A nationwide study of air pollution from particulate matter and daily hospitalizations for respiratory diseases in Italy.

BACKGROUND/AIM: The relationship between air pollution and respiratory morbidity has been widely addressed in urban and metropolitan areas but little is known about the effects in non-urban settings. Our aim was to assess the short-term effects of PM10 and PM2.5 on respiratory admissions in the whole country of Italy during 2006-2015. METHODS: We estimated daily PM concentrations at the municipality level using satellite data and spatiotemporal predictors. We collected daily counts of respiratory hospital admissions for each Italian municipality. We considered five different outcomes: all respiratory diseases, asthma, chronic obstructive pulmonary disease (COPD), lower and upper respiratory tract infections (LRTI and URTI). Meta-analysis of province-specific estimates obtained by time-series models, adjusting for temperature, humidity and other confounders, was applied to extrapolate national estimates for each outcome. At last, we tested for effect modification by sex, age, period, and urbanization score. Analyses for PM2.5 were restricted to 2013-2015 cause the goodness of fit of exposure estimation. RESULTS: A total of 4,154,887 respiratory admission were registered during 2006-2015, of which 29% for LRTI, 12% for COPD, 6% for URTI, and 3% for asthma. Daily mean PM10 and PM2.5 concentrations over the study period were 23.3 and 17 µg/m3, respectively. For each 10 µg/m3 increases in PM10 and PM2.5 at lag 0-5 days, we found excess risks of total respiratory diseases equal to 1.20% (95% confidence intervals, 0.92, 1.49) and 1.22% (0.76, 1.68), respectively. The effects for the specific diseases were similar, with the strongest ones for asthma and COPD. Higher effects were found in the elderly and in less urbanized areas. CONCLUSIONS: Short-term exposure to PM is harmful for the respiratory system throughout an entire country, especially in elderly patients. Strong effects can be found also in less urbanized areas.

Assessing Pretest Clinical Risk of Pulmonary Thromboembolism in the Emergency Department: Proposal of a Simple Modification to the Wells' Score.

BACKGROUND: Clinical scores have been proposed to stratify the risk of pulmonary thromboembolism (PTE), although this approach suffers a low specificity and the unavoidable need for computed tomography pulmonary angiography (CTPA) scans. OBJECTIVE: Our study aimed to investigate a simple modification to the already validated Wells' score to improve its diagnostic accuracy in the emergency department (ED). METHODS: We retrospectively reviewed all CTPA scans performed in the ED setting to rule out PTE over a 1-year (2017) period. Clinical variables potentially associated with PTE were assessed to improve diagnostic accuracy of the Wells' score, thus introducing a modified Wells' score (mWells). RESULTS: Four thousand four hundred thirteen CTPAs were identified, of which 504 were for suspected PTE. The prevalence of PTE was 23.9%. Among clinical data, only peripheral capillary oxygen saturation was consistently correlated with PTE at univariate (odds ratio 2.75 [95% confidence interval 1.61-4.73]) and multivariate (odds ratio 3.78 [95% confidence interval 2.13-6.72]) logistic regression analysis. The mWells' score had a higher area under the receiver operating characteristic curve compared with the original Wells' score: 0.71 (95% confidence interval 0.67-0.75) vs. 0.65 (95% confidence interval 0.61-0.69) (p < .01) and improved diagnostic accuracy. CONCLUSIONS: Current clinical stratification tools for PTE are characterized by low specificity, leading to an overuse of CTPA. mWells', rather than Wells', score showed a better predictive performance of PTE detection. Our results suggest that current diagnostic pathway for PTE may be improved by simple adjustments (i.e., mWells') of clinical prediction scores.

[Exposure assessment to air pollutants: dispersion models versus human biomonitoring]. / La valutazione dell'esposizione a contaminanti ambientali: modelli di dispersione e biomonitoraggio umano.

