Search

Since 2006, epidemiological surveillance of populations living in Italian contaminated sites has been ongoing (SENTIERI Project). Updated global estimates of mortality (2013-2017) and hospitalization (2014-2018) are reported. The excess deaths (observed-expected) for the main groups of diseases were calculated for all the 46 sites together. Through a random-effect meta-analysis of the standardized mortality and hospitalization rates (SMR/SHR), the pooled SMR/SHR for all the sites and their groupings were estimated. In the 46 sites, 8,342 exceeding deaths (1,668/year) were estimated, 4,353 in males and 3,989 in females, resulting in an excess risk of 2% in both genders. The risk of hospitalization for all causes was in excess of 3%. These excesses are mainly attributable to malignant tumours. In subgroups of sites, exceeding SMRs were observed for all mesotheliomas and pleural mesotheliomas, lung and colorectal cancers in both genders. SHR for all causes were observed in excess in the first year of life (+8%), in the group 0-19 and 20-29 years (+3-5%); no excesses of mortality were observed in the group 0-29 years.

The SENTIERI Project analyses the health profile of the populations residing in Italian national priority contaminated sites in specific calendar periods using a cross-sectional approach. An aspect that has not been evaluated so far is the analysis over a long period, for understanding the changes in health profiles over time and studying them also in function of the changes occurred in the territories. This article studies temporal trends by birth cohort and calendar period for overall mortality and lung cancer mortality from 1980 to 2018, separately for men and women, for three sites: Priolo (Sicily Region, Southern Italy), Pitelli (Liguria Region, Northern Italy), and Terni-Papigno (Umbria Region, Central Italy). A method for selecting the temporal model that best fits the data is then proposed. General mortality presents complex temporal profiles when considering cumulative risks, and usually the most important temporal axis is the birth cohort for cumulative SMRs (i.e., after adjusting for trends in the reference population). For lung cancer, the most important time axis is the birth cohort and the age-cohort model is the most appropriate, in particular for men of Priolo and Terni.

