence of COPD and ACO. CONCLUSION: Respiratory diseases such as asthma and COPD are common in the general population, with differences among countries worldwide. Our findings show, on the basis of the main confirmed risk factor, namely smoking, that it is useful to plan target programs and actions in order to reduce smoking, thus improving the quality of life in public health.

[Effects on mortality and morbidity among the population living close to the Valmadrera (Lombardy Region, Northern Italy) incinerator]. / Effetti sulla mortalità e morbilità nella popolazione residente nei pressi dell'inceneritore di Valmadrera (LC).

OBJECTIVES: assessment of the health effects on the resident population around the incinerator for municipal solid waste in Valmadrera (Lombardy Region, Northern Italy) in relation to the exposure level to the pollutants produced by the plant. DESIGN: historical cohort study, based on the resident population from 2003 to 2016 in the study area. With a dispersion model, based on PM10 emitted by the plant, three areas of exposure (high, medium, low) were defined and, on the basis of the residence of the cohort, different exposure levels were attributed to the subjects. The association between level of exposure and health effects were estimated by comparing the high and medium exposure levels with the low exposure level, using a Cox model, adjusted for age and socioeconomic deprivation index. MAIN OUTCOME MEASURES: mortality rates, hospitalization rates, cancer incidence rates, and perinatal outcomes were analysed for the main causes potentially associated with exposure to incineration plants. RESULTS: the subjects enrolled in the cohort were 106,056 (1,000,242 person-years). There were no statistically significant excesses of risk for almost all the outcomes investigated. Excessive mortality and hospitalization were found for liver/biliary cancers (HR women: 2.57; 95%CI 1.15-2.79; HR men: 2.22; 95%CI 1.10-4, 84). In the municipality where the plant is located, an excess prevalence (OR 1.78; 95%CI 1.43-2.21) of hepatitis C was found. CONCLUSIONS: the results suggest the absence of a relationship between residence in areas with different levels of pollutants emitted by the plant and the onset of almost all diseases. The associated causes do not have aetiological plausibility with exposure to pollutants from waste incineration. In particular, for liver/liver and biliary cancer, the association with infectious causes rather than exposure to environmental pollutants is more plausible.

Impact of the COVID-19 Pandemic on Total and Cause-Specific Mortality in Pavia, Northern Italy.

The COVID-19 pandemic had an unfavorable impact on overall mortality in Italy, with the strongest consequences in northern Italy. Scant data are available on cause-specific mortality. This study aims at investigating the impact of the pandemic on the overall and cause-specific mortality in one province in northern Italy, Pavia. We linked individual-level administrative data (i.e., death certification and population data) from the Health Protection Agency (HPA) in Pavia province between 2015 and 2020. We computed age-standardized mortality rates (Italian population 2011) by cause, sex, and calendar year, and computed the rate ratio and the corresponding 95% confidence intervals to compare rates in 2020 versus 2015-2019. The 2020 excess total mortality in Pavia was 24% in men and 25% in women, reaching rates of 1272.6/100,000 and 1304.4/100,000, respectively. Significant excesses were found for infectious and parasitic diseases, excluding COVID-19 (about +30% in both sexes); respiratory system diseases (44% in men; 30% in women); and dementia and Alzheimer's disease among men (24%). Reductions were reported for neoplasms (-14% in men); cerebrovascular diseases (-25% in men); and ischemic diseases (-13% in women), but also for transport accidents in men. COVID-19 was the third cause of death in both sexes with rates of 274.9/100,000 men (859 total deaths) and 213.9/100,000 women (758 total deaths). Excess mortality in Pavia was higher than Italy but lower than Lombardy. Increases in mortality from causes related to infectious and respiratory diseases can likely be explained by underdiagnosed deaths from COVID-19.

Health impact assessment should be based on correct methods.

The methodology of health impact assessment (HIA), originally proposed by WHO, is widely used to predict the potential health effects in a community living in a place in which a new project (e.g., an industrial plant) will be implemented. One of the key quantities to calculate the impact (i.e., the number of attributable cases) is the baseline (i.e., before the project implementation) rate of selected diseases in the community. In a recent paper on this journal, this methodology has been challenged. Specifically, the use of baseline rate has been questioned, proposing to use only the fraction of the baseline rate due to the exposures related to the project, and not the rate due to all risk factors for the disease. In this commentary, we argue that the proposal is logically and epidemiologically unsound, and devoid of scientific motivation. The conclusion that the traditional approach overestimates the health impact should be rejected as based on flawed assumptions. On the contrary, the proposal may produce a (seriously biased) underestimation of attributable cases.