BACKGROUND: the assessment of individual exposure to toxicants in industrially contaminated areas is difficult when multiple productions are actively close to residential areas. Two thermoelectric power plants (one recently converted to coal) and a large harbour have been operating since the Sixties in the area of Civitavecchia (North of Rome, Lazio Region, Central Italy). Detailed exposure assessment of pollutants from industrial sources, heating (biomass combustion), and urban traffic were not available. OBJECTIVES: to assess the individual exposure of residents by using both dispersion models and human biomonitoring. DESIGN: cross-sectional study. SETTING AND PARTICIPANTS: residents in the area of Civitavecchia since 2001 aged 35-69 years were enrolled and their addresses were geocoded. Exposure assessment to power plants emissions (PM10), traffic (NOx), harbour (PM10), and biomass burning (PM10) was performed at individual residential address using Lagrangian dispersion models. The "Ambiente e Biomarcatori a Civitavecchia" study (Environment and biomarkers in Civitavecchia - ABC study) made available urinary concentrations of metals (i.e., Cd, Pt, W, Pd, Hg, Tl, Cr, Pd, Ni, As) in a sample of residents, while information on personal characteristics, lifestyles, work history, clinical history, and use of drugs was collected by interview. MAIN OUTCOME MEASURES: for each metal, a linear regression analysis was implemented to study the association between its log-transformed values (adjusted for urinary creatinine) and the linear terms of the estimated pollutants concentrations, adjusted for age, gender, period, and other risk factors (i.e., educational level, smoking habit, alcohol, BMI). Geometric Mean Ratios (GMR) and the corresponding confidence intervals (95%CI) were computed. RESULTS: in the ABC sample of 1,141 residents (42% male, mean age 53.5 years, SD 9.7), there was a positive association between PM10 from power plants and urinary cadmium (Cd) (GMR: 1.12; 95%CI 1.00-1.25), traffic pollution (NOx) and platinum (Pt) (GMR: 1.17; 95%CI 1.00-1.38), PM10 from biomass burning and Cd (GMR: 1.14; 95%CI 1.05-1.24), and tungsten (W) (GMR: 1.19; 95%CI 1.03-1.37) and palladium (Pd) (GMR: 1.11; 95%CI 1.00-1.23). Other associations observed did not reach statistical significance. CONCLUSIONS: although it may not be said that dispersion models can replace biomonitoring studies, they certainly represent an excellent tool for exposure assessment and, therefore, they may be used for the estimation of the individual exposure of populations living in industrially contaminated areas.

Estimation of daily PM10 and PM2.5 concentrations in Italy, 2013-2015, using a spatiotemporal land-use random-forest model.

Particulate matter (PM) air pollution is one of the major causes of death worldwide, with demonstrated adverse effects from both short-term and long-term exposure. Most of the epidemiological studies have been conducted in cities because of the lack of reliable spatiotemporal estimates of particles exposure in nonurban settings. The objective of this study is to estimate daily PM10 (PM < 10 µm), fine (PM < 2.5 µm, PM2.5) and coarse particles (PM between 2.5 and 10 µm, PM2.5-10) at 1-km2 grid for 2013-2015 using a machine learning approach, the Random Forest (RF). Separate RF models were defined to: predict PM2.5 and PM2.5-10 concentrations in monitors where only PM10 data were available (stage 1); impute missing satellite Aerosol Optical Depth (AOD) data using estimates from atmospheric ensemble models (stage 2); establish a relationship between measured PM and satellite, land use and meteorological parameters (stage 3); predict stage 3 model over each 1-km2 grid cell of Italy (stage 4); and improve stage 3 predictions by using small-scale predictors computed at the monitor locations or within a small buffer (stage 5). Our models were able to capture most of PM variability, with mean cross-validation (CV) R2 of 0.75 and 0.80 (stage 3) and 0.84 and 0.86 (stage 5) for PM10 and PM2.5, respectively. Model fitting was less optimal for PM2.5-10, in summer months and in southern Italy. Finally, predictions were equally good in capturing annual and daily PM variability, therefore they can be used as reliable exposure estimates for investigating long-term and short-term health effects.

Long-term exposure to air pollutants from multiple sources and mortality in an industrial area: a cohort study.

BACKGROUND AND AIMS: Residents near industrial areas are exposed to several toxins from various sources and the assessment of the health effects is difficult. The area of Civitavecchia (Italy) has several sources of environmental contamination with potential health effects. We evaluated the association between exposure to pollutants from multiple sources and mortality in a cohort of people living in the area. METHODS: All residents of the area in 1996 were enrolled (from municipal registers) and followed until 2013. Long-term exposures to emissions from industrial sources (PM10) and traffic (NOx) at the residential addresses were assessed using a dispersion model. Residence close to the harbour was also considered. Cox survival analysis was conducted including a linear term for industrial PM10 and NOx exposure and a dichotomous variable to indicate residence within 500 m of the harbour. Age, sex, calendar period, occupation and area-based socioeconomic position (SEP) were considered (HRs, 95% CI). RESULTS: 71 362 people were enrolled (52% female, 43% low SEP) and 14 844 died during the follow-up. We found an association between industrial PM10 and mortality from non-accidental causes (HR=1.06, 95% CI 1.01 to 1.12), all cancers (HR=1.11, 95% CI 1.01 to 1.21) and cardiac diseases (HR=1.12, 95% CI 1.01 to 1.23). We also found an association between NOx exposure from traffic and mortality from all cancers (HR=1.13, 95% CI 1.01 to 1.26) and neurological diseases (HR=1.50, 95% CI 1.01 to 2.20). Living near the harbour was associated with higher mortality from lung cancer (HR=1.31, 95% CI 1.04 to 1.66) and neurological diseases (HR=1.51, 95% CI 1.05 to 2.18). CONCLUSIONS: Estimated exposures to different pollution sources in this area were independently associated with several mortality outcomes while adjusting for occupation and socioeconomic status.