Introduction Adn Objectives: The Sixth Report presents the results of the "SENTIERI Project: implementation of the permanent epidemiological surveillance system of populations residing in Italian Sites of Remediation Interest", promoted and financed by the Italian Ministry of Health (Centre for Disease Control and Prevention - CCM Project 2018). The aim of this study is to update the mortality and hospitalization analyses concerning the 6,227,531 inhabitants (10.4% of the Italian population) residing in 46 contaminated sites (39 of national interest and 7 of regional interest). The sites include 316 municipalities distributed as follows: 15 in the North-East (20.3% of the investigated population); 104 in the North-West (12% of the investigated population), 32 in the Centre (12.6% of the investigated population), 165 in the South and Islands (55.5% of the investigated population). Analyses were carried out on the paediatric-adolescent (1,128,396 residents) and youth (665,284 residents) population, and a study on congenital anomalies (CA) was carried out at sites covered by congenital malformation registers. Accompanying the epidemiological assessments, site-specific socioeconomic conditions were examined and an overall estimate of excess risk for populations residing at contaminated sites was drawn up. By means of a systematic review of the scientific literature, the epidemiological evidence on causal links between sources of environmental exposure and health effects was updated to identify pathologies of a priori interest., Methodology: In the 46 sites included in the SENTIERI Project, mortality (time window: 2013-2017) and hospital admissions (time window: 2014-2018) of the general population of all ages, divided by gender, and of the paediatric-adolescent (0-1 year, 0-14 years, 0-19 years), youth (20-29 years), and overall (0-29 years) age groups, divided by gender, were analysed. In 21 sites, CA diagnosed within the first year of life were studied. Standardised mortality ratios (SMR) and hospitalization ratios (SHR) were calculated with reference to the rates in the regions to which the sites belong. The reference population was calculated net of residents in the sites. CA were studied by calculating the prevalence per 10,000 births and the ratio, multiplied by 100, between the cases observed at the site and those expected on the basis of the prevalences observed in the reference area (region or sub-regional area of belonging, according to the geographical coverage of the registry). The socioeconomic condition studied in the 46 sites is based on the convergence of three deprivation indicators with respect to the reference region: deprivation index at municipal level, deprivation index at census section level, premature mortality indicator (age range 30-69 years) for chronic non-communicable diseases. For the estimation of excess risk for the entire study population, meta-analysis of the mortality and hospitalization risk estimates for each site was carried out and the number of excess deaths estimated for the sites as a whole. The epidemiological evidence was updated through a systematic literature review (January 2009-May 2020), following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The search was carried out on the search engines MEDLINE, EMBASE and Web of Science; the quality of the studies included in the review was assessed using the AMSTAR 2 checklist for systematic reviews and the NewCastle-Ottawa Scale for observational studies in the case of cohort and case-control studies and a modified version thereof for ecological and cross-sectional studies. The update was based on the selection of 14 systematic reviews, 15 primary studies, 6 monographs/reports from international scientific organisations on health effects due to the presence of environmental exposure sources., Results: Mortality. The a priori causes of interest that occur most frequently in excess are, in descending order: malignant lung cancer, malignant mesothelioma of the pleura, malignant bladder cancer, respiratory diseases, non-Hodgkin lymphomas, malignant liver cancer, all malignant tumours, malignant colorectal cancer, malignant stomach cancer, total mesotheliomas, malignant breast cancer, and asbestosis. Hospitalization. The a priori causes of interest that occur most frequently in excess are represented in descending order by: respiratory diseases, malignant lung cancer, malignant tumours of the pleura, malignant bladder cancer, malignant breast cancer, malignant liver cancer, asthma, malignant colorectal cancer, all malignant tumours, malignant stomach cancer, non-Hodgkin's lymphomas, acute respiratory diseases, leukaemias. The differences observed between mortality and hospitalization can be attributed to the intrinsic characteristics of the diseases (higher or lower lethality, gender differences in incidence), lifestyles, and occupational phenomena. Age classes. Excesses of general mortality were observed in the first year of life at the Manfredonia, Basso Bacino Fiume Chienti, Litorale Domizio Flegreo and Agro Aversano sites; in the 0-1 year and 0-19 year age groups at Casale Monferrato; in the paediatric age group at Serravalle Scrivia and at the Trento Nord site; in the 0-19 year age group at Sassuolo Scandiano; in the young age group (0-29 years) at the two municipalities of Cerchiara and Cassano (Crotone-Cassano-Cerchiara site). With regard to hospitalization due to natural causes, risk excesses in both genders are found in the first year of life in 35% of the sites (Porto Torres industrial areas, Bari-Fibronit, Basso bacino fiume Chienti, Bolzano, Crotone-Cassano-Cerchiara, Cerro al Lambro, Bologna ETR large repair workshop, Gela, Manfredonia, Massa Carrara, Pioltello Rodano, Pitelli, Priolo, Sesto San Giovanni, Trento Nord, and Trieste). These same sites, with the addition of Casale Monferrato, Cengio e Saliceto, Serravalle Scrivia, and Sulcis-Iglesiente-Guspinese (total: 43% of sites), show excesses for all natural causes, in both genders, even in the paediatric-adolescent age group (0-19 years). Among young adults (20-29 years), the analyses show excesses of hospitalization for all natural causes in both genders in the Bolzano, Crotone-Cassano-Cerchiara, Gela, Manfredonia, Pitelli, Priolo, and