Social contacts, epidemic spreading and health system. Mathematical modeling and applications to COVID-19 infection.

Lockdown and social distancing, as well as testing and contact tracing, are the main measures assumed by the governments to control and limit the spread of COVID-19 infection. In reason of that, special attention was recently paid by the scientific community to the mathematical modeling of infection spreading by including in classical models the effects of the distribution of contacts between individuals. Among other approaches, the coupling of the classical SIR model with a statistical study of the distribution of social contacts among the population, led some of the present authors to build a Social SIR model, able to accurately follow the effect of the decrease in contacts resulting from the lockdown measures adopted in various European countries in the first phase of the epidemic. The Social SIR has been recently tested and improved through a fruitful collaboration with the Health Protection Agency (ATS) of the province of Pavia (Italy), that made it possible to have at disposal all the relevant data relative to the spreading of COVID-19 infection in the province (half a million of people), starting from February 2020. The statistical analysis of the data was relevant to fit at best the parameters of the mathematical model, and to make short-term predictions of the spreading evolution in order to optimize the response of the local health system.

The role of aircraft noise annoyance and noise sensitivity in the association between aircraft noise levels and medication use: results of a pooled-analysis from seven European countries.

BACKGROUND: Few studies have considered aircraft noise annoyance and noise sensitivity in analyses of the health effects of aircraft noise, especially in relation to medication use. This study aims to investigate the moderating and mediating role of these two factors in the relationship between aircraft noise levels and medication use among 5860 residents of ten European airports included in the HYENA and DEBATS studies. METHODS: Information on aircraft noise annoyance, noise sensitivity, medication use, and demographic, socio-economic and lifestyle factors was collected during a face-to-face interview at home. Medication was coded according to the Anatomical Therapeutic Chemical (ATC) classification. Outdoor aircraft noise exposure was estimated by linking the participant's home address to noise contours using Geographical Information Systems (GIS) methods. Logistic regressions with adjustment for potential confounding factors were used. In addition, Baron and Kenny's recommendations were followed to investigate the moderating and mediating effects of aircraft noise annoyance and noise sensitivity. RESULTS: A significant association was found between aircraft noise levels at night and antihypertensive medication only in the UK (OR = 1.43, 95%CI 1.19-1.73 for a 10 dB(A)-increase in Lnight). No association was found with other medications. Aircraft noise annoyance was significantly associated with the use of antihypertensive medication (OR = 1.33, 95%CI 1.14-1.56), anxiolytics (OR = 1.48, 95%CI 1.08-2.05), hypnotics and sedatives (OR = 1.60, 95%CI 1.07-2.39), and antasthmatics (OR = 1.44, 95%CI 1.07-1.96), with no difference between countries. Noise sensitivity was significantly associated with almost all medications, with the exception of the use of antasthmatics, showing an increase in ORs with the level of noise sensitivity, with differences in ORs among countries only for the use of antihypertensive medication. The results also suggested a mediating role of aircraft noise annoyance and a modifying role of both aircraft noise annoyance and noise sensitivity in the association between aircraft noise levels and medication use. CONCLUSIONS: The present study is consistent with the results of the small number of studies available to date suggesting that both aircraft noise annoyance and noise sensitivity should be taken into account in analyses of the health effects of exposure to aircraft noise.

Spatial-Temporal Modelling of Disease Risk Accounting for PM2.5 Exposure in the Province of Pavia: An Area of the Po Valley.

Spatio-temporal Bayesian disease mapping is the branch of spatial epidemiology interested in providing valuable risk estimates in certain geographical regions using administrative areas as statistical units. The aim of the present paper is to describe spatio-temporal distribution of cardiovascular mortality in the Province of Pavia in 2010 through 2015 and assess its association with environmental pollution exposure. To produce reliable risk estimates, eight different models (hierarchical log-linear model) have been assessed: temporal parametric trend components were included together with some random effects that allowed the accounting of spatial structure of the region. The Bayesian approach allowed the borrowing information effect, including simpler model results in the more complex setting. To compare these models, Watanabe-Akaike Information Criteria (WAIC) and Leave One Out Information Criteria (LOOIC) were applied. In the modelling phase, the relationship between the disease risk and pollutants exposure (PM2.5) accounting for the urbanisation level of each geographical unit showed a strong significant effect of the pollutant exposure (OR = 1.075 and posterior probability, or PP, >0.999, equivalent to p < 0.001). A high-risk cluster of Cardiovascular mortality in the Lomellina subareas in the studied window was identified.