Morbidity and mortality of people who live close to municipal waste landfills: a multisite cohort study.

BACKGROUND: The evidence on the health effects related to residing close to landfills is controversial. Nine landfills for municipal waste have been operating in the Lazio region (Central Italy) for several decades. We evaluated the potential health effects associated with contamination from landfills using the estimated concentration of hydrogen sulphide (H2S) as exposure. METHODS: A cohort of residents within 5 km of landfills was enrolled (subjects resident on 1 January 1996 and those who subsequently moved into the areas until 2008) and followed for mortality and hospitalizations until 31 December 2012. Assessment of exposure to the landfill (H2S as a tracer) was performed for each subject at enrolment, using a Lagrangian dispersion model. Information on several confounders was available (gender, age, socioeconomic position, outdoor PM10 concentration, and distance from busy roads and industries). Cox regression analysis was performed [Hazard Ratios (HRs), 95% confidence intervals (CIs)]. RESULTS: The cohort included 242 409 individuals. H2S exposure was associated with mortality from lung cancer and respiratory diseases (e.g. HR for increment of 1 ng/m(3) H2S: 1.10, 95% CI 1.02-1.19; HR 1.09, 95% CI 1.00-1.19, respectively). There were also associations between H2S and hospitalization for respiratory diseases (HR = 1.02, 95% CI 1.00-1.03), especially acute respiratory infections among children (0-14 years) (HR = 1.06, 95% CI 1.02-1.11). CONCLUSIONS: Exposure to H2S, a tracer of airborne contamination from landfills, was associated with lung cancer mortality as well as with mortality and morbidity for respiratory diseases. The link with respiratory disease is plausible and coherent with previous studies, whereas the association with lung cancer deserves confirmation.

Air Pollution and Cognitive Development at Age 7 in a Prospective Italian Birth Cohort.

BACKGROUND: Early life exposure to air pollution has been linked with cognitive impairment in children, but the results have not been conclusive. We analyzed the association between traffic-related air pollution and cognitive function in a prospective birth cohort in Rome. METHODS: A cohort of 719 newborns was enrolled in 2003-2004 as part of the GASPII project. At age 7 years, 474 children took the Wechsler Intelligence Scale for Children-III to assess their cognitive development in terms of IQ composite scores. Exposure to air pollutants (NO2, PMcoarse, PM2.5, PM2.5 absorbance) at birth was assessed using land use regression models. We also considered variables indicating traffic intensity. The effect of environmental pollution on IQ was evaluated performing a linear regression model for each outcome, adjusting for gender, child age at cognitive test, maternal age at delivery, parental educational level, siblings, socio-economic status, maternal smoking during pregnancy, and tester. To account for selection bias at enrollment and during follow-up, the regression models were weighted for the inverse probabilities of participation and follow-up. RESULTS: A 10 µg/m³ higher NO2 exposure during pregnancy was associated with 1.4 fewer points (95% confidence interval = -2.6, -0.20) of verbal IQ, and 1.4 fewer points (95% confidence interval = -2.7, -0.20) of verbal comprehension IQ. Similar associations were found for traffic intensity in a 100 m buffer around home. Other pollutants showed negative associations with larger confidence intervals. CONCLUSIONS: Consistent with previous evidence, this study suggests an association of exposure to NO2 and traffic intensity with the verbal area of cognitive development.See Video Abstract at http://links.lww.com/EDE/B12.

Mortality and morbidity in a population exposed to multiple sources of air pollution: A retrospective cohort study using air dispersion models.