Sulcis-Iglesiente-Guspinese sites. Among young women only, excesses for all natural causes are also found in Brescia Caffaro, Brindisi, Broni, Casale Monferrato, Crotone-Cassano-Cerchiara, Falconara Marittima, Fidenza, and Massa Carrara. Congenital anomalies. In the 21 sites investigated for CA, 10,126 cases of CA, validated by participating registers, were analysed out of 304,620 resident births. Genital CA is the subgroup for which the greatest number of excesses was observed (in 6 out of 21 sites). The available evidence does not allow a causal link to be established between the excesses observed for specific subgroups of ACs and exposure to industrial sources, but the results suggest further action. The interpretation of the results appears, in fact, particularly complex as the scientific literature on the association between exposure to industrial sources and AC is very limited. Socioeconomic status. The sites in which the indicators converge to show the presence of fragility are: Litorale Vesuviano area, Val Basento industrial areas, Basso Bacino fiume Chienti, Biancavilla, Crotone-Cassano-Cerchiara, Litorale Domizio Flegreo and Agro Aversano, Livorno, Massa Carrara, Trieste. Global impact. Over the period 2013-2017, an estimated 8,342 excess deaths (CI90% 1,875-14,809) or approximately 1,668 excess cases/year, 4,353 excess deaths among males (CI90% 334-8,372) and 3,989 among females (CI90% -1,122;9,101). The pooled excess risk of general mortality is 2% in both genders (pooled SMR 1.02; CI90% 1.00-1.04). The proportion of excess deaths to total observed deaths is almost constant over time, rising from 2.5% in 1995-2002 to 2.6% in 2013-2017. The number of deaths in absolute value is also very similar between the periods analysed. Deaths from all malignant tumours contribute the most by accounting for 56% of the observed excesses, the excess risk of mortality from malignant tumours across all sites, compared to the reference populations, is 4% in the male population (pooled SMR 1.04; CI90% 1.01-1.06) and 3% among the female population (pooled SMR 1.03; CI90% 1.01-1.05). Hospitalization (2014-2018) in the 46 sites as a whole was in excess of 3% for all causes, in both genders, for all major disease groups (males: SHR pooled 1.03; CI90% 1.01-1.04 - females: SHR pooled 1.03; CI90% 1.01-1.05). The results for the pooled estimates at the 46 sites on the general population, both with regard to mortality and hospitalization, are consistent in indicating excess risk in both genders for all the diseases considered and, in particular, for all malignancies. A total of 1,409 paediatric-adolescent deaths and 999 young adult deaths were observed, and the pooled analysis of mortality across the 46 sites showed no critical issues, with pooled estimates for all causes, perinatal morbid conditions and all malignancies falling short of expectations. The analysis of hospitalizations, on the other hand, showed an excess risk of 8% (males: SHR pooled 1.08; CI90% 1.03-1.13 - females: SHR pooled 1.08; CI90% 1.03-1.14) for all causes in the first year of life, and in paediatric-adolescent and juvenile age of 3-4% among males (age 0-19 years: SHR pooled 1.04; CI90% 1.02-1.06 - age 20-29 years: SHR pooled 1.03; CI90% 1.00-1.05) and 5% among females (in both age groups; SHR pooled 1.05; CI90% 1.02-1.08). The pooled analysis of mortality for the a priori identified diseases reported excesses for specific diseases in the group of sites with sources of exposure associated with them. Mortality from total mesotheliomas is three times higher at sites with asbestos present (males: pooled SMR 3.02; CI90% 2.18-3.87 - females: pooled SMR 3.61; CI90% 2.33-4.88) and that from pleural mesotheliomas more than two times higher at the group of sites with asbestos and port areas (males: pooled SMR 2.47; CI90% 1.94-3.00 - females: pooled SMR 2.43; CI90% 1.67-3.19). Lung cancer was in excess by 6% among males (pooled SMR 1.06; CI90% 1.03-1.10) and 7% among females (pooled SMR 1.07; CI90% 1.00-1.13). In addition, there are excess mortalities for colorectal cancer at sites with chemical plants, by 4 % among males (SMR pooled 1.04; CI90% 1.01-1.08) and 3 % among females (SMR pooled 1.03; CI90% 1.00-1.07) and for bladder cancer among the male population of sites with landfills (+6 %: SMR pooled 1.06; CI90% 1.02-1.11). Among the diseases of a priori interest, stomach and soft tissue cancers are at fault as a cause of death among all the sites considered., Literature Review: The update of the epidemiological evidence underlying the Sixth SENTIERI Report has highlighted in the general population a possible association, previously undiscovered, between certain diseases and residence near petrochemical and steel plants, landfills, coal mines and asbestos sources., Conclusions and Perspectives: Despite the fact that this is an ecological study, and the excesses of pathologies with multifactorial aetiology can never be mechanically attributed solely to the environmental pressure factors that exist or existed in the areas studied, the ability to identify the excesses found in the contaminated sites investigated by the SENTIERI Project confirms the validity of this method of assessing the site-specific health profile, based on the use of epidemiological evidence to identify pathologies of interest a priori. In interpreting the data and lending robustness to what has been observed, comparison with the results obtained in previous Reports is essential. The global estimates give an overall picture that shows excess mortality and hospitalization in these populations compared to the rest of the population, and show how, for specific pathologies, comparable effects are produced at sites with similar contamination characteristics. The themes developed in the in-depth chapters broaden the vision and understanding of the complex interactions between environment and health, describe the possibilities offered by new ways of communicating the results, and confirm the modernity of a Project that began way back in 2006, and that could be grafted onto the objectives of the National Recovery and Resilience Plan within the framework of the Operational Programme Health, Environment, Biodiversity and Climate.