The role of aircraft noise annoyance and noise sensitivity in the association between aircraft noise levels and hypertension risk: Results of a pooled analysis from seven European countries.

INTRODUCTION: Many studies, including the HYENA and the DEBATS studies, showed a significant association between aircraft noise exposure and the risk of hypertension. Few studies have considered aircraft noise annoyance and noise sensitivity as factors of interest, especially in relation to hypertension risk, or as mediating or modifying factors. The present study aims 1) to investigate the risk of hypertension in relation to aircraft noise annoyance or noise sensitivity; and 2) to examine the role of modifier or mediator of these two factors in the association between aircraft noise levels and the risk of hypertension. METHODS: This study included 6,105 residents of ten European airports from the HYENA and DEBATS studies. Information on aircraft noise annoyance, noise sensitivity, and demographic, socioeconomic and lifestyle factors was collected during an interview performed at home. Participants were classified as hypertensive if they had either blood pressure levels above the WHO cut-off points or physician-diagnosed hypertension in conjunction with the use of antihypertensive medication. Outdoor aircraft noise exposure was estimated for each participant's home address. Poisson regression models with adjustment for potential confounders were used. Interactions between noise exposure and country were tested to consider possible differences between countries. RESULTS: An increase in aircraft noise levels at night was weekly but significantly associated with an increased risk of hypertension (RR = 1.03, 95% CI 1.01-1.06 for a 10-dB(A) increase in Lnight). A significant association was found between aircraft noise annoyance and hypertension risk (RR = 1.06, 95%CI 1.00-1.13 for highly annoyed people compared to those who were not highly annoyed). The risk of hypertension was slightly higher for people highly sensitive to noise compared to people with low sensitivity in the UK (RR = 1.29, 95%CI 1.05-1.59) and in France (RR = 1.11, 95%CI 0.68-1.82), but not in the other countries. The association between aircraft noise levels and the risk of hypertension was higher among highly sensitive participants (RR = 1.00, 95%CI 0.96-1.04; RR = 1.03, 95%CI 0.90-1.11; RR = 1.12, 95%CI 1.01-1.24, with a 10-dB(A) increase in Lnight for low, medium, and high sensitive people respectively) or, to a lesser extent, among highly annoyed participants (RR = 1.06, 95%CI 0.95-1.18 for a 10-dB(A) increase in Lnight among highly annoyed participants, and RR = 1.02, 95%CI 0.99-1.06 among those not highly annoyed). CONCLUSIONS: The present study confirms findings in the small number of available studies to date suggesting adverse health effects associated with aircraft noise annoyance and noise sensitivity. The findings also indicate possible modifier effects of aircraft noise annoyance and noise sensitivity in the relationship between aircraft noise levels and the risk of hypertension. However, further investigations are needed to better understand this role using specific methodology and tools related to mediation analysis and causal inference.

Risk Perception and COVID-19.

The call for articles for the International Journal of Environmental Research and Public Health Special Issue "Research about risk perception in the Environmental Health domain" was proposed at the beginning of 2020 as part of multidisciplinary efforts to understand the complex interactions between people and the environment [...].

[Rt or RDt, that is the question!] / Rt or RDt, that is the question!