BACKGROUND AND AIMS: A landfill, an incinerator, and a refinery plant have been operating since the early 1960s in a contaminated site located in the suburb of Rome (Italy). To evaluate their potential health effects, a population-based retrospective cohort study was conducted using dispersion modeling for exposure assessment. METHODS: A fixed cohort was enrolled in the Rome Longitudinal Study in 2001, mortality and hospitalizations were followed-up until 2010. Exposure assessments to the landfill (H2S), the incinerator (PM10), and the refinery plant (SOX) were performed for each subject using a Lagrangian dispersion model. Individual and small-area variables were available (including exposures levels to NO2 from traffic and diesel trucks). Cox regression analysis was performed (hazard ratios, HRs, 95% CI) using linear terms for the exposures (5th-95th percentiles difference). Single and bi-pollutant models were run. RESULTS: The cohort included 85,559 individuals. The estimated annual average exposures levels were correlated. H2S from the landfill was associated with cardiovascular hospital admissions in both genders (HR 1.04 95% CI 1.00-1.09 in women); PM10 from the incinerator was associated with pancreatic cancer mortality in both genders (HR 1.40 95% CI 1.03-1.90 in men, HR 1.47 95% CI 1.12-1.93 in women) and with breast morbidity in women (HR 1.13 95% CI 1.00-1.27). SOx from the refinery was associated with laryngeal cancer mortality in women (HR 4.99 95% CI 1.64-15.9) and respiratory hospital admissions (HR 1.13 95% CI 1.01-1.27). CONCLUSIONS: We found an association of the pollution sources with some cancer forms and cardio-respiratory diseases. Although there was a high correlation between the estimated exposures, an indication of specific effects from the different sources emerged.

[Morbidity in a population living close to urban waste incinerator plants in Lazio Region (Central Italy): a retrospective cohort study using a before-after design]. / Stato di salute della popolazione residente nei pressi dei termovalorizzatori del Lazio: uno studio di coorte retrospettivo con approccio pre-post.

BACKGROUND: the body of evidence on health effects of residential exposure to urban waste incinerators suggests association with reproductive outcomes and some cancers, but the overall evidence is still limited. OBJECTIVES: we evaluated the impact of two incinerators on hospital admissions for respiratory and cardiovascular diseases in a cohort of people living nearby two incineration plants in Lazio Region (Central Italy) using a before-and-after design. METHODS: the study area was defined as the 7-km radius around the incinerators. People who were resident in the area from 1996 to 2008 were enrolled in a retrospective longitudinal study. All addresses were geocoded. A Lagrangian dispersion model (SPRAY) for PM10 (ng/m³) was used for incinerators exposure assessment. Average annual concentration of background PM10 (µg/m³) was estimated on a regional basis by means of RAMS and FARM models. Both PM10 exposures were estimated at the residential address. All subjects were followed for hospital admissions in the period before (1996-2002) and after (2003-2008) the activation of the plants. The association between exposure to emissions from incinerators and hospitalizations in the two periods was estimated using the multivariate Cox model (for repeated events), adjusting for age, area-level socioeconomic status, distance from industries, traffic roads and highways. An interaction term between the period of follow-up (before or after the activation of the plants) and the exposure levels was used to test the effect of the incinerators. RESULTS: 47,192 subjects resident in the study area were enrolled. No clear association between pollution exposure from incinerators and cause-specific morbidity of residents in highest concentration areas was found when compared to the reference group. However, an effect of PM10 on respiratory diseases and chronic obstructive pulmonary disease was suggested. The effect was due to excesses of hospitalizations for the same causes among men living in highest exposure areas in respect to the reference group (hazard ratio - HR: 1.26; 95%CI 0.99-1.60, and HR: 1.86; 95%CI 1.04-3.33, respectively). There were associations between exposure to background pollution from other sources and hospitalizations for diseases of the circulatory system (HR: 1.08; 95%CI 1.03-1.13) and respiratory diseases (HR: 1.07; 95%CI 1.02-1.11) (for a unitary increment of PM10, µg/m³). CONCLUSIONS: living in areas with high PM10 levels due to incinerators was associated with increased morbidity levels for respiratory disorders among men. The study area is critical from an environmental point of view, hence an epidemiological surveillance is recommended.

[Residential cohort approach in industrial contaminated sites: the ERAS Lazio project]. / Lo studio di coorte di popolazione in aree a forte pressione ambientale: il programma ERAS Lazio.