This paper describes the development and the envisioned use of concept maps in the framework of the SENTIERI communication strategies as an information and scientific communication tool applied to epidemiological surveillance in contaminated sites. The concept map of SENTIERI 2019-2022 was designed and implemented to foster access to complex scientific information ensuring usability of the contents and communication with the various stakeholders. The concept map aims to promote environmental health literacy in contaminated sites. The methodology adopted to create the map includes the following phases: 1. choice of a dynamic focus question; 2. selection of the representative terms of the addressed topics; 3. elaboration of the glossary of the selected terms; 4. representation of the links among the selected terms; 5. identification of the significant propositions that make explicit the meaning of each link. Online access to the map is guaranteed by the Mindomo software. The use of the concept map promotes active learning of the topics that characterize SENTIERI 2019-2022 through knowledge paths chosen because of the specific interests and learning purposes. The concept map derives from the integration of specific approaches of the epidemiological discipline with those of the social sciences and offers the possibility of developing site-specific maps through the interactions with local actors and the integration of elements related to emerging problems as well as institutional and local interests.

Currently, there are more and more requests for a characterization of the health profile by populations living in areas affected by several types of environmental contaminations, notably for the presence of previously unknown and accidentally discovered landfills. The aim of the present paper is to describe the mortality profile of the residents of Piazzola sul Brenta (Veneto Region, Northern Italy). In this area, it was discovered an environmental contamination of the soil in the nearby of a large school building, where was formerly located a phosphate fertiliser plant. Using cause of death data provided by the Italian National Institute of Health, 10th International Classification 2013-2018, standardised mortality ratios (SMRs) and 90% confidence intervals (CIs) were calculated by gender and specific causes of death. Compared to the provincial reference population, no excess was found, for both genders, for all-causes mortality and for circulatory diseases. However, an excess for malignant tumours was found, 523 observed deaths over 498 expected deaths, an SMR of 105 (IC90% 98-113), and 85% probability of excess cancer mortality; lung cancer (SMR 117; IC90% 100-135) and lympho-hematopoietic tumours (in men only, SMR 134; IC90% 101-178).In light of these results and of the potential human exposure to carcinogenic substances, present results support further epidemiological investigations and environmental remediation.