The article compares two of the most followed indices in the monitoring of COVID-19 epidemic cases: the Rt and the RDt indices. The first was disseminated by the Italian National Institute of Health (ISS) and the second, which is more usable due to the lower difficulty of calculation and the availability of data, was adopted by various regional and local institutions.The rationale for the Rt index refers to that for the R0 index, the basic reproduction number, which is used by infectivologists as a measure of contagiousness of a given infectious agent in a completely susceptible population. The RDt index, on the other hand, is borrowed from the techniques of time series analysis for the trend of an event measurement that develops as a function of time. The RDt index does not take into account the time of infection, but the date of the diagnosis of positivity and for this reason it is defined as diagnostic replication index, as it aims to describe the intensity of the development of frequency for cases recognized as positive in the population.The comparison between different possible applications of the methods and the use of different types of monitoring data was limited to four areas for which complete individual data were available in March and April 2020. The main problems in the use of Rt, which is based on the date of symptoms onset, arise from the lack of completeness of this information due both to the difficulty in the recording and to the absence in asymptomatic subjects.The general trend of RDt, at least at an intermediate lag of 6 or 7 days, is very similar to that of Rt, as confirmed by the very high value of the correlation index between the two indices. The maximum correlation between Rt and RDt is reached at lag 7 with a value of R exceeding 0.97 (R2=0.944).The two indices, albeit formally distinct, are both valid; they show specific aspects of the phenomenon, but provide basically similar information to the public health decision-maker. Their distinction lies not so much in the method of calculation, rather in the use of different information, i.e., the beginning of symptoms and the swabs outcome.Therefore, it is not appropriate to make a judgment of preference for one of the two indices, but only to invite people to understand their different potentials so that they can choose the one they consider the most appropriate for the purpose they want to use it for.

[Covid-19 and clinical-epidemiological research in Italy: proposal of a research agenda on priority topics by the Italian association of epidemiology]. / Covid-19 e ricerca clinico-epidemiologica in Italia: proposta di un'agenda di ricerca su temi prioritari da parte dell'Associazione italiana di epidemiologia.

BACKGROUND: the Covid-19 pandemic has provoked a huge of clinical and epidemiological research initiatives, especially in the most involved countries. However, this very large effort was characterized by several methodological weaknesses, both in the field of discovering effective treatments (with too many small and uncontrolled trials) and in the field of identifying preventable risks and prognostic factors (with too few large, representative and well-designed cohorts or case-control studies). OBJECTIVES: in response to the fragmented and uncoordinated research production on Covid-19, the   italian Association of Epidemiology (AIE) stimulated the formation of a working group (WG) with the aims of identifying the most important gaps in knowledge and to propose a structured research agenda of clinical and epidemiological studies considered at high priority on Covid-19, including recommendations on the preferable methodology. METHODS: the WG was composed by 25 subjects, mainly epidemiologists, statisticians, and other experts in specific fields, who have voluntarily agreed to the proposal. The agreement on a list of main research questions and on the structure of the specific documents to be produced were defined through few meetings and cycles of document exchanges. RESULTS: twelve main research questions on Covid-19 were identified, covering aetiology, prognosis, interventions, follow-up and impact on general and specific populations (children, pregnant women). For each of them, a two-page form was developed, structured in: background, main topics, methods (with recommendations on preferred study design and warnings for bias prevention) and an essential bibliography. CONCLUSIONS: this research agenda represents an initial contribution to direct clinical and epidemiological research efforts on high priority topics with a focus on methodological aspects. Further development and refinements of this agenda by Public Health Authorities are encouraged.

Saliva cortisol in relation to aircraft noise exposure: pooled-analysis results from seven European countries.

BACKGROUND: Many studies have demonstrated adverse effects of exposure to aircraft noise on health. Possible biological pathways for these effects include hormonal disturbances. Few studies deal with aircraft noise effects on saliva cortisol in adults, and results are inconsistent. OBJECTIVE: We aimed to assess the effects of aircraft noise exposure on saliva cortisol levels and its variation in people living near airports. METHODS: This study focused on the 1300 residents included in the HYENA and DEBATS cross-sectional studies, with complete information on cortisol sampling. All the participants followed a similar procedure aiming to collect both a morning and an evening saliva cortisol samples. Socioeconomic and lifestyle information were obtained during a face-to-face interview. Outdoor aircraft noise exposure was estimated for each participant's home address. Associations between aircraft noise exposure and cortisol outcomes were investigated a priori for male and female separately, using linear regression models adjusted for relevant confounders. Different approaches were used to characterize cortisol levels, such as morning and evening cortisol concentrations and the absolute and relative variations between morning and evening levels. RESULTS: Statistically significant increases of evening cortisol levels were shown in women with a 10-dB(A) increase in aircraft noise exposure in terms of LAeq, 16h (exp(ß) = 1.08; CI95% = 1.00-1.16), Lden (exp(ß) = 1.09; CI95% = 1.01-1.18), Lnight (exp(ß) = 1.11; CI95% = 1.02-1.20). A statistically significant association was also found in women between a 10-dB(A) increase in terms of Lnight and the absolute variation per hour (exp(ß) = 0.90; CI95% = 0.80-1.00). Statistically significant decreases in relative variation per hour were also evidenced in women, with stronger effects with the Lnight (exp(ß) = 0.89; CI95% = 0.83-0.96) than with other noise indicators. The morning cortisol levels were unchanged whatever noise exposure indicator considered. There was no statistically significant association between aircraft noise exposure and cortisol outcomes in men. CONCLUSIONS: The results of the present study show statistically significant associations between aircraft noise exposure and evening cortisol levels and related flattening in the (absolute and relative) variations per hour in women. Further biological research is needed to deepen knowledge of the pathway between noise exposure and disturbed hormonal regulation, and specially the difference in effects between genders.