The population-based cohort study is the best design for assessing the possible health effects resulting fromliving in contaminated sites. The ERAS (Epidemiology,Waste disposal, Environment and Health) Project was established to study the health of people living in close proximity to urban solid waste treatment (RU) plants in Lazio. It was conducted using an integrated approach, which consisted in studying mortality and hospital discharges of residential cohorts surrounding urban waste treatment plants. The level of exposure of each address was assigned using pollution dispersion models and studying the effects on mortality and hospital discharges. Further studies were conducted on residents of areas adjacent to waste disposal sites (includingMalagrotta in Rome), incinerators andmechanical biological treatment plants. The final version of the ERAS Report is available at www.eraslazio.it. The residential cohort approach and the combination of environmental and health-related information proved invaluable in the assessment of the health impact of solid waste treatment in Lazio.

Associations between particulate matter elements and early-life pneumonia in seven birth cohorts: results from the ESCAPE and TRANSPHORM projects.

Evidence for a role of long-term particulate matter exposure on acute respiratory infections is growing. However, which components of particulate matter may be causative remains largely unknown. We assessed associations between eight particulate matter elements and early-life pneumonia in seven birth cohort studies (N total=15,980): BAMSE (Sweden), GASPII (Italy), GINIplus and LISAplus (Germany), INMA (Spain), MAAS (United Kingdom) and PIAMA (The Netherlands). Annual average exposure to copper, iron, potassium, nickel, sulfur, silicon, vanadium and zinc, each respectively derived from particles with aerodynamic diameters ≤ 10 µm (PM10) and 2.5 µm (PM2.5), were estimated using standardized land use regression models and assigned to birth addresses. Cohort-specific associations between these exposures and parental reports of physician-diagnosed pneumonia between birth and two years were assessed using logistic regression models adjusted for host and environmental covariates and total PM10 or PM2.5 mass. Combined estimates were calculated using random-effects meta-analysis. There was substantial within and between-cohort variability in element concentrations. In the adjusted meta-analysis, pneumonia was weakly associated with zinc derived from PM10 (OR: 1.47 (95% CI: 0.99, 2.18) per 20 ng/m(3) increase). No other associations with the other elements were consistently observed. The independent effect of particulate matter mass remained after adjustment for element concentrations. In conclusion, associations between particulate matter mass exposure and pneumonia were not explained by the elements we investigated. Zinc from PM10 was the only element which appeared independently associated with a higher risk of early-life pneumonia. As zinc is primarily attributable to non-tailpipe traffic emissions, these results may suggest a potential adverse effect of non-tailpipe emissions on health.

[Cancer incidence and mortality in the cohort of residents close to the Italian nuclear power plants of Borgo Sabotino and Garigliano]. / Incidenza di tumori e mortalità nella coorte dei residenti in prossimità delle centrali nucleari italiane di Borgo Sabotino e del Garigliano.

INTRODUCTION: the potential health impacts due to the decommissioned Nuclear power plants (NPP) located in Borgo Sabotino and Garigliano in Central Italy (active from the early 1960s to the late 1980s) have raised several concerns. Brain, thyroid, breast and lung cancer and leukaemia have been associated with exposure to ionizing radiations, but the health effects of nuclear plants on the resident populations are controversial. OBJECTIVE: to evaluate whether living close to NPPs is associated with an increased risk of cancer incidence and mortality. METHODS: we defined a cohort of residents within 7 km from the NPPs during the period 1996-2002. Individual follow-up for vital status at 01.01.2007 was conducted using municipality data. Gender specific Standardized Incidence and Mortality Ratios, adjusted for age, were calculated (SIR and SMR) using the regional population as reference. Each participant's address was assigned to a distance from the NPP on the basis of a GIS. A relative risk (RR, CI95%), adjusted for age and socioeconomic status, was calculated in 3 bands of increasing radius from the plants: 0-2, 2-4, and 4-7 km (reference group), using a Poisson regression model. RESULTS: the cohort was of 39,775 people, 32%of whom lived near (0-4 km) the NPP. No differences in mortality was found when comparing the cohort with the regional population; among women living within 7 km from the NPP, we found thyroid cancer incidence higher than expected (SIR 1.53 CI95% 1.18-1.95). However, when the analysis was conducted on the basis of the distance from the NPP, we found a statistically significant increase in male mortality only for causes unrelated to radiation exposure (all causes, stomach cancer, and cardiovascular diseases). No mortality excess was observed among women living close to the NPPs. No statistically significant distance-related gradient was observed for cancer incidence both in men and women. CONCLUSIONS: living close to the NPP was not associated with mortality for causes related to radiation exposure. However, the results suggest to continue the epidemiological surveillance of the population.