Introduction and Objectives: This volume provides an update of the health status of the populations living in the National Priority Contaminated Sites (NPCSs) included in the SENTIERI Project. This update is part of an epidemiological surveillance programme carried out in NPCSs, promoted by the Italian Ministry of Health as a further step of a project started in 2006, when the health status of residents in contaminated sites was first addressed within the National Strategic Program "Environment and Health". The Report focuses on five health outcomes: mortality, cancer incidence, hospital discharges, congenital anomalies, and children, adolescents and young adults' health. A key element of SENTIERI project is the a priori evaluation of the epidemiological evidence of a causal association between the considered cause of disease and the exposure. When an a priori evidence is identified, it is given a greater importance in the comment of the study findings., Methods: The present update of the SENTIERI Project concerns 45 NPCSs including in all 319 Italian Municipalities (out of over 8,000 Municipalities), with an overall population of 5,900,000 inhabitants at the 2011 Italian Census. Standardized Mortality Ratios (SMRs) and Standardized Hospitalization Ratios (SHRs), referring to a time window of 2006-2013, were computed for all the 45 NPCSs, using as a reference the corresponding mortality and hospitalization rates of the Regions where each NCPS is located. Standardized Incidence Ratios (SIRs) were computed by the Italian Association of Cancer Registries (AIRTUM) for the 22 NPCSs served by a Cancer Registry. AIRTUM covers about 56% of Italy, with partly different time-windows. SIRs have been estimated using as reference population the 4 macroareas in which Italy is divided (North-West, North-East, Centre, South). Prevalence of congenital anomalies was computed for 15 NPCSs., Results: An all-cause excess of 5,267 and 6,725 deaths was observed, respectively, in men and women; the cancer death excess was of 3,375 in men and 1,910 in women. It was estimated an excess of cancer incidence of 1,220 case in men and 1,425 in women over a five-year time window. With regard to the diseases with an a priori environmental aetiological validity, an excess for malignant mesothelioma, lung, colon, and gastric cancer, and for non-malignant respiratory diseases was observed. Cancer excess mainly affected NPCSs with presence of chemical and petrochemical plants, oil refineries, and dumping hazardous wastes. An excess of non-malignant respiratory disease was also detected in NPCSs in which steel industries and thermoelectric plants were present. An excess of mesothelioma was observed in NPCSs characterized by presence of asbestos and fluoro-edenite; it was also observed where the presence of asbestos was not reported in the legislative national decrees which define the NPCS areas. It is worth noting that, even if the presence of asbestos is not reported in many NPCSs legislative decrees, petrochemical plants and steel industries, for instance, are often characterized by the presence of a large amount of this mineral that, in the past, was extensively used as an insulating material. For the first time, the present Report includes a focus on the health status of children and adolescents (1,160,000 subjects, aged 0-19 years), and young adults (660,000 subjects, aged 20-29 years). Among infants (0-1 year), an excess of 7,000 hospitalizations was observed, 2,000 of which due to conditions of perinatal origin. In the age class 0-14, an excess of 22,000 hospitalizations for all causes was observed; 4,000 of them were due to acute respiratory diseases, and 2,000 to asthma. Data on cancer incidence for subjects aged 0-24 years were derived from general population cancer registries for twenty NPCSs, and from children cancer registries (age group: 0-19 years) for six NPCSs; 666 cases where diagnosed in the age group 0-24 years, corresponding to an excess of 9%. The main contributions to this excess are from soft tissue sarcomas in children (aged 0-14 years), acute myeloid leukaemia in children (aged 0-14 years) and in the age group 0-29 years, non-Hodgkin lymphoma and testicular cancer in young adults (aged 20-29 years). In seven out of 15 NPCSs, an excess prevalence rate of overall congenital anomalies at birth was observed. Congenital anomalies excesses included the following sites: genital organs, heart, limbs, nervous system, digestive system, and urinary system., Conclusions: The main findings of SENTIERI Project have been the detection of excesses for the diseases which showed an a priori epidemiological evidence of a causal association with the environmental exposures specific for each considered NPCS. These observations are valuable within public health, because they contribute to priority health promotion activities. Looking ahead, the health benefits of an improved environmental quality might be appreciated in terms of reduction of the occurrence of adverse health effects attributable to each Site major pollutant agents. Due to the methodological approach of the present study, it was not possible to adjust for several confounding factors reported to be risk factors for the studied diseases (e.g., smoking, alcohol consumption, obesity). Even if excesses of mortality, hospitalization, cancer incidence, and prevalence of congenital anomalies were found in several NPCSs, the study design and the multifactorial aetiology of the considered diseases do not permit, for all of them, to draw conclusions in terms of causal links with environmental contamination. Moreover, it must be taken into consideration that economic factors and the availability of health services may also play a relevant role in a diseases outcome. A few observations regarding some methodological limitations of SENTIERI Project should be made. There is not a uniform environmental characterisation of the studied NPCSs in term of quality and detection of the pollutants, because this information is present in different databases which at present are not adequately connected. Moreover, the recognition of a contaminated site as a National Priority Site is based on soil and groundwater pollution, and the available information on air quality is currently sparse and not homogenous. Another limitation, in term of statistical power, is the small population size of many NPCSs and the low frequency of several health outcomes. A special caution must be paid in data interpretation when considering the correspondence between the contaminated areas and the municipality boundaries, as they do not always coincide perfectly: in some cases, a small municipality with a large industrial site, while in other settings only a part of the municipality is exposed to the sources of pollution. Furthermore, all available health information systems are currently accessible at municipality level. The real breakthrough is essentially comprised of the development and fostering of a networking system involving all local health authorities and regional environmental protection agencies operating in the areas under study. The possibility to integrate the geographic approach of SENTIERI Project with a set of ad hoc analytic epidemiological investigations, such as residential cohort studies, case control studies, children health surveys, biomonitoring surveys, and with socioepidemiological studies, might greatly contribute to the identification of health priorities for environmental remediation activities. Finally, as discussed in the last section of the report, there is a need to adopt, in each NPCS, a two-way oriented communication plan involving public health authorities, scientific community, and resident population, taking into account that the history, the cultural frame and the network of relationships specific of each local context play a major role in the risk perception perspective.

The integration of current data sources is now a practice widely used in epidemiology, especially in the environmental field. To better describe the health profile of populations residing in proximity to areas characterized by a "strong environmental pressure", the combined use of multiple indicators (i.e., mortality, hospitalization, cancer incidence) is recommended. To choose an indicator is complex, as indicators should be contextualized and they need to be related to the several issues involved in the studied pathology. This chapter explores the general considerations that are to be addressed both at the time of the study design, during the selection of outcomes and of the proper data sources, and at the time of the discussion of the results, when different and complementary data are compared. A special focus is devoted to the case of mesothelioma.

The Report considers three health outcomes - mortality, cancer incidence and hospital discharges - studied using homogenous methods and using data from official sources, namely the National Institute of Statistics (Istat), Italian Network of Cancer Registries (AIRTUM) and the Health Ministry. The timeframes of observation are: 2003-2010 for mortality, 1996-2005 for cancer incidence and 2005-2010 for hospital discharges. The causes of death are those examined by the SENTIERI Project. Hospital discharges are analysed with reference to the main diagnosis. The study of cancer incidence applies to the sites selected by AIRTUM. Statistical parameters (SMR, Standardized Mortality Ratio; SIR, Standardized Incidence Ratio; SHR, Standardized Hospitalization Ratio) were computed with a 90% confidence interval; the estimators were adjusted for age and socioeconomic status.

Of the 18 National Priority Contaminated Sites (NPCSs) analysed in this Report, some have a single source of environmental contamination (such as fluoro-edenite in Biancavilla). In most cases, however, we are looking at multiple heterogeneous sources of contamination. In this respect, the a priori causal evaluation of the association between diseases and environmental exposures in NPCSs, based on epidemiological evidence, can help trace the health impact back to specific types of environmental exposure. There are several cases in which the project's findings have been consistent with a priori evidence: stomach cancer (both genders, excess cancer incidence) in the Fidenza NPCS; stomach cancer (women, excess mortality, cancer incidence and hospital discharges) in the Laguna di Grado e Marano NPCS; excess hospitalisation from respiratory diseases in Brescia-Caffaro, Milazzo and Terni Papigno NPCSs; excesses for non-Hodgkin lymphomas and melanoma (incidence and hospitalisation in men and women) and breast cancer (incidence and hospital discharges, women) in Brescia-Caffaro NPCS. In preorder to properly evaluate the population's health profile, we must also observe whether results remain consistent for all three health outcomes or in both genders. The first is the case of excess mortality, cancer incidence and hospital discharges for bladder cancer (men) in Porto Torres and diseases of the urinary tract in the Basso bacino del fiume Chienti NPCS). Gender consistency is observed, for instance, for all cancer in Bolzano, Porto Torres, Venice, Litorale Domizio Flegreo, Priolo, and Taranto, for all causes in Taranto, Litorale Domizio Flegreo and Trieste. The health impact in the various NPCSs needs to be considered carefully and used as a springboard for further analytical research that could confirm and explain causal links to specific environmental exposures. The observations can, however, already be considered as a basis for mandatory primary prevention measures.

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.

The methods of mortality analysis in Italian polluted sites (IPS) are described. The study concerned 44 IPSs; each one included one or more municipalities. Mortality at municipality level was studied in the period 1995-2002, using the following indicators: crude rate, standardized rate, standardized mortality ratio (SMR), and SMR adjusted for an ad hoc deprivation index. Regional populations were used as reference for indirect standardization. The deprivation index was constructed using the 2001 national census variables representing the following socioeconomic domains: education, unemployment, dwelling ownership, overcrowding. Mortality indicators were computed for 63 single or grouped causes. The results for all the 63 analysed causes of death are available for each IPS, and in this Chapter the results for each IPS for causes selected on the basis of a priori evidence of risk from local sources of environmental pollution are presented. The procedures and results of the evidence evaluation have been published in the 2010 Supplement of Epidemiology & Prevention devoted to SENTIERI.

In Italy, complete municipality-level data on specific-cause mortality have been available at central level since 1980; Italy's National Institute of Statistics (Istat) collects data from all municipalities using two sources: i) the Office of Vital Statistics; and ii) the Civil Status Office. The Office of Vital Statistics records data on events such as births, deaths and migration for the population with official residence in the municipality, with the aim of describing the resident population's structure and composition. The Civil Status Office records data on the demographic dynamics (not only marital status but also causes of death); the data refer to the population living in the municipality, independently of official residence. Changes in the status of a municipality (e.g., the creation of a new municipality or the unification of diverse municipalities) are often not recorded simultaneously by these two offices, so that the data do not correspond.

The availability of Electronic Health Archives (EHA) has increased remarkably over the last twenty years. As part of a joint project of the Italian Association of Epidemiology (AIE) and the Italian Association of Medical Statistics and Clinical Epidemiology (SISMEC), a workgroup of experts was set up in 2005 with the aim of comparing various experiences and of standardizing the procedures by which electronic sources can be integrated. In particular, the workgroup's aim was to estimate the frequency of certain major diseases using standard algorithms applied to EHA. This volume is published with the purpose of making available in a common publication the methods and the results obtained. The results from a multicentre study using a standard approach to probabilistic record-linkage procedures are also included in a specific chapter. Eleven Italian centres from five Italian regions with an overall population of 11,932,026 collected and treated more than 21,374,426 records (year 2003) from five electronic information sources: death certificates, hospital discharge records (including outpatient discharges), drug prescriptions, tax- exemptions, and pathology records in order to estimate the frequency of the following diseases: diabetes, ischemic heart diseases, acute myocardial infarction, stroke, asthma, chronic obstructive pulmonary disease, obstructive lung diseases. For each pathology a specific algorithm was developed and used by all centres for the identification of the prevalent/incident cases of the selected diseases. Standardized methods were used to estimate the rates. The results confirm the need for a common standard approach to produce estimates based on EHA, considering the variability of the quality and of the completeness of the archives, and the difficulties of standardizing record-linkage operations in the various centres. The main achievement of this work was the elimination of the variability due to the use of different algorithms to identify cases using EHA.

Following the unusually hot summer this year and the dramatic news from neighboring countries such as France, the Italian Minister of Health requested an epidemiologic mortality study during summer 2003, to investigate whether there had been an excess of deaths in Italy, particularly for the elderly population. Communal offices, which provide vital statistics, were asked for the number of deaths among resident people, occurred from June 1 to August 31, for 2003 and 2002, for the 21 Italian regions capitals. A mortality increase of 3,134 deaths was observed for 2003; most of them (92%) were people aged 75 years and older. The highest increases were observed in the North Western cities (Turin, Milan, Genoa). The relationship between mortality and climatic indexes (T. max, Humidex) was investigated and a clear correlation was observed.

The Authors studied the antibacterial activity "in vitro" and "in vivo" of cefuroxime, cefamandole and cephalexin on the Gram-positive and Gram-negative bacterial strains of recent isolation. The results showed a greater antibacterial activity of cefuroxime than the other two cephalosporins, mainly on the Gram-negative beta-lactamase producing bacterial strains.

In this paper are reported the results of a comparative study of 4 "NAG" vibrio strains isolated in Italy and the vibrio biotype "E1 Tor" responsible of the 1973 outbreak. The "NAG" vibrios were practically identical with the "E1 Tor" vibrio in biochemical properties, polypeptide composition, enteritogenic activity in rabbit ileal loops and showed various antigenic similarities in gel precipitation and indirect immunofluorescence tests. The possible pathogenic role of the "NAG" vibrios is briefly discussed.