Risk perception in the population living near the Turin municipal solid waste incineration plant: survey results before start-up and communication strategies.

BACKGROUND: The start-up of the Turin municipal solid waste incineration plant (2013) was accompanied by surveillance of health effects, which included a human biomonitoring campaign. Here we present the results of the risk perception survey of local residents before the plant went into operation. METHODS: The survey sample was 394 local residents: 198 residing near the plant (exposed group) and 196 residing in an area distant from the plant site (unexposed group). The survey questionnaire investigated awareness of environmental and health issues, including a section on the perception of environmental health risks. Multivariate Poisson regressions were performed to determine the differences in risk perception between the two groups (exposed vs. unexposed). RESULTS: The exposed group was more concerned about natural hazards (prevalence ratio [PR] 1.61; 95% confidence interval [CI] 0.99-2.61), anthropogenic hazards (PR 1.35; 95% CI 1.03-1.77), and waste management (PR 1.19; 95% CI 0.94-1.50). There were no significant differences in opinions about environmental pollution-related diseases between the two groups, though the exposed considered themselves to be at risk for developing these diseases. The survey population placed its trust more in health care providers than in any other category. CONCLUSIONS: The risk perception survey questionnaire yielded data that enabled a better understanding and interpretation of the social context: residents living near the incineration plant were more concerned than those living distant from it, especially about anthropogenic hazards. This information was subsequently incorporated into the design the communication tools.

Human biomonitoring health surveillance for metals near a waste-to-energy incinerator: The 1-year post-operam study.

This human biomonitoring (HBM) follow-up survey, within the SPoTT project, assessed the temporal and spatial trends of exposure to 18 metals in a cohort living around the waste-to-energy (WTE) incinerator of Turin (Italy) before (T0, 2013) and after 1-year of plant activity (T1, 2014). Urine of 380 adult individuals (186 exposed and 194 unexposed subjects, classified on fallout maps) were analyzed by sector field inductively coupled mass spectrometry. A decrease trend of the majority of metals in all subjects indicates that the overall air quality of the studied sites was not significantly compromised, also in proximity of the WTE plant, as corroborated also by air monitoring data of the regional agency. The only relevant exception was the higher Cr levels found at T1 than T0 in exposed subjects, suggesting a possible contribution from the WTE plant. Chromium, Mn and Pt urine levels were also higher in the site far from the WTE, in relation to other sources as vehicular traffic, industrial and civil activities. Whilst, As and Cd were influenced by fish intake and tobacco smoke. A very small number of individuals at T1, equally distributed in both areas, exceeded the health-based guidance values and so, at current knowledge, living near the Turin incineration did not significantly influence the exposure status of the population.

LIFE Med Hiss: An innovative cohort design for public health.

The aim of MED HISS methodology was to test the effectiveness of a low-cost approach to study long-term effects of air pollution, applicable in all European countries. This approach is potentially exportable to other environmental issues where a cohort representative of the country population is needed. The cohort is derived from the National Health Interview Survey, compulsory in European countries, which has information on individual lifestyle factors. In Life Med Hiss approach, subjects recruited have been linked at individual level with health data and have been then followed-up for mortality and hospital admissions outcomes. Exposure values of air pollution (PM2.5 and NO2) have been assigned using national dispersion models, enhanced by the information derived from monitoring station with data fusion techniques, and then upscaled at municipality level (highest level of detail achievable for the Italian Survey). Results for mortality have been used to test the effectiveness of this methodology and are encouraging if compared with European ones. The advantages of this technique are summarized below: •It uses a cohort already available and compulsory in European countries•It uses air quality modelling data, available for most of the countries•It permits to implement versatile environmental surveillance